SURGICAL PROCEDURE

a position statement on the routine circumcision of male infants was rejected without debate during the annual meeting of the Registered Nurses' Association of British Columbia. The rejection followed strong objections from a group of Victoria nurses. Citing cultural, religious and freedom-of-choice issues as reasons, they suggested that neonatal circumcision is too controversial an issue and any such discussion would not be in the public interest. For a minor surgical procedure that has long been considered routine, circumcision has caused a surprising amount of debate in recent years. Although few people classify themselves as "pro-circumcision," conflicting viewpoints are still strong La circoncision 'a des fins non medicales


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Nonmedical circumcision can no longer be considered routine in a new era of children's rights and more careful scrutiny of the medical necessity of surgical procedures. Although the minor procedure has been practised for centuries, custom and cultural factors may have had greater influence on the incidence of circumcision than the prevalence of problems such as penile cancer and urinary-tract infection that it was thought to prevent. I n April 1994, a motion to develop a position statement on the routine circumcision of male infants was rejected without debate during the annual meeting of the Registered Nurses' Association of British Columbia. The rejection followed strong objections from a group of Victoria nurses. Citing cultural, religious and freedom-of-choice issues as reasons, they suggested that neonatal circumcision is too controversial an issue and any such discussion would not be in the public interest.
For a minor surgical procedure that has long been considered routine, circumcision has caused a surprising amount of debate in recent years. Although few people classify themselves as "pro-circumcision," conflicting viewpoints are still strong La circoncision 'a des fins non medicales ne peut plus etre consideree comme une intervention de routine a une nouvelle epoque de droits des enfants out lon examine de plus pres la n6cessit6 m6dicale d'interventions chirurgicales. Meme si cette intervention mineure est pratique depuis des sikcles, la couLtume et les facteurs culturels peuvent avoir eu plus d'effet sur lincidence de la circoncision que la prevalence des complications comme le cancer du penis et linfection des voies urinaires qu'elle devait pr6venir, croyait-on. enough across Canada to generate debate when opinion articles appear in medical or nursing journals.
Although circumcision has been practised for centuries, examination of the reasons for doing it has been a much more recent phenomenon. Classification of neonatal circumcision as a "routine" procedure had removed any need to question why it was being done. If prophylaxis against urinary-tract infection, recurrent balanitis and penile or cervical cancer did not serve as a reason, then religion, tradition or custom -"because Father is" often would.
"Routine" also effectively obscured awareness of circumcisions gone wrong when hemorrhage, infection, penile amputation and other problems occurred. As well, the belief that babies were not developed enough to sense pain shielded parents and many physicians from the reality that infants denied anesthesia did, indeed, feel every cut that was made.
Custom and cultural factors, and not the prevalence of problems that circumcision was thought to prevent, appear to have had the greatest influence on the incidence of circumcision. In the US, where some 80% of males are circumcised, the incidence of penile cancer is similar to that in Scandinavia, where circumcision is uncommon. In Israel, where circumcision is prevalent, the incidence of cervical cancer is similar to that in Scandinavia.
The use of surgery to prevent possible urinary-tract infection, which can be readily treated without surgery, may have encouraged organizations such as the Canadian Paediatric Society (CPS) to begin viewing "routine" circumcision as unnecessary as early as 1975. Routine circumcision was similarly delisted as an insured service by provincial health ministries in the mid-1980s.
In the 1990s, the likelihood of a baby being circumcised is influenced by an expanding array of usually nonmedical factors: circumcision status of the father, attitude of the mother, age of the attending physician, sex and circumcision status of the physician, geographic location and religion factors that have little to do with the baby himself.
In both Canada and the US, cir- The performance of unnecessary surgery on minors who have no say in the matter does not sit well with many people who consider circumcision a denial of basic human rightsspecifically an infant's right to the respect and autonomy fundamental to Canadian law. The law recognizes a person as an autonomous decision maker whose rights are guaranteed within provisions of the Canadian Charter of Rights and Freedoms. Section 7 provides for the right to life, liberty and security of the person. Section 2(a) guarantees the right to freedom of thought, conscience and religion, while section 15(1) further guarantees equality in protection and legal benefit irrespective of age.
Removal of a normally functioning healthy body part without medical indication has also been viewed as a violation of the Hippocratic oath, falling under the United Nations' definition of genital mutilation. As such, circumcision is seen as being against the Universal Declaration of Human Rights and the UN Convention on the Rights of the Child.
