THE CIRCUMCISION REFERENCE LIBRARY
The article "Circumcision no longer a `routine' surgical procedure" (Can Med Assoc J 1995, 152: 1873-1876), by Eleanor LeBourdais prompts me to write. I cannot help but see attacks on traditional Jewish circumcision as little more than thinly disguised anti-Semitism. I am hard-pressed to find any Jewish men who feel chat the "mutilation" they supposedly suffered as 8 day-old baby has affected their later sexual fulfilment or emotional and psychic well-being.
Interest groups such as RECover A Penis (RECAP) and End the Horror of Infant Circumcision (ETHIC) should poll a sample of Jewish men to establish the extent of the damage suffered as a result of their involuntary circumcision as infants. I have spent 39 years in the company of Jewish men, and I have never heard a single complaint or regret about the loss of a foreskin from a fellow Jew. I am rather proud of my foreskinless penis -- I see it as a badge of honour, setting me apart from those whose traditions do not demand its removal.
The presence or absence of medical indications for circumcision is irrelevant to my decision that my sons would also be circumcised, the Mosaic law, prescribed 57 centuries age, is sufficient justification. Regardless of the hysteria whipped up by interest groups that try to convince me of the psychic harm caused by neonatal circumcision, I have no intention of violating a tradition that uniquely symbolizes the enduring covenant between Jew and God. If you were to ask me whether I would violate the law to maintain this tradition my answer would be an unequivocal Yes.
I applaud the colleges of physicians clans and surgeons of British Columbia and Ontario, which have resisted the demands of anti-circumcision groups that circumcision be prohibited. Members of these colleges who perform ritual neonatal male circumcision would be justified in seeing a proscription on circumcision as en infringement of their religious freedom.
Members of anti-circumcision groups who claim that they are harmed by their lack of a foreskin are welcome to restore the missing bit by any means deemed appropriate. I welcome correspondence to CMAJ from all those intent on preserving the Mosaic tradition in the face of the latest onslaught.
Robin Chorn, BSc, MBChB, FRCPC
Eleanor LeBourdais' article is a regrettable attempt to attack the performance of neonatal circumcision, but it is CMAJ that should be taken to task for printing it. It is unconscionable that this article can now influence physicians' viewpoints and advice to patients.
LeBourdais states that "Few people classify themselves as 'pro-circumcision,'" yet she also states that those opposed to circumcision meet resistance when they try to abolish the procedure. From her own data, she found that at 40% of male infants in British Columbia were circumcised last year. Thus, unquestionably 40% of new parents are strongly pro-circumcision, as their actions readily show.
These courageous parents maintain their stance despite the prejudice against the procedure in the BC health care system. Many patients have remarked on the great lengths to which they had to go, against the advice of nurses and to obtain circumcision for their infant sons. Others who wished to obtain the procedure have simply given up. Is the present bias against routine circumcision justified?
The information LeBourdais presents on cancer of the penis only emphasizes her wish to abolish the procedure without regard for the facts. Squamous cell carcinoma of the penis occurs only among uncircumcised men, and neonatal circumcision is effective prophylaxis. Had LeBourdais pointed out that this type of cancer is rare, or that regular hygiene by uncircumcised men (as taught and practiced in Scandinavia) will probably also prevent it, she would have provided more reasonable support for her position.
If LeBourdais were to write objectively, she would also have mentioned that acquiring sexually transmitted diseases, including HIV infection, is significantly more likely among those with foreskins than among those without. This has been documented in many epidemiologic studies. Any balanced discussion of the procedure must include the information that circumcision provides some protection against potentially fatal contagious diseases.
As a practicing dermatologist with expertise in cutaneous disorders of the penis, I regularly see men who arc suffering from recurrent balanoposthitis, a condition prevented by neonatal circumcision. Other cutaneous disorders such as lichen sclerosus (balanitis xerotica obliterans), which can cause cancer, or plasma cell balanitis of Zoon, which is benign but troublesome, are found only among those who are uncircumcised. All too often circumcision is required to cure these diseases: however, the chance of morbidity from the procedure cure is much higher among adults than among infants. Many patients have expressed regret that they were not circumcised. early in life. If the costs of care throughout their lives for uncircumcised men were correctly calculated, we might well find that neonatal male circumcision is indeed cost-effective.
LeBourdais' most objectionable tactic is to suggest that those responsible and caring physicians who continue to perform neonatal circumcision my face criminal charges. This is a not-very-subtle attempt to frighten physicians and prevent access to circumcision.
The journal of our national medical association should acknowledge that there was no justification for publishing this abysmal article in the guise of accurate and objective analysis.
Brian W. Gregory, BSc, MD, FRCPC
The author responds:
Dr. Gregory is to his opinion on the value and benefits of circumcision. He should realize, however, that a significant number of Canadians do not share his views, and his objections would be more appropriately directed at such organizations as Health Canada, which has stated that "there appear to be no medical reasons for circumcision of an infant," or the Canadian Paediatric Society, which has said that 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."
I did not dwell on the benefits or drawbacks of circumcision, since these have been debated extensively elsewhere. Rather, my intent was to review historical and cultural reasons for the performance of circumcision and the possible effect of new legislation and changing Western perceptions of children's rights.
In Canada, we are seeing increasing instances of young adults seeking legal restitution fur procedures or actions performed without consent when they were children. An example is the recent court award to an Alberta woman who was sterilized at age 14 with goverment sanction.
Adolescents are now empowered to consent to or refuse such procedures as abortion and blood transfusion. Gregory may not like the idea but, as I stated in my article, the Canadian Charter of Rights and Freedoms, the United Nations Convention on the Rights of the Child and British Columbia Infants Act all contain provisions thee could be used in a court action or a human-rights challenge. As an adult, it is for each man to decide whether circumcision is beneficial or harmful for him. It is, therefore, possible that a man circumcised infancy could later conclude there were no acceptable reasons for subjecting him to such a painful experience and that his rights were violated.
I am puzzled about why Gregory is so enraged. The degree of his disturbance suggests that continued discussion of this topic in the medical media is both warranted and necessary. I regret that he mounted a character assassination of me as well. He would do better to remember that we live in a democracy.
Port Moody, BC
COVERAGE OF CIRCUMCISION
CMAJ 1995; 153 (10): 1420
Thanks to Eleanor LeBourdais for her accurate article, Circumcision No Longer a Routine Surgical Procedure (CMAJ 52: 1873–1876, June 1, 1995). Indeed, Canadian Provincial Health agencies have come to recognise that circumcision should no longer be paid for. In 1975, forty-four percent (44%) of males born in Canada were circumcised and paid for by Provincial Health agencies. By 1995, only four percent (4%) of male births had circumcisions paid for by Provincial or Territorial health agencies. (The number of recent circumcisions paid for privately is not known.) In a country where virtually all health care is paid for by Provincial or Territorial health agencies, these agencies have come, one by one, to the same significant conclusion, that the routine removal of normal penile tissue is contraindicated.
There remain but three countries in the world (United States of America, Australia, and New Zealand) where the removal of normal penile tissue for nonreligious reasons is inflicted on significant numbers of unconsenting minors. This activity still has the tacit acquiescence of physicians in these countries.
George C. Denniston MD, MPH
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