OTTAWA: Canadian Paediatric Society does not recommend "routine circumcision"

CTV News
September 8, 2015

Canadian Paediatric Society re-affirms position against routine circumcision

The Canadian Paediatric Society has released an updated statement re-affirming its position against routine circumcision for newborn males.

The society said recent evidence about the potential health benefits associated with circumcision prompted them to undergo a review of the current medical research. Its last position statement on the matter was published in 1996.

While medical literature has pointed to potential health benefits of circumcision, including the prevention of urinary tract infections and some sexually transmitted infections, the benefits generally don't outweigh the risks, the society said.

"While there may be a benefit for some boys in high risk populations and the procedure could be considered as a treatment or to reduce disease, in most cases, the benefits of circumcision do not outweigh the risks," Dr. Thierry Lacaze, chair of the CPS Fetus and Newborn Committee, said in a separate statement released Tuesday.

The updated statement also included the following recommendations:
Parents of newborn males must receive the most up-to-date, unbiased and personalized medical information about circumcision, so they can weigh the risks and benefits in the context of their own familial, religious and cultural beliefs;
Parents who opt for circumcision should be referred to a practitioner who is trained in the procedure, and whose skills are up to date;
Newborns who are circumcised should be followed-up in the early post-surgery time period;
At the time of discharge from the hospital, parents should understand how to properly care for their son's penis, and be aware of possible complications.
Circumcision has become a contentious issue in Canada, as it raises ethical and legal considerations, in part "because it has lifelong consequences and is performed on a child who cannot give consent," the statement said.

However, waiting until a child is old enough to give consent can increase risks, as doctors [which doctors?]  recommend the surgery be performed within the first week of life. [When he can afford to lose only 35ml of blood, and will not alert anyone that he is bleeding out.]

While circumcision used to be quite popular in Canada starting in the 1950s, rates have declined over the past decades to the current average of 32 per cent, CPS said.

To the original press release

Excerpts from the Canadian Pediatric Society POSITION STATEMENT Newborn male circumcision Posted: Sep 8 2015 Abstract The circumcision of newborn males in Canada has become a less frequent practice over the past few decades. This change has been significantly influenced by past recommendations from the Canadian Paediatric Society and the American Academy of Pediatrics, who both affirmed that the procedure was not medically indicated. Recent evidence suggesting the potential benefit of circumcision in preventing urinary tract infection and some sexually transmitted infections, including HIV, has prompted the Canadian Paediatric Society to review the current medical literature in this regard. 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. The foreskin ... In the male newborn, the mucosal surfaces of the inner foreskin and glans penis adhere to one another; the foreskin is not redundant skin. The foreskin gradually separates from the glans during childhood. By six years of age, 50% of boys can retract their foreskins, although the process of separation may not be complete until puberty: 95% of boys have retractile foreskin by 17 years of age. Parents may be reassured by their observation of an unimpaired urinary stream in a boy with a nonretracted foreskin. Until this developmental process is complete, the best descriptor to use is ‘nonretractile foreskin’ rather than the confusing and perhaps erroneous term ‘physiologic phimosis’. Appropriate care for the uncircumcised penis has been well reviewed and should include anticipatory guidance on hygiene and an understanding of the normal nonretractile foreskin. ... Ethics and legalities of circumcision Neonatal circumcision is a contentious issue in Canada. The procedure often raises ethical and legal considerations, in part because it has lifelong consequences and is performed on a child who cannot give consent. [This is new.] Infants need a substitute decision maker – usually their parents – to act in their best interests. [But only when a decision needs to be made. In most of the developed world, genital cutting is not even considered.] Yet the authority of substitute decision makers is not absolute. In most jurisdictions, authority is limited only to interventions deemed to be medically necessary. In cases in which medical necessity is not established or a proposed treatment is based on personal preference, interventions should be deferred until the individual concerned is able to make their own choices.

[This is a very wishywashy policy:

• It nowhere actually recommends against cutting healthy babies, and sets a very low bar for "medical necessity", barely higher than parental whim.
• The summary seems to have been written by cutting advocates, with the benefits played up and the risks and harms played down.
• One of the  three "selected resources" is by cutting fanatic Professor Brian Morris.
• The table of risks and benefits mentions "unsatisfactory cosmetic results" but offers no figure for their frequency.
• The cited articles seem largely cherrypicked from the  works of other cutting advocates.

A plus is the emphasis on the normality of infant non-retractility, and the suggested expression " ‘nonretractile foreskin’ rather than the confusing and perhaps erroneous term ‘physiologic phimosis’." But a warning against premature retraction is only hinted at, when it should be explicit and strong, since that is a major cause of the "infections" which commonly make genital cutting "necessary". ]

BERKELEY: AAP circumcision policy rebutted in Journal of Medical Ethics

the Journal of Medical Ethics
March, 2013

Lawyer and pediatrician dismantle the AAP policy

An article in the Journal of Medical Ethics comprehensively takes down the American Academy of Pediatrics' 2012 circumcision policy.

Written by Michigan State University Clinical Professor Robert Van Howe and Berkeley lawyer J Steven Svoboda, it focuses on the ethical issues rather than the medical issues that concern the European pediatricians whose rebuttal is released today.

“The AAP ignores so many important topics that it is hard to know where to begin," Svoboda says. "For example, the anatomy and function of the foreskin are not mentioned. The AAP’s circumcision recommendations contradict its own bioethics policy statement, which requires pediatric care to be based only on the needs of the patient. Non-therapeutic circumcision is incompatible with widely accepted ground rules for surgical intervention in minors.”

