NEWSLETTER, College of Physicians and Surgeons of Manitoba, Volume 38, Number 4, December 2002.

[CIRP note: This excerpt from the Saskatchewan College of Physicians and Surgeon's position papers was posted on the CPSBC because of the intense interest in their contents.]

Caution Regarding Routine Circumcision of Newborn Male Infants

Over the past six months, the Saskatchewan College has provided all its members with two documents discussing the issue of routine male circumcision. With permission of that College, the following excerpts are presented for your consideration:

A. Recommendations by the Saskatchewan College:

(i) Be sure that you as a physician are fully and accurately informed about the research literature on this subject, which serves as the basis for the Canadian Paediatric Society position against routine circumcision of newborn male infants. A copy of this position paper and a summary of the relevant research may be obtained from the CPSS website.

(ii) In any dialogue with patients about potential circumcision of newborn male infants, be sure that you accurately and effectively convey the message that this is not a recommended procedure.

(iii) If parents remain adamant in their preference that circumcision be performed, notwithstanding their awareness of the research on the subject, remember that you are under no obligation to perform any surgical procedure for which there are not valid medical indications. You may, and should consider, respectfully declining to perform the procedure just as you respectfully decline to carry out other requested medical acts that you regard to be inappropriate.

(iv) If the parental request for infant male circumcision is based exclusively upon religious beliefs and values, and you are inclined to act in deference to those religious beliefs and values, you would be prudent to require parental signature on the consent document which clearly stipulates that the circumcision in question is not medically indicated and is being performed with parental religious practices.

B. It is the expectation of the College that all physicians exercise sound professional judgement in all the professional decisions they make. In the exercise of professional judgement, physicians ought to consider many factors, including the preference of patients (guardians), the best available evidence with respect to potential benefits and risks of a contemplated intervention, and alternatives to that intervention. Maintenance of professionