Changes

A report on non-therapeutic [[circumcision ]] in Canada.

Non-therapeutic circumcision of children is not part of the culture of many Canadian minorities. 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 |url=https://www.thecanadianencyclopedia.ca/en/article/residential-schools |archived= |trans-title= |language= |last=Miller |first= |init=JR |author-link= |publisher=Canadian Encyclopedia |website= |date=2021-06-01 |accessdate=2022-10-26 |quote=}}</ref> The indigenous people who do circumcise today received [[circumcision]] as a cultural procedure from the English-speaking Canadians in the Residential Schools.<ref name="euringer2005">{{REFnews |title=BC Health Pays to Restore Man’s Foreskin |url=https://thetyee.ca/News/2006/07/25/Circumcision/ |last=Euringer |first=Amanda |init=A |publisher=The Tyee |date=2006-07-25 |accessdate=2022-08-21 }}</ref> [[Paul Tinari]], a Métis, attended a residential school near Montreal where he was [[circumcised]] at the age of eight by a Catholic priest and a Jewish [[mohel]]. Tinari states "thousands of young native and Métis boys were [[circumcised]] during their stays in the notorious residential school system."<ref name="euringer2005" />

The medicalized genital cutting of infants and children was first promoted in Canada during the mid to late 19th century by English-speakers after the fashion at the time of the [[United Kingdom]]. Doctors encouraged the genital cutting of both male and female children to prevent [[masturbation ]] as well as various diseases like epilepsy and tuberculosis.<ref name="chhrp2018">{{REFdocument

|date=2018-07-11 |accessdate=20192020-1106-1623

 Pirie (1927), in a presentation to the Canadian Society for the Study of Diseases of Children, described [[circumcision ]] as "very common".<ref name="pirie1927">{{REFjournal

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 on the complications a [[complication]] rate of 55 percent experienced in a series of 100 consecutive male infantsinfant 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

Canada, like other English-speaking nations , formerly [[circumcised ]] many of its boys, with circumcision rates in the 40 to 70 percent range in the 1960s.<ref>{{REFjournal

}}</ref> The [[Canadian Paediatric Society]] (CPS) issued its first statement on neonatal circumcision in 1975. The statement said "there is no [[medical indication]] for circumcision during the neonatal period." The CPS called the amputation an "obsolete operation" and anticipated a "sharper decrease in the percentage of infants circumcised".<ref name="cps1975">{{REFjournal |last=Swyer |init=PW |author-link= |last2=Boston |init2=RW |author2-link= |etal=yes |url=http://www.cirp.org/library/statements/cps1975/ |title=FN 75-01 Circumcision in the newborn period |journal=Canadian Paediatric Society News Bulletin Supplement |date=1975 |volume=88 |issue=2 |pages=1-2 |accessdate=2022-03-18}}</ref>

[[Eleanor LeBourdais ]] (1995) declared that male [[circumcision ]] is "clearly can no longer be regarded as routine procedure."<ref name="lebourdais1995">{{REFjournal

|date=1995-06-01

==Position statements of medical societies==  === Canadian Paediatric Society (CPS) ===The [[Canadian Paediatric Society]] (CPS) took a position against non-therapeutic circumcision of boys in 1975, declaring it to have "no [[medical indication]]" and to be an "obsolete operation".<ref name="cps1975" />

The [[Canadian Paediatric Society]] (CPS) took a position against non-therapeutic revisited circumcision of boys in 1975, declaring it to have "no medical indication" 1996 and to be an "obsolete operation".<ref name="cps1975">{{REFjournal |last=Swyer |init=PR |author-link= |last2=Boston |init2=RW |author2-link= |last3=Murdock |init3=A |author3-link= |last4=Paré |init4=C |author4-link= |last5=Rees |init5=E |author5-link= |last6=Segal |init6=S |author6-link= |last7=Sinclair |init7=JC |author7-link= |etal=no |title=FN 75 Circumcision in the newborn period |journal=CPS News Bull Suppl |location= |date=1975 |volume=8 |issue=2 |pages=1-2 |url=httprecommended://www.cirp.org/library/statements/cps1975/ |quote= |pubmedID= |pubmedCID= |DOI= |accessdate=2019-10-25}}</ref>

The CPS revisited circumcision in 1996 and recommended, "{{Citation |Text=Circumcision should not be routinely performed." |ref=<ref name="chhrp2018" /><ref name="cps1996">{{REFjournal

The [https://www.cpsbc.ca/ College of Physicians and Surgeons of British Columbia] has issued three guidances for its members regarding non-therapeutic male CPS again considered infant circumcision of childrenin 2015. The most recent (2009) says in part:<blockquote>You are not obliged to act upon a request to circumcise an infant, but you must discuss the medical evidence and the current thoughts in bioethics that dissuade you from performing this procedure. You must also inform the parents that they have the right to see another physician.<ref>{{REFdocument |title=Circumcision (Infant Male) |trans-title= |language= |url=httpCPS stated://www.cirp.org/library/statements/cpsbc2009/cpsbc-circ-stmt2009.pdf |contribution= |quote= |trans-quote= |quote-lang= |last= |first= |author-link= |publisher=College of Physicians and Surgeons of British Columbia |format=PDF |date=2009-09 |accessdate=2019-11-18}}</ref></blockquote>

The CPS again considered infant circumcision in 2015. The CPS stated:{{Citation<blockquote> |Text=While there may be a benefit for some boys in high-risk populations and circumstances where the procedure could be considered for disease reduction or treatment, the Canadian Paediatric Society does not recommend the routine circumcision of every newborn male. |ref=<ref name="cps2015">{{REFjournal

|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: {{Citation |Text=You are not obliged to act upon a request to circumcise an infant, but you must discuss the medical evidence and the current thoughts in bioethics that dissuade you from performing this procedure. You must also inform the parents that they have the right to see another physician. |ref=<ref>{{REFdocument |title=Circumcision (Infant Male) |trans-title= |language= |url=http://www.cirp.org/library/statements/cpsbc2009/cpsbc-circ-stmt2009.pdf |contribution= |quote= |trans-quote= |quote-lang= |last= |first= |author-link= |publisher=College of Physicians and Surgeons of British Columbia |format=PDF |date=2009-09 |accessdate=2019-11-18}}</blockquoteref> |Author=College of Physicians and Surgeons of British Columbia}} === Canadian Urological Association (CUA) === The [[Canadian Urological Association]] (CUA) considered the matter of circumcision and issued a statement in February 2018. The CUA concluded:

The [http://www.cua.org/en Canadian Urological Association] (CUA) considered the matter of circumcision and issued a statement in February 2018. The CUA concluded: <blockquote>"{{Citation |Text=Given the socioeconomic, educational status, and health demographics of our population, universal neonatal circumcision cannot be justified based on the current evidence available. |ref=<ref name="cua2018">{{REFjournal

|pubmedID=29381455 |pubmedCID=5937397 |DOI=10.5489/cuaj.5034. Epub 2017 Dec 1

}}</ref></blockquote> |author=[[Canadian Urological Association]]}} ==Non-availability of third-party payment==

==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 the 1980s1984. 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

[[Third-party payment]] for non-therapeutic circumcision is not presently available anywhere in Canada.<ref name="skeldon2008"/> <ref name="jamesloewen2019">[[James Loewen]] (2019). Personal communication.</ref> Parents who wish to have a son [[circumcised ]] must pay out-of-pocket for the costs of the circumcision.<ref name="rediger-muller2013">{{REFjournal

}}</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 ]] 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" />

[[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.

|author-link=Suzanne Bouclin

 * Never participate in or support practices that violate basic [[human rights]].

The ''New York Post'' (2019) reports reported that a Canadian woman of African ancestry took her nine-day-old son to the [https://www.vemcregina.com/ Victoria East Medical Clinic] in Regina, SK to be [[circumcised]]. In the course of the circumcision, the tip of his penis was allegedly cut off. An ambulance was called but the [http://www.rqhealth.ca/facilities/regina-general-hospital Regina General Hospital] was unable to reattach the severed part.