“When physicians decide whether to do a procedure, they must, and normally do, exclude from their medical decisions non-medical factors regarding the parents’ culture. Contrary to what the AAP suggests, doctors are not cultural brokers. Their duty is promoting and protecting the health of their patients, not following practices lacking a solid ethical and medical foundation.”

Van Howe and Svoboda accuse the AAP of cherry-picking articles that support circumcision, and of taking passages out of context from within articles that do not support it.

They conclude that male circumcision should be neither recommended to parents nor funded by government insurance systems.

A few months ago, the Royal Dutch Medical Association favorably cited an earlier version of Svoboda’s and Van Howe’s article, noting that even if benefits do exist, the procedure can safely be delayed until the boy himself can make the decision.

Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision by J Steven Svoboda, Attorneys for the Rights of the Child, Berkeley, California, USA Robert S Van Howe, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, Marquette, Michigan ABSTRACT The American Academy of Pediatrics recently released a policy statement and technical report on circumcision, in both of which the organisation suggests that the health benefits conferred by the surgical removal of the foreskin in infancy definitively outweigh the risks and complications associated with the procedure. While these new documents do not positively recommend neonatal circumcision, they do paradoxically conclude that its purported benefits ‘justify access to this procedure for families who choose it,’ claiming that whenever and for whatever reason it is performed, it should be covered by government health insurance. The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. These deficiencies include the exclusion of important topics and discussions, an incomplete and apparently partisan excursion through the medical literature, improper analysis of the available information, poorly documented and often inaccurate presentation of relevant findings, and conclusions that are not supported by the evidence given.

CANADA: Paediatricians foreshadow circumcision policy change

O Canada
March 3, 2013

Canada's pediatricians set to reveal new policy on circumcision

The Canadian Paediatric Society is preparing to revise its position on circumcision.

Canada’s pediatricians are about to update their advice on whether baby boys should be circumcised, revising their stand for the first time in 17 years.

Their review comes as new Canadian research suggests half of expectant parents would consider circumcision if they had a son — and that the single most important factor is the circumcision “status” of the father.

The Canadian Paediatric Society’s old policy, issued in 1996, opposed routine circumcision of newborns.

The new statement is expected to be more neutral.

“There isn’t going to be a ‘prescription’ for Canadian males in terms of circumcision,” society president Dr. Richard Stanwick, chief medical health officer for the Vancouver Island Health Authority, told Postmedia News.

The organization has been struggling to put forward a balanced position “that captures the risks, and the benefits, but is also respectful of personal preferences [whose?], religious issues and many other things that dictate this decision,” Stanwick said.

The issue is so loaded with emotion and controversy that the new statement has been three years in the making. “There are very strong opinions on both sides of this issue,” Stanwick said.

“We know that we’re wading into something that, no matter what we write, will not be strong enough for probably either side.”

Last year, the American Academy of Pediatrics announced that the health benefits of newborn male circumcision outweigh the risks, a move that provoked demonstrations by anti-circumcision activists who view the procedure as genital mutilation of newborns. [No, who view it as unethical.]

The old policy deemed circumcision medically unnecessary for the “well-being of the child.”

But after a special task force reviewed more than 1,000 studies published over the past 15 years, the American doctors’ group now says that circumcision provides protection against urinary tract infections, penile cancer and the transmission of some sexually transmitted infections, including HIV.

The organization isn’t recommending universal circumcision. Instead, it says the final decision should be left to parents.

Circumcision involves the surgical remove of some, or all, of the foreskin from the penis. It is one of the most common surgical procedures performed worldwide. In hospitals, the procedure is usually performed by obstetricians soon after birth.

“Clearly there has been a lot of literature around the potential role of the avoidance of infection,” Stanwick said.

“But this also has to be balanced off against the fact that this is still a surgical procedure, and it is not without risk.”

Those risks can include bleeding and hemorrhage, infection, inflammation and tightening at the end of the penis [and major complications, loss of the penis and death.]

Any shift in policy would have to ensure, “are there enough skilled professionals around to do this, so that we don’t have a complication rate that is unacceptable and so that we’re not seeing males being significantly harmed by not having the properly trained people to do it,” Stanwick said. [Not any shift, only a shift towards recommending it. Sounds like he's gearing up for a major increase, and needing to recruit!]

The new policy statement is expected to be released before the pediatric group’s annual meeting in June.

“It would be great if we had absolute answers, but on this one, I don’t think we will,” Stanwick said.

“At the end of the day . . . it will very much be influenced by dad’s status, as well as the cultural and religious issues.” [What other surgical procedures are influenced by the father's status, cultural or religious issues?]

A new study found that the circumcision rates are heavily influenced by whether or not the father is circumcised.

University of Saskatchewan researchers, in a study published in the journal Canadian Family Physician, surveyed 230 parents attending prenatal classes in Saskatoon.

Overall, half — 56 per cent — said they would consider pursuing circumcision if they had a son. In cases where the father of the expected baby was circumcised, 82 per cent were in favour of circumcision, versus 15 per cent when the father wasn’t circumcised.

According to the researchers, Canada’s current circumcision rate is 32 per cent. In the U.S., rates are increasing, to 61 per cent of men, they said. [No, it is slowly falling,and 61% is approximately the rate at which babies are being circumcised.]