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Canada and circumcision

A report on non-therapeutic circumcision in Canada.

History

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 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.[1]

Pirie (1927), in a presentation to the Canadian Society for the Study of Diseases of Children, described circumcision as "very common".[2]

Douglas Gairdner's classic 1949 paper, The Fate of the Foreskin: A Study of Circumcision,[3] 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.

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 Kingston General Hospital in Kingston, Ontario. Patel reported an incidence of circumcision of 48 percent. This is for one hospital in Kingston, ON but has been widely and falsely cited as the rate for all Canada.[4]

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.[5]

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".[6]

LeBourdais (1995) declared that male circumcision is "clearly can no longer be regarded as routine procedure."[7]

Dr. Arif Bhimji (2000) applied international human rights law and the Canadian Charter of Rights and Freedoms to the practice of non-therapeutic child circumcision. He concluded:

Circumcision of male infants is a clear violation of the rights guaranteed to all persons by the Canadian Charter of Rights and Freedoms. Furthermore, the practice contravenes human rights legislation on provincial and international levels.[8]

Reported incidence of non-therapeutic child circumcision

The reported incidence of child circumcision in Canada varies by province and has diminished over time. Newfoundland has always had a very low incidence of child circumcision while Alberta and Ontario have had a higher incidence of child circumcision.

Johnston (1995) reported that the incidence of child circumcision in Canada had fallen from 60 percent a generation ago to an estimated 25 percent.[9]

The Montreal Gazette (2006) reported that the incidence of circumcision has fallen by 36 percent to 14 percent according to the Association for Genital Integrity, while Statistics Canada (2006) reported a high of 29.5 percent in P.E.I. and a low of 1.1 percent in Nova Scotia.[10][11]

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".[6]

The CPS revisited circumcision in 1996 and recommended:

Circumcision should not be routinely performed.
– Canadian Paediatric Society (1996)[1][12]

The CPS again considered infant circumcision in 2015. The CPS stated:

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.
– Canadian Paediatric Society (2015)[13]

College of Physicians and Surgeons of British Columbia (CPSBC)

The 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:

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.
– College of Physicians and Surgeons of British Columbia[14]

Canadian Urological Association (CUA)

The Canadian Urological Association (CUA) considered the matter of circumcision and issued a statement in February 2018. The CUA concluded:

Given the socioeconomic, educational status, and health demographics of our population, universal neonatal circumcision cannot be justified based on the current evidence available.[15]

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 the 1980s. 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 St. Boniface Hospital.[16] [17]

Third-party payment for non-therapeutic circumcision is not presently available anywhere in Canada.[17] [18] Parents who wish to have a son circumcised must pay out-of-pocket for the costs of the circumcision.[19]

Reasons for circumcision

Brown & Brown (1987) and Rediger & Muller (2013), working in Saskatoon, found "newborn male circumcision rates continue to be heavily influenced by the circumcision status of the child's father."[20] [19]

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.

Canadian circumcision deaths

Various deaths caused by circumcision have been reported in Canada, one in British Columbia and two in Ontario. There may be others because death by circumcision may not be properly reported.

See also: Fatalities.

Non-therapeutic circumcision and Canadian law

Non-therapeutic circumcision of children in Canada is a practice that is of uncertain lawfulness.

The Charter of Rights and Freedoms (1982), Article 7 provides every Canadian with the right to security of the person.[1]

In addition, Canada is a state-party to the United Nations Covenant on Civil and Political Rights (1966) and the 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.

Margaret A. Somerville, then Director of the McGill Centre for Medicine, Ethics and Law, wrote to Pierre Blais in 1993, then Minister for Justice and Attorney-General, to propose that "male circumcision would not be totally banned. Rather circumcision of those persons unable to consent for themselves (which would, of course, include all infants) would not be allowed under the Criminal Code as it presently stands." However, no action was taken.[21]

Several decisions of the Supreme Court of Canada call consent for non-therapeutic circumcision of a child into question, but no case so far has ruled on the matter of circumcision.

Suzanne Bouclin (2005) has examined the issues and concluded:

Where a parent or substitute decision maker has deemed that it is in the child’s best interest to undergo a treatment, there may be some conflict between that privilege and the fundamental right to security of the person protected under Section 7 of the Charter. Because the State’s power to intervene is broad and can be permanent, parental decision making has been protected under the Charter. Nevertheless, the Court has determined that parents’ rights are not absolute and that the State will intervene when necessity is demonstrated.

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 (Somerville, 2000).

Given that a portion of the medical community has agreed that routine 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 Section 7 rights. As stated at the 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.

Public awareness is increasing, as evidenced by the numerous parents, health practitioners, children’s rights activists, ethicists, lawyers, and concerned citizens who have voiced their opinion. Insofar as male circumcision is the removal of healthy erogenous flesh without medical purpose and without the consent of the child and given that it is a painful procedure, neonatal circumcision is unnecessary and may well violate a child’s bodily integrity.[22]

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.[23]

It therefore appears that non-therapeutic circumcision of boys is unethical in Canada.