Jackie Smith (2002) discussed the growing consensus against non-therapeutic child circumcision, which she called an "anachronism".<ref name="smith2002">{{REFnews

===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 was Manitoba HIP ended payment in 2006.<ref name="skeldon2008" /> No insurance coverage of non-therapeutic circumcision is currently available. ===The incidence of circumcision varies widely by region===

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

The incidence of 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 Canada.  ===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.

* The longhealth insurance plans (HIPs) do not support non-term trend in the incidence of therapeutic circumcision in Canada is down.<ref name="skeldon2008" />

* The health insurance plans 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 support nonwant any son to be [[circumcised]] (See [[Adamant father syndrome]]), so they will usually not have a son [[circumcised]].<ref name="rediger-therapeutic muller2013" /> This will cause a further decline in the incidence of [[circumcision]].

* The ratio large numbers of [[intact fathers to circumcised fathers ]] boys growing up healthy and happy 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, so they will usually not have a son circumcised.<ref name="redigerfurther eroding support for non-muller2013" /> This will cause a further decline in the incidence of 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]].<ref>{{REFnews

* Most hospitals do not provide non-therapeutic circumcision, however [https://www.wrh.on.ca/ Windsor Regional Hospital] is an exception to the general rule. Windsor Regional Hospital still promotes medically-unnecessary, non-therapeutic [[circumcision ]] to parents of normal, healthy male infants in apparent violation of the infants' [https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/check/art7.html Section 7 rights]. The hospital is reported to circumcise 51 percent of boys born in the hospital. This is far higher than the incidence of non-therapeutic circumcision elsewhere in Ontario and Canada.<ref>{{REFnews

|quote=Dr. Tony Hammer, a Windsor family doctor, said his colleagues may be performing the medically unnecessary procedure simply to make a buck. <b>…</b> There is a financial incentive for physicians, and I wonder if they are fully informing their patients of a lack of medical need,.}}</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.

<blockquote>{{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

}}</ref> |Author=DeMaria et al. (2013)}} The CBC (2018) reported that Pakistani [https://www.ratemds.com/doctor-ratings/78555/Dr-Ejaz-Ahmad-Winnipeg-MB.html/ Dr. Ejaz Ahmad], who practiced medicine on Portage Avenue in Winnipeg, had been suspended from the practice of medicine for five months by the [https://cpsm.mb.ca/ College of Physicians and Surgeons of Manitoba], after he performed 18 circumcisions from June 2016 to July 2017 on pediatric patients and two boys almost bled to death.<ref name="glowaki2018">{{REFnews |title=2 boys almost bled to death in botched circumcisions by Manitoba doctor |url=https://www.cbc.ca/news/canada/manitoba/winnipeg-doctor-suspended-botched-circumcisions-1.4953561 |last=Glowaki |first=Laura |init= |author-link= |last2= |init2= |author2-link= |publisher=CBC News |website= |date=2018-12-20 |season= |accessdate=2022-07-05 |format= |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. He neglected to warn parents about the risks of their surgeries, failed to create records and when families went to other doctors for help, he told them not to disclose who had carried out the surgeries. In one instance, Ahmad told a doctor and nurses in an emergency room the procedure had been performed by a "traditional man" and not, in fact, himself.<ref name="glowaki2018" /></blockquote> The [https://www.gov.mb.ca/health/ Manitoba Department of Health] issued a ''Patient Safety Learning Advisory'' in February 2018 regarding an incident in which a newly [[circumcised]] infant boy experienced [[bleeding]] after his non-therapeutic [[circumcision]]. A blood pressure cuff suitable for infants was not available so a proper diagnosis was not made. The boy was discharged home, however [[bleeding]] continued and the boy was returned to the emergency department but was then transferred to a tertiary care facility. The boy suffered multiple complications.<ref>{{REFweb |title=Patient Safety Learning Advisory |url=https://www.gov.mb.ca/health/patientsafety/docs/psla61.pdf |archived= |trans-title= |language= |last= |first= |author-link= |publisher=Manitoba Health, Seniors and Active Living |website= |date=2018-02 |accessdate=2022-07-04 |format=PDF |quote=The infant required transfer to a tertiary care site by the neonatal transport team due to multiple complications.}}</ref> Infant boys have very little blood in their tiny bodies so the ability to withstand [[bleeding]] is very limited. Typically, exsanguination and hypovolemic shock occurs. Manitoba Services (2022) reported Winnipeg attorney [https://www.bestlawyers.com/lawyers/martin-j-pollock/76357 Martin Pollock] filed a Statement of Claim on 22 June 2022 in the Court of Queen's Bench on behalf of the Muslim mother of a five-year-old boy who was circumcised in Portage la Prairie in 2017. The suit names [https://www.gov.mb.ca/health/ Manitoba Health] and three health care workers as defendants. The mother "alleges in the lawsuit that the injuries suffered by her son were caused or contributed to by the negligence of the two doctors, the nurse and the health region named in the suit, which led to 'severe and permanent injuries.'"<ref>{{REFnews |title=Baby who bled for hours after circumcision was sent home from ER twice, suffered brain damage: lawsuit |url=https://manitobaservices.com/news/baby-who-bled-for-hours-after-circumcision-was-sent-home-from-er-twice-suffered-brain-damage-lawsuit/ |last=Manny |first= |init= |author-link= |last2= |init2= |author2-link= |publisher=Manitoba Services |website= |date=2022-07-03 |season= |accessdate=2022-07-05 |format= |quote=The child, now five years old, lives with motor impairment, irreversible brain damage, impaired vision and speech, and developmental delay. He “will continue to suffer the effects of his disabilities for the balance of his lifetime,” the suit says.}}</ref>

