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Several decisions A decision of the [https://www.scc-csc.ca/home-accueil/index-eng.aspx Supreme Court of Canada] call calls consent for non-therapeutic circumcision of a child into question, <ref>{{REFdocument |title=E. (Mrs.) v. Eve |url=https://decisions.scc-csc.ca/scc-csc/scc-csc/en/item/170/index.do |contribution= |last= |first= |publisher=Supreme Court of Canada |format= |date=1986-10-23 |accessdate=2024-09-05}}</ref> but no case so far has ruled on the matter of circumcision.
[[Christopher Guest]], {{MD}}, {{FRCPC}}, of Barrie, ON, discusses circumcision in Canada:<br><br><youtube>7-vbutOy4X8</youtube><br>===A news report on circumcision in Canada.<br>===
→Factors pushing the incidence of non-therapeutic circumcision down
[[File:Flag_of_Canada.svg|thumb|150px|Flag of Canada]]
'''{{FULLPAGENAME}}''' is a federal state,a parliamentary democracy, and a constitutional monarchy.<ref>{{REFdocument
|title=Discover Canada
|url=https://www.canada.ca/content/dam/ircc/migration/ircc/english/pdf/pub/discover.pdf
|contribution=
|last=
|first=
|publisher=Citizenship and Immigration Canada
|format=
|date=
|page=2
|format=PDF
|accessdate=2024-09-15
}}</ref>
== Canada and circumcision ==
==History==
The practice of harmful, [[pain| painful]] medically-unnecessary, non-therapeutic [[circumcision]] is concentrated among the English-speaking population and is a declining practice.
The French-speaking people of Quebec and elsewhere generally do not favour circumcision. Male circumcision is not part of the native culture of indigenous Inuit, First Nations, and Métis populations (4.3% of the population). The Canadian Government established Residential Schools from about 1880 to assimilate the indigneous people into Euro-Canadian culture.<ref name="residential2021">{{REFweb
|title=Residential Schools in Canada
[[Douglas Gairdner]]'s classic 1949 paper, ''The Fate of the Foreskin: A Study of Circumcision'',<ref name="gairdner1949">{{GairdnerDM 1949}}</ref> seems to have been ignored in Canada.
Bruce Peter Reimer, later known as [[David Reimer]], was born in Winnipeg, Manitoba on 22 August 1965. His penis was destroyed in an accident during medically-unnecessary, non-therapeutic [[circumcision]] by Dr. [[Jean-Marie Huot]].
Patel (1966) reported his findings on neonatal [[circumcision]] in Kingston, Ontario, Canada. Patel reported a [[complication]] rate of 55 percent experienced in a series of 100 consecutive male infant circumcisions. He also reported on the incidence of circumcision at [http://www.kingstonhsc.ca/ Kingston General Hospital] in Kingston, Ontario. Patel reported an incidence of [[circumcision]] of 48 percent. This is for one hospital in Kingston, {{CAPTC|ON }} but has been widely and falsely cited as the rate for all Canada.<ref>{{REFjournal
|last=Patel
|first=Hawa
}}</ref>
[[Eleanor LeBourdais ]] (1995) declared that male [[circumcision]] is "clearly can no longer be regarded as routine procedure."<ref name="lebourdais1995">{{REFjournal
|last=LeBourdais
|first=Eleanor
|journal=Can Med Assoc J
|location=
|date=1995-06-01
|volume=152
|issue=11
}}</ref>
</blockquote>
== Research into pain of circumcision ==
Canada has been the the location of important research regarding the [[pain]] of circumcision.
[[Janice Lander| Lander]] et al. (1997) conducted a comparison of neonatal non-therapeutic circumcision without anesthesia (current practice in 1997), ring block, dorsal penile nerve block, and a topical eutectic mixture of local anesthetics ([[EMLA]]) at the {{UNI|University of Alberta|UAlberta}}, Edmonton, AB.<ref name="lander1997">{{LanderJ etal 1997}}</ref>
With no anaesthesia, the infants screamed continuously. Newborns in the untreated placebo group exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the [[circumcision]] and following. Two newborns in the placebo group became ill following circumcision (choking and apnea). One experienced projectile vomiting.<ref name="lander1997" />
[[EMLA]] was the least effective pain control. Dorsal penile nerve block (DPNB) was more effective, and ring block was the most effective. The authors reported "[w]ithout exception, newborns in this study who did not receive an analgesic suffered great distress during and following the circumcision, and they were exposed to unnecessary risk (from choking or apnea)." The authors were so alarmed that they terminated the no anaesthesia arm of the study early.<ref name="lander1997" />
Taddio et al. (1997), working at the [https://www.sickkids.ca/ Hospital for Sick Children], Toronto, {{CAPTC|ON}}, concluded:
{{Citation
|Text=Although postsurgical central sensitisation (allodynia and hyperalgesia) can extend to sites of the body distal from the wound, suggesting a supraspinal effect, the long-term consequences of surgery done without anaesthesia are likely to include post-traumatic stress as well as pain. It is, therefore, possible that the greater vaccination response in the infants circumcised without anesthesia may represent an <u>infant analogue of a post-traumatic stress disorder</u> triggered by a traumatic and painful event and re-experienced under similar circumstances of pain during vaccination.
|Author=Taddio et al. (1997)
|ref=<ref name="taddio1997">{{TaddioA KatzJ IlersichAL KorenG 1997}}</ref>
}}
==Reported incidence of non-therapeutic child circumcision==
|Author=Canadian Paediatric Society (2015)
}}
This statement received criticism from [[Intact America]] and [[NOCIRC]] in a joint statement.<ref>{{REFdocument
|title=Joint statement in response to the Canadian Paediatric Society
|url=https://intactamerica.org/joint-statement-in-response-to-the-canadian-paediatric-society/
|contribution=
|last=
|first=
|publisher=Intact America
|format=
|date=2015-10-02
|accessdate=2024-06-09
}}</ref>
=== College of Physicians and Surgeons of British Columbia (CPSBC) ===
The [https://www.cpsbc.ca/ College of Physicians and Surgeons of British Columbia] has issued three guidances for its members regarding non-therapeutic male circumcision of children. The most recent (2009) says in part:
=== Canadian Urological Association (CUA) ===
The [[Canadian Urological Association]] (CUA) considered the matter of circumcision and issued a statement in February 2018. The CUA concluded:
==Non-availability of third-party payment==
Canada has fourteen single-payer health insurance plans (HIPs) — one for each of the ten provinces and three territories and a 14th plan for government employees. The British Columbia HIP stopped paying for non-therapeutic [[circumcision]] in 1984. Ontario HIP stopped payment for non-therapeutic circumcision in July 1995; Saskatchewan stopped in 1996. One by one, all other HIPs have stopped paying for non-therapeutic circumcision. In 2006, Manitoba HIP was the last to stop, but only after the wrong boy was [[circumcised]] at [http://www.sbgh.mb.ca/ St. Boniface Hospital].<ref>{{REFnews
|title=Circumcision mix-up
|url=httphttps://www.cirp.org/news/canadacom112006/2006-1807-05/18_winnipegfreepress.php |last=Skerrit |first=Jen |publisher=Canada.comWinnipeg Free Press |accessdate=20192024-10-2608
}}</ref> <ref name="skeldon2008">{{REFdocument
|title=The Medicalization and Resultant Decline of Circumcision in Canada
|DOI=
|accessdate=2019-11-10
}}</ref> <ref name="rediger-muller2013"/>
With the decline in the incidence of [[circumcision]] in Canada that started decades ago, there are fewer and fewer [[circumcised]] fathers, so one would expect the incidence of circumcision in Canada to continue to decline.
==Non-therapeutic circumcision and Canadian law==
The Government of Canada officially states:
<blockquote>
The equality of Women and Men
In Canada, men and women are equal under the law. Canada’s openness and generosity do not extend to barbaric cultural practices that tolerate spousal abuse, “honour killings,” female genital mutilation, forced marriage or other gender-based violence. Those guilty of these crimes are severely punished under Canada’s criminal laws.<ref>{{REFbook
|last=Anonymous
|first=
|init=
|year=2021
|title=Discover Canada
|url=https://www.canada.ca/content/dam/ircc/migration/ircc/english/pdf/pub/discover.pdf
|chapter=Rights and Responsibilities of Citizenship
|page=8
|scope=
|location=Ottawa
|publisher=Citizenship and Immigration Canada
|ISBN=978-0-660-39273-8
|accessdate=2024-09-15
|format=PDF
}}</ref>
</blockquote>
Non-therapeutic [[circumcision ]] of children in Canada is a practice that is of uncertain lawfulnessin Canada.
The ''Charter of Rights and Freedoms'' (1982), [https://www.canada.ca/en/canadian-heritage/services/how-rights-protected/guide-canadian-charter-rights-freedoms.html#a2e Article Section 7] provides every Canadian with the right to security of the person.<ref name="chhrp2018" />
In addition, Canada is a state-party to the United Nations ''[https://www.ohchr.org/EN/ProfessionalInterest/Pages/CCPR.aspx Covenant on Civil and Political Rights]'' (1966) and the ''[https://www.ohchr.org/en/professionalinterest/pages/crc.aspx Convention on the Rights of the Child]'' (1989), both of which provide various [[human rights]] to children, which are violated by non-therapeutic child circumcision.