Some opponents suggest that body-altering measures conducted for religious reasons should be postponed until the child is old enough to make his own decision. They say such an approach is not denial of religious or cultural freedom so much as preservation of the child's right to choose and have his own beliefs.
In BC, the Infants Act stipulates that a child should be accorded the same protection under law as adults: if an adult male cannot be forced to undergo circumcision in adulthood, it follows that he shouldn't be forced to have it in infancy simply because he is too small to resist.
Although ostensibly done for the child's benefit, nontherapeutic circumcision is treatment that may not really be in the best interests of the child. The CPS has suggested that the primary concern of physicians caring for children must be just that. It defines "best interests" as the balance of potential benefit over potential harm or distress resulting from the pursuit of a given type of treatment.
Evidence that some recipients of nonmedical circumcision consider themselves to have been harmed may be found in the formation of groups such as RECAP (RECover A Penis), which was established in the US in 1990; members have attempted various means of recovering their lost foreskins. In 1988, a Vancouver urologist was obliged to pay $40 000 in damages to a patient who required plastic surgery as an adult because of a circumcision performed when the patient was 12.
Since We're not about to make a policy statement on a medical decision; we don't have a policy statement on gallbladders either." Vanandel acknowledges that the position is not absolute and in the future the college might produce some sort of guideline stating that routine circumcision of infants is unnecessary and is required only for certain medical conditions. "We have guidelines for who should have mammograms, prostate testing, for many things. If there's a demand for it, we might have a guideline [stating] which infants should or should not be circumcised, but we're not likely to be making a statement of protocol on it." Organizations specifically concerned with child health and child welfare have similarly made no statements or only limited ones on circumcision. The Canadian Institute of Child Health, which is secretariat for the Postpartum Parent Support Program of Health Canada, has no "official position that can be reported," says national project coordinator Susan Hodges. However, a program leaflet produced by Health Canada notes that "there appear to be no medical reasons for circumcision of an infant." It says the main advantage of forgoing circumcision involves the avoidance of surgery-related risks such as bleeding, infection, surgical trauma and pain.
In its yet-to-be-published statement, Neonatal Circumcision Revisited, the CPS essentially reiterates the conclusions its Fetus and Newborn Committee reached in 1975. "A careful review of the potential benefits (including the reported decrease in urinary tract infection) and the complications of circumcision does not support this as a routine procedure.
The available evidence does not indicate that routine neonatal circumcision would be cost effective." Some opposition to nonmedical circumcision has involved concerns about subjecting infants to needless pain and suffering. Many physicians continue to perform circumcision without anesthesia, and some are reluctant to employ any analgesic measures whatever. "I strongly disagree with the use of any form of analgesia with this procedure," says Dr. Robert Brown, a family physician in Abbotsford, BC. "Certainly pain is experienced but this pain does not appear to last any longer than 15 seconds af-Vancouver has been using local anesthesia since late 1991 for the roughly 10 circumcisions he performs monthly at the BC Women's Hospital (formerly Grace Hospital). Although anesthesia can substantially decrease or possibly eliminate surgical pain for an infant, he doesn't think circumcision should be done routinely.
"I think nature put the foreskin "Female circumcision is an extremely disfiguring and potentially hazardous procedure. Male circumcision doesn't carry all the baggage that female circumcision does, so I don't think it is logical to compare them and transform this into a gender-equality issue." Dr. Morris Vanandel, BC College of Physicians and Surgeons ter the procedure, as it is always easy to comfort the infant and have him stop crying." While some,pediatricians and family physicians have begun to use dorsal penile nerve block, currently the only form of local anesthesia considered safe for newborns, the procedure requires expertise and still obliges the infant to endure painful needles.
In its new statement, the CPS suggests that further study of adequate levels of analgesia is required. "The most effective and least risky type of analgesia remains to be clarified. No currently available method of pain control during and following circumcision is fully satisfactory." Concern about causing infants unnecessary pain has encouraged some physicians to refuse any involvement with circumcision. "I had somebody the other day," says one Vancouver family physician, "who insisted on circumcision and I said in that case you'll have to call up a pediatric surgeon and arrange it yourself. I would give them the name of a pediatrician but I would refuse to refer them." As a pediatrician heavily involved in neonatology, Dr. Paul Thiessen of there for a reason and when parents ask my opinion I say there may be an increased incidence of urinary-tract infection in the first year of life that may [result from] not being circumcised, but I think that on balance I would leave it alone." With its removal from medicare coverage, nonmedical circumcision became a billable item for which parents in BC pay physicians $50 to $100 and hospitals up to $100. Removal from insurance coverage also made circumcision a procedure that could be done away from hospitals, a factor that could make circumcision rates reported by hospitals an inaccurate indication of the true incidence.