Lawsuit

The New York Post (2019) reported that a Canadian woman of African ancestry took her nine-day-old son to the 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 Regina General Hospital was unable to reattach the severed part.

The family has retained Kolade Oladokun who has filed a lawsuit.[24]

Canada and circumcision in the 21st century

Jackie Smith (2002) discussed the growing consensus against non-therapeutic child circumcision, which she called an "anachronism".[25]

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 ended in 2006.[17]

The incidence of circumcision varies widely by region

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."[26]

The most recent survey was done in 2006-7

The 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.)

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.[27]

In all provinces and territories, only a minority of boys are being circumcised. Sheldon (2008) reported an incidence of 13.9 percent.[17] The incidence of circumcision in Labrador and Newfoundland is reported to be close to zero.[28]

The incidence of circumcision in Canada is believed to be one-half or less than that of the United States.

The above referenced survey provides the most recent available statistics on the incidence of non-therapeutic child circumcision in Canada.

There are various 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 health insurance plans (HIPs) do not support non-therapeutic circumcision.[17]
  • 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.[29]
  • Most hospitals do not provide non-therapeutic circumcision, however 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' 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.[30]

DeMaria et al. (2013) surveyed physicians in southwest Ontario who still perform circumcisions. They concluded from their survey:

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.
– DeMaria et al. (2013)[31]

The CBC (2018) reported that Pakistani Dr. Ejaz Ahmad, who practiced medicine on Portage Avenue in Winnipeg, had been suspended from the practice of medicine for five months by the 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.[32] The CBC reported:

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.[32]

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:

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.[32]

The 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.[33] 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 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 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.'"[34]

As of 2022, third-party payment for non-therapeutic circumcision has not been available anywhere in Canada since 2006.[17] Moreover, non-therapeutic circumcision is not done in most hospitals,[18] 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.[35]

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,[20] [19] 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.[36]

Schröder et al. (2021) reviewed the experience of the Hospital for Sick Children in Toronto with regard to circumcision-related emergency admissions between 2000 and 2013. They found that 19 previously healthy neonates had emergency admissions for circumcision complications. The records of patients who had died were searched to identify those who had been circumcised.

Four of the boys had post-circumcision bleeding. Four of the boys had glans amputations. Two previously healthy boys died.[37] Based on the data provided, the estimated death rate is one dead boy for every 84,000 circumcisions.

Non-circumcision or genital integrity is the norm in all parts of Canada.

Video

Christopher Guest, M.D.[a 1], FRCPC[a 2], of Barrie, ON, discusses circumcision in Canada:

See also

External links

Abbreviations

  1. REFweb Doctor of Medicine, Wikipedia. Retrieved 14 June 2021.
  2. REFweb Royal College of Physicians and Surgeons of Canada, Wikipedia. Retrieved 13 January 2021.