}}</ref>
[[Suzanne Bouclin]] (2005) has examined the issues and concluded:
Section 7 of the Charter provides everyone with a certain degree of autonomy in decisions concerning their private lives, including those concerning medical treatment. The protection of the security of the person is so fundamental that medical treatment administered without a patient’s [[informed consent]] may amount to battery. In the context of circumcision, if a medical practitioner performs routine neonatal circumcision without an infant’s parental consent, that practitioner may be liable for criminal assault as well as for damages for any harm that resulted from her or his negligence ([[Margaret A. Somerville|Somerville]], 2000).
Given that a portion of the medical community has agreed that routine infant male circumcision is nontherapeutic and that it may be in and of itself be a harmful practice, it is arguable that when performed on neonates for nontherapeutic reasons, it amounts to a violation of the child’s [https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/check/art7.html Section 7] rights. As stated at the [[Declaration of the First International Symposium on Circumcision (1989)| Declaration of the First International Symposium on Circumcision]], “parents and/or guardians do not have the right to consent to the surgical removal or modification of their children’s normal genitalia.” The Declaration adds that the only person who may consent to medically unnecessary procedures upon herself or himself is that individual, having reached a stage in life where she or he can consent and only upon being fully informed about the risks and benefits of the procedure. Note, however, that the Declaration is not a binding legal instrument.
'''…'''
===Canadian Medical Association Code of Ethics and Professionalism===
The CMA code has two statements relevant to the non-therapeutic circumcision of male infants:
* Never participate in or support practices that violate basic [[human rights]].
* Never participate in or condone the practice of torture or any form of cruel, inhuman, or degrading procedure.<ref name="cma2018">{{REFdocument
|accessdate=2021-07-08
}}</ref>
It therefore appears that non-therapeutic circumcision of boys is unethical in Canada.
===Lawsuit===
|quote=
}}</ref>
===Third-party payment is not available===
At the beginning of the 21st Century, only the Manitoba Health Insurance Plan (HIP) still paid for non-therapeutic circumcision, however that Manitoba HIP ended payment in 2006.<ref name="skeldon2008" />No insurance coverage of non-therapeutic circumcision is currently available. There is a long-standing general consensus for a half-century that there are no medical indications for [[circumcision]] in the newborn period.<ref name="cps1975" /> <ref name="cps1996" /> A report in 2024 indicates that the Manitoba HIP reinstated [[third-party payment]] for non-therapeutic circumcision in the first 28 days of life, apparently for political reasons and as a [[Financial incentive| benefit]] for physicians.<ref>{{REFweb |url=https://buenafeclinic.com/circumcision/baby-infant-newborn/ |title=Baby & Newborn Circumcision at our Winnipeg Clinic |last=Buenafe |first=Joy |init= |author-link= |publisher=Buenafe Clinic |date= |accessdate=2024-10-06}}</ref>
===The incidence of circumcision varies widely by region===
The incidence of non-therapeutic child circumcision Labrador and Newfoundland is reported to be close to zero while Saskatchewan had an incidence of circumcision in 2000 and 2001 of 27.6 percent. The Saskatchewan College of Physicians and Surgeons said in 2002 that was much too high and should be reduced substantially. The Registrar, Dr. Dennis Kimble, said, "they [doctors] aren't required to carry out a procedure simply because parents want it done."<ref>{{REFnews
|title=Sask. college wants circumcision rates reduced
|url=http://www.cirp.org/news/medicalpost03-18-02/
|quote=
}}</ref>
===The most recent survey was done in 2006-7===
The [https://www.canada.ca/en/public-health.html Public Health Agency of Canada] carried out a survey of mothers' birth experiences in 2006-7. Item 38 was male infant non-therapeutic circumcision. (See pages 224-5.)The survey did not provide information for the three territories where the incidence of non-therapeutic circumcision is believed to be extremely low. The Atlantic provinces except for PEI and Quebec had a markedly lower incidence than the other provinces. PEI then had a high rate of circumcision but is now reported to have zero circumcisions.