As of 20192022, [[third-party payment]] for non-therapeutic [[circumcision is ]] has not been available anywhere in Canadasince 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

The prevalence of circumcision is higher among older males, but lower among younger males. As older, mostly [[circumcised ]] males die and are replaced in the population by younger, mostly [[intact ]] males, the overall prevalence of [[circumcised ]] men in Canada is gradually declining. [[Intact ]] males usually do not want any son to be [[circumcised]],<ref name="brown-brown1987" /> <ref name="rediger-muller2013" /> so the demand for [[circumcision ]] in Canada is declining.

Mayan et al. (2021) carried out a massive empirical study of the male population of the province of Ontario, Canada (569,950 males), of whom 203,588 (35.7%) were [[circumcised ]] between 1991 and 2017. The study concluded that circumcision status is not related to risk of [[HIV ]] infection.<ref name="mayan2021">{{REFjournal

|archived= |quote=We found that circumcision was not independently associated with the risk of acquiring [[HIV ]] among men from Ontario, Canada.

* [[Circumcision: The Whole Story]]* [[Child Circumcision: Rites or Rights?]]* [[College_of_Physicians_and_Surgeons_of_Ontario]]

* [[Child Circumcision: Rites or Rights?Trauma]]

* {{REFdocumentREFnews |title=International NGO Council on Genital Autonomy Supplementary Country Report Submission on Canada to the U.N. Committee on the Rights of the ChildCircumcision: Do risks outweigh benefits? |url=httphttps://chhrpwww.orgtheglobeandmail.com/wplife/health-contentand-fitness/uploadshealth/2019/11/Canada-Supplementary-Report.pdf |contribution= |last=Antinuk |first=Kira |author-link=Kira Antinuk |publisher=Children's Health and Human Rights Partnership |format=PDF |date=2018circumcision-07do-11 |accessdate=2020risks-06outweigh-23}}* {{REFjournalbenefits/article18105881/ |last=BhimjiWeeks |first=ArifCarly |init=A

|titlelast2=Infant Male Circumcision: A violation of the Canadian Charter of Rights and Freedoms. |journal=Health Care Law |date=2000-01 |volume=1 |issue= |pages=1-33 |url=http://www.cirp.org/library/legal/Canada/court1/ |accessdate=2019-11-07}}* {{REFweb |url=https://canadiancrc.com/Circumcision_Genital_Mutilation_Male-Female_Children.aspx |title=Canadian Children's Rights Council |lastinit2= |first= |accessdate=2020-06-22}}* {{REFweb |url=http://can-fap.net/ |title=Canadian Foreskin Awareness Project |last=Callender |first=Glen |authorauthor2-link=Glen Callender |publisher=The Globe and Mail

|date=2014-04-22 |accessdate=20192024-1206-1621 |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.