References

  1. a b c REFdocument Antinuk, Kira: International NGO Council on Genital Autonomy Supplementary Country Report Submission on Canada to the U.N. Committee on the Rights of the Child PDF, Children's Health & Human Rights Partnership. (11 July 2018). Retrieved 23 June 2020.
  2. REFjournal Pirie GR. The story of circumcision. Can Med Assoc J. July 1927; 17(12): 1540-2. Retrieved 26 October 2019.
  3. REFjournal Gairdner DMT. The fate of the foreskin: a study of circumcision. British Medical Journal. 1949; 2(4642): 1433-7. PMID. PMC. DOI. Retrieved 28 October 2019.
  4. REFjournal Patel H. The problem of routine infant circumcision. Can Med Assoc J. 1966; 95: 576-81. Retrieved 25 October 2019.
  5. REFjournal Wirth JL. Current circumcision practices: Canada. Pediatrics. 1980; 66(5): 705-8. PMID. Retrieved 25 October 2019.
  6. a b REFjournal Swyer PW, Boston RW, et al. FN 75-01 Circumcision in the newborn period. Canadian Paediatric Society News Bulletin Supplement. 1975; 88(2): 1-2. Retrieved 18 March 2022.
  7. REFjournal LeBourdais, Eleanor. Circumcision no longer a "routine" surgical procedure.. Can Med Assoc J. 1995; 152(11): 1873-6. PMID. PMC. Retrieved 4 November 2019.
  8. REFjournal Bhimji A. Infant Male Circumcision: A violation of the Canadian Charter of Rights and Freedoms.. Health Law in Canada Journal (HLCJ). January 2000; 1: 1-33. Retrieved 7 November 2019.
  9. REFnews Johnston, David (11 September 1995)."Under the Knife", Toronto Star. Retrieved 26 October 2019.
  10. REFnews (23 March 2006)."Rates of circumcision slashed in past 30 years.", The Gazette. Retrieved 26 October 2019.
  11. REFnews MacDonald, Andrea (25 March 2006)."Circumcisions continue to drop: Province has second-lowest rate in the country", Halifax Daily News. Retrieved 26 October 2019.
  12. REFjournal Outerbridge E. Neonatal circumcision revisited. Can Med Assoc J. 15 March 1996; 154(6): 769-80. PMID. PMC. Retrieved 26 October 2019.
  13. REFjournal Sorokin ST, Finlay JC, Jeffries AL, et al. Newborn male circumcision. Paediatr Child Health. August 2015; 20(6): 311-20. PMID. PMC. DOI. Retrieved 26 October 2019.
  14. REFdocument Circumcision (Infant Male) PDF, College of Physicians and Surgeons of British Columbia. (September 2009). Retrieved 18 November 2019.
  15. REFjournal Dave S, et al. Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (abridged version). Can Urol Assoc J. February 2018; 12(2): 18-28. PMID. PMC. Epub 2017 Dec 1 DOI. Retrieved 26 October 2019.
  16. REFnews "Circumcision mix-up", Canada.com. Retrieved 26 October 2019.
  17. a b c d e f REFdocument Skeldon, Sean: The Medicalization and Resultant Decline of Circumcision in Canada PDF, University of Calgary. (March 2008). Retrieved 24 June 2022.
  18. a b James Loewen (2019). Personal communication.
  19. a b c d REFjournal Rediger C, Muller AJ. Parents' rationale for male circumcision. Can Fam Physician. February 2013; 59(2): e110-115. PMID. PMC. Retrieved 26 October 2019.
  20. a b REFjournal Brown MS, Brown CA. Circumcision Decision: Prominence of Social Concerns. Pediatrics. August 1987; 80(2): 215-219. PMID. Retrieved 10 November 2019.
  21. REFweb Somerville, Margaret (28 January 1993). Letter to Pierre Blais, Minister of Justice. Retrieved 4 November 2019.
  22. REFjournal Bouclin S. An examination of legal and ethical issues surrounding male circumcision: the Canadian context. Int J Mens Health. 2005; 4(3): 205-23. Retrieved 27 October 2019.
  23. REFdocument CMA Code of Ethics and Professionalism, Canadian Medical Association. (2018). Retrieved 8 July 2021.
  24. REFnews Steinbuch, Yaron (19 August 2019)."Canadian woman sues after tip of son’s penis cut off in circumcision", New York Post. Retrieved 16 June 2020.
  25. REFnews Smith, Jackie (30 August 2002)."The growing consensus against circumcision", National Post. Retrieved 27 October 2019.
  26. REFnews Driver, Deana (19 March 2002)."Sask. college wants circumcision rates reduced", Medical Post. Retrieved 22 July 2021.
  27. REFdocument What Mothers Say: The Canadian Maternity Experiences Survey PDF, Public Health Agency of Canada. (2009). Retrieved 27 October 2019.
  28. REFweb Goodwin, Caitlin (6 May 2019). Circumcision: Pros and Cons, MomLovesBest. Retrieved 10 July 2021.
    Quote: Labrador and Newfoundland have close to zero
  29. REFnews Williams, Nicole (24 June 2019)."Mom 'enraged' she can't find doctor to perform circumcision on P.E.I.", CBC News. Retrieved 27 October 2019.
  30. REFnews Williamson, Doug (19 March 2005)."Circumcisions spark debate", Windsor Star. Retrieved 22 July 2021.
    Quote: Dr. Tony Hammer, a Windsor family doctor, said his colleagues may be performing the medically unnecessary procedure simply to make a buck. There is a financial incentive for physicians, and I wonder if they are fully informing their patients of a lack of medical need.
  31. REFjournal De Maria J, Abdulla A, Pemberton J, Roees A, Braga LH. Are Physicians Performing Neonatal Circumcisions Well Trained?. Can Urol Assoc J. 2013; 7(7-8): 260-4. PMID. DOI. Retrieved 24 June 2021.
  32. a b c REFnews Glowaki, Laura (20 December 2018)."2 boys almost bled to death in botched circumcisions by Manitoba doctor", CBC News. Retrieved 5 July 2022.
  33. REFweb (February 2018). Patient Safety Learning Advisory Icons-mini-file pdf.svg, Manitoba Health, Seniors and Active Living. Retrieved 4 July 2022.
    Quote: The infant required transfer to a tertiary care site by the neonatal transport team due to multiple complications.
  34. REFnews Manny (3 July 2022)."Baby who bled for hours after circumcision was sent home from ER twice, suffered brain damage: lawsuit", Manitoba Services. Retrieved 5 July 2022.
    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.
  35. REFweb Circumcision Pricing & Insurance Coverage, Gentle Procedures Clinic. Retrieved 6 November 2019.
  36. REFjournal Mayan, Madhur, Hamilton, Robert J., Juurlink, David N., Austin, Peter C., Jarvi, Keith A.. Circumcision and Risk of HIV Among Males From Ontario, Canada. J Urol. 23 September 2021; PMID. DOI. Retrieved 2 October 2021.
    Quote: We found that circumcision was not independently associated with the risk of acquiring HIV among men from Ontario, Canada.
  37. REFjournal Schröder, Annette, Farhat, Walid A., Chiasson, David, Wilson, Gregory J., Koyle, Martin A.. Serious and Fatal Complications after Neonatal Circumcision. Eur Urol. 12 December 2021; 29: S2405-4569(21)00316-3. PMID. DOI. Retrieved 15 January 2022.