<blockquote>
Among women with a male baby, 31.9% (95% CI: 30.3–33.6) reported circumcising their baby. There was marked regional variation in circumcision. In the 10 jurisdictions in which at least five circumcisions were reported, the proportion of women who reported having their male baby [[circumcised ]] ranged from 44.3% (95% CI: 39.2–49.4) in Alberta and 43.7% (95% CI: 40.6–46.8) in Ontario to 9.7%† (95% CI: 5.2–14.2) in the Northwest Territories and 6.8%† (95% CI: 3.6–10.0) in Nova Scotia.<ref>{{REFdocument
|title=What Mothers Say: The Canadian Maternity Experiences Survey
|url=https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/rhs-ssg/pdf/survey-eng.pdf
</blockquote>
In all provinces and territories, only a minority of boys are being [[circumcised]]. Sheldon (2008) reported an incidence of 13.9 percent.<ref name="skeldon2008" /> The incidence of circumcision in Labrador and Newfoundland is reported to be close to zero.<ref>{{REFweb
|url=https://momlovesbest.com/choosing-circumcision
|title=Circumcision: Pros and Cons
|accessdate=2021-07-10
|format=
|quote=Labrador and Newfoundland have close to zero.
}}</ref>
The incidence of child circumcision in Canada is believed to be one-half or less than that of the [[United States]].
The above referenced survey (2006-7) provides the most recent available statistics on the incidence of non-therapeutic child circumcision in Canadabut is now becoming out-of-date. [[Foreskinned]] males appear to be in the majority in every province and territory.
===Factors pushing the incidence of non-therapeutic circumcision down===
It is likely that the incidence of circumcision has further declined since the survey was taken for the following reasons:
* The long-term trend in the incidence of [[circumcision]] in Canada is down.<ref>{{REFweb |url=https://www.ctvnews.ca/health/will-canada-ban-circumcision-not-likely-observers-say-1.3824863 |title=Will Canada ban circumcision? Not likely, observers say |last=Szklarsk |first=Cassandra |init= |author-link= |publisher=The Canadian Press |date=2018-03-01 |accessdate=2024-11-06}}</ref>
* The health insurance plans (HIPs) do not support non-therapeutic circumcision.<ref name="skeldon2008" />
* The ratio of [[intact]] fathers to [[circumcised]] fathers is changing toward more [[intact]] fathers and fewer [[circumcised ]]fathers. Boys who were born after the decline in circumcision started and who are [[intact]] are now reaching the age at which they start families and become fathers. [[Intact]] men usually do not want any son to be [[circumcised]] (See [[Adamant father syndrome]]), so they will usually not have a son [[circumcised]].<ref name="rediger-muller2013" /> This will cause a further decline in the incidence of [[circumcision]].
* The large numbers of [[intact]] boys growing up healthy and happy is further eroding support for non-therapeutic [[circumcision]]. * The survey (2006) found that the incidence of circumcision on Prince Edward Island was 38 percent. A recent report (2019) indicated that non-therapeutic circumcision of boys is no longer available on P.E.I. because no practitioner will perform the non-therapeutic [[amputation]] of part of a boy's [[penis]].<refname="williams2019">{{REFnews
|title=Mom 'enraged' she can't find doctor to perform circumcision on P.E.I.
|url=https://www.cbc.ca/news/canada/prince-edward-island/p-e-i-no-doctors-circumcision-1.5187284
}}</ref>
* The [https://www.cpso.on.ca/ College of Physicians and Surgeons of Ontario] (2010) issued a special order to prohibit paediatrician [[Daniel Marshall]], who operated the Circumcision Centre in Hamilton, {{CAPTC|ON }} from examining or being alone with youths.
DeMaria et al. (2013) surveyed physicians in southwest Ontario who still perform circumcisions. They concluded from their survey:
{{Citation
|Text=Our survey findings indicate that most physicians performing neonatal circumcisions in our community have received informal and unstructured training. This lack of formal instruction may explain the complications and unsatisfactory results witnessed in our pediatric urology practice. Many practitioners are not aware of the contraindications to neonatal circumcision and most non-surgeons perform the procedure without being able to handle common post-surgical complications.
|ref=<ref name="demaria2013">{{REFjournal
|last=De Maria
|first=
|quote=
}}</ref> The CBC reported:
<blockquote>
Among the complications, two boys were rushed to hospital with potentially life-threatening bleeds, one after a portion of his [[penis ]] was amputated and the other with arterial bleeding.
Other boys experienced complications like swelling, pain, embedded gauze from improper wound care, possible infections and disfigurement.
At least one boy's [[penis ]] was left so deformed he required a revision surgery.<ref name="glowaki2018" />
</blockquote>
The circumcisions performed by Dr. Ahmad were performed for cultural reasons, not medical reasons, so they were not insured by Manitoba Health. The CBC reported:
<blockquote>
Along with malpractice, the college found Ahmad displayed several "multi-dimensional" professional shortcomings.
