Letter of Eugene W. Outerbridge, MD, to Thomas Anderson, PhD, July 27, 1997.



July 25, 1997

Thomas Anderson, Ph.D.
Box 1825
Summerland, B.C.
V0H 1Z0

Dear Dr. Anderson:

Your letter to Elizabeth Moreau of the Canadian Paediatric Society has been passed on to me for comment as I was the principal author of the CPS clinical practice guidelines on circumcision and am therefore familiar with the discussions and perspectives that went into their preparation.

If we had found references that were other than mere statements of opinion regarding the function of the prepuce and the consequences of its removal we would have included them. However we found only one in our extensive literature search. That was Dr. Taylor's paper describing the specialized nerve endings in the inner mucosal surface of the prepuce. It had not been published in a peer reviewed journal by the time the CPS clinical practice guidelines were published in March 1996. However we knew about this work, thought it was important to include and used an earlier reference from the proceedings of a conference at which Dr Taylor had presented his data, in order to develop the discussion in the paragraph "What is the prepuce?" If the Globe and Mail's medical reporter had read that paragraph I do not believe he would have written what he wrote. Actually the CPS practice guidelines are on the internet and that paragraph title stands out clearly when you read the list of contents. So he would not even have had to phone or write the CPS for a copy, or wait for it to come. However the description of the prepuce as a simple fold of skin is what is written in the medical and anatomy textbooks, when it is commented upon at all. In reality it will take some time before this newer information becomes incorporated in medical textbooks, as there is at least a two to three year period for the preparation and publication of any new edition of a medical text. The real problem here may be that no one had actually looked at the histologic structure of the tissue previously.

There is no one, or simple answer to your question. I am sure you know some of the answers (e.g. parental choice for religious reasons, or because other family members are circumcised) even though you may feel they are not acceptable. I personally do not believe legal processes are the answer in and of themselves. My understanding of the UN Convention on the Rights of the Child is what you state. But in Egypt in 1997, the female circumcision rate is 70% although Egypt (also a signatory I believe) has laws against the practice, (which incidentally were not upheld in a recent Egyptian court decision). Also on a point of accuracy, female circumcision is not generally performed by physicians in Egypt, but by others from my understanding.

Abolition of child poverty is also a component of the Convention on the Rights of the Child, yet more than 20% of the children in Canada now live below the poverty line and the percentage is increasing. We have a lot yet to do in Society to correct inappropriate practices, and inequities. While the circumcision rate in Canada is now about 25%, that is about half what it was in the early 1970s. I think it will likely continue to fall. Indeed several provinces no longer pay for routine neonatal circumcision, which will also encourage the downward trend. A goodly number of parents however feel sufficiently strongly that they want their sons circumcised, that they will, and do, pay for the procedure themselves.

In the long term I agree with you that education is the key to a reduction of the practice, education of health professionals, and of the public. However I have concern that it is very difficult to alter practices that are a part of religious or cultural beliefs. Until we better understand the origins of such practices, and how to alter people's belief structures I do not see a total end to the practice. I hope however, that we will see a continued reduction in its incidence without medical misinformation further contributing to the controversy.

Yours sincerely
E.W.Outerbridge MD FRCP(C)

cc: Elizabeth Moreau, Dr D McMillan

(File revised 30 September 2006)

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