Opponents suggest that circumcisions have become a means of easy money for some physicians who perform them in their offices. "You could do that, sure," acknowledges Thiessen, "but you'd have to purchase the equipment and get it sterilized and so on, and I don't know, frankly, why anyone would want to do that. I don't personally know of anyone doing it." While governments, medical associations and other groups have been reluctant to take a stand against non-medical circumcision, their response to the "circumcision" of young girls commonly called female genital mutilation (FGM) in the Westhas been quite different. (According to a fact sheet, female circumcision, or FGM, takes many forms. Most common are removal of the clitoral prepuce, excision of the clitoris, or removal of the clitoris and labia minora and occasionally much of the labia majora, suturing the two sides together to occlude the vagina. The procedures are usually performed prior to adolescence.) Countries such as Sweden, Great Britain and France have had no qualms about enacting legislation banning FGM. And when violations occur, there is no reluctance to enforce the law. In France, a woman from Gambia recently received a 5-year prison sentence for "circumcising" her two daughters.
In Canada, the federal Department of Justice warns that anyone performing any type of surgery on female genitalia for cultural, religious or cosmetic reasons may be prosecuted under assault provisions of the Criminal Code. No such warnings have been issued about the much more widespread practise of cultural, religious or cosmetic surgery involving male genitals, despite the existence of human-rights legislation that prohibits discrimination based on sex.
In March 1992 the colleges of physicians and surgeons in Ontario and BC banned the performance of FGM by their members, ruling it an act of professional misconduct. The Ontario college further ruled that any physician aware of such a procedure performed by another physician must advise the college about it.
Vanandel, spokesman for the BC college, says the absence of any medical reason for ever performing FGM renders any comparison of male and female circumcision spurious. "My suggestion is that it's apples and oranges. It happens to involve the same area but the problems with it and reasons for doing it are widely different. Female circumcision is an extremely disfiguring and potentially hazardous procedure. Male circumcision doesn't carry all the baggage that female circumcision does, so I don't think it is logical to compare them and transform this into a gender-equality issue." Although the practice of female circumcision is relatively new in the West, where it's considered abhorrent, there is a very different perception in some 40 countries where it is the norm, and often has been for centuries. Although it was outlawed in 1947, women and young girls in Somalia continue to view circumcision as a painful but still desirable tenet of their society and culture.
Earlier efforts to ban female circumcision in Sudan in 1946 were met with a rush to perform FGM before the law took effect. Widely seen as alien to the country's social system and way of life, the legislation was never accepted and was ultimately perceived as a failure.
In studies of women in Somalia, where virtually all females undergo FGM, approval of female circumcision appears universal irrespective of educational or economic status.
Reasons for wanting circumcision commonly relate to the erroneous but still widespread belief that Islamic religion requires it, and the equally widespread belief that no man will marry an "uncircumcised" girl. The connection between female circumcision and adult status is so entrenched that Somali women have great difficulty conceiving that it is not a necessary part of womanhood. In view of previous legislative failures, the education of medical students, nurses, midwives and the general public is seen as the only way to eventually change social attitudes, and subsequently reduce the incidence of FGM.
With an estimated 85 to 114 million women having been circumcised around the world, and with some 5500 girls undergoing the procedure each day, its acceptability clearly relates to the society and perspective from which it is being viewed. In the West, the circumcision of male infants for reasons related to custom and tradition has had the same widespread acceptance and long-term history.
Children will likely continue to be governed by the viewpoints of their parents, but a new era of human rights and children's rights has brought a new variable into the equation. The physician who performs circumcisions may some day find himself subject to legislative action, or even charged with sexual assault. A May 1994 decision of the Supreme Court of Canada placed the best interests of the child above parental rights.
In the 1990s, circumcision clearly can no longer be regarded as a routine procedure. e 1876 CAN MED ASSOC J* ler JUIN 1995;152 (11) CMA advertises more than 3500 career opportunities every year. What makes that so special?
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