}}</ref>
As of 2022, [[third-party payment]] for non-therapeutic [[circumcision]] has not been available anywhere in Canada since 2006.<ref name="skeldon2008" /> Moreover, non-therapeutic circumcision is not done in most hospitals,<ref name="jamesloewen2019" /> so parents who want to have a boy [[circumcised ]] must take the boy to the surgery of a practitioner who specializes in non-therapeutic male circumcision, and furthermore must pay out of pocket. For example, the cost of circumcision of a newborn boy in New Brunswick is C$425 ranging up to C$1500 for a teenager or adult.<ref>{{REFweb
|url=https://gentleproceduresnb.ca/circumcision/cost-how-much/
|title=Circumcision Pricing & Insurance Coverage
Non-circumcision or [[genital integrity]] is the norm in all parts of Canada.
===Abusive promotion of non-therapeutic circumcision in Ontario===
Dr. Omar Afandi, an Ontario paediatrician, improperly accessed hospital records at [https://www.wrh.on.ca/ Windsor General Hospital] and elsewhere to learn the names of mothers who had given birth to a boy. He then telephoned the mothers to offer them an unnecessary [[circumcision]] in his clinic in Windsor. The records of as many as 800 mothers may have been accessed.<ref>{{REFnews
|title=Windsor doctor has privileges revoked after allegedly accessing newborn data for profit
|url=https://windsor.ctvnews.ca/windsor-doctor-has-privileges-revoked-after-allegedly-accessing-newborn-data-for-profit-1.6977821
|last=Fortnum
|first=Travis
|init=
|author-link=
|last2=
|init2=
|author2-link=
|publisher=CTV News
|website=
|date=2024-07-26
|accessdate=2024-09-05
|format=
|quote=
}}</ref> Ontario Health Insurance Plan does not pay for non-therapeutic [[circumcision]], so parents would have to pay out of pocket for the harmful unneeded surgical amputation at WE Kidz Pediatrics.<ref>{{REFweb
|url=https://intactamerica.org/oh-no-canada/
|title=Oh (no) Canada!
|last=Ashford
|first=Jeannie
|init=
|author-link=
|publisher=Intact America
|date=2024-08-16
|accessdate=2024-09-05
}}</ref>
==Video==
<youtube>Yf06OSHcZc8</youtube>
===[[Christopher Guest]], {{MD}}, {{FRCPC}}, of Barrie, {{CAPTC|ON}}, discusses circumcision in Canada:===<bryoutube>?v=TQIp9f4krVQ</youtube>===A Historical and Medical Critique of Circumcision - Dr. Christopher Guest===<youtube>v=XwZiQyFaAs0</youtube>
{{SEEALSO}}
* [[Canadian Children's Rights Council]]
* [[Canadian Foreskin Awareness Project (CAN-FAP)]]
* [[Circumcision]]
* [[Circumcision maps]]
{{LINKS}}
* {{URLwikipedia|Canada|Canada}}
* {{REFnews
|title=P.E.I. has highest rate of circumcision in Canada
|url=https://www.cirp.org/news/2007/2007-01-22_cbc-news.php
|last=Anonymous
|first=
|init=
|author-link=
|publisher= CBC News
|website=
|date=2007-01-22
|accessdate=2024-01-22
|quote=The procedure is not covered by medicare.
}}
* {{REFnews
|title=Ontario infant dies after circumcision
|url=https://www.cirp.org/news/2007/2007-06-14_canwest.php
|last=Mark Brennae
|first=Mark
|init=
|author-link=
|publisher=CanWest News Service
|website=
|date=2007-06-14
|accessdate=2024-07-28
|quote=The child's death was attributed to septic shock—"an overwhelming infection, leading to multi-organ failure," Cairns said.
}}
* {{REFnews
|title=Circumcision: Do risks outweigh benefits?
|url=https://www.theglobeandmail.com/life/health-and-fitness/health/circumcision-do-risks-outweigh-benefits/article18105881/
|last=Weeks
|first=Carly
|init=
|author-link=
|last2=
|init2=
|author2-link=
|publisher=The Globe and Mail
|website=
|date=2014-04-22
|accessdate=2024-06-21
|format=
|quote=Instead of coming down on one side of the debate, the [[Canadian Paediatric Society]] could help parents more by offering guidance that clearly spells out the potential advantages and risks of [[circumcision]], without bias or omission.
}}
* {{REFweb
|url=httphttps://canintactamerica.org/oh-no-fap.netcanada/ |title=Canadian Foreskin Awareness ProjectOh (no) Canada! |last=CallenderAshford |first=GlenJeannie |init= |author-link=Glen Callender |publisher= |website=Intact America |date=2024-08-16 |accessdate=20192024-1208-1617
}}
{{ABBR}}
{{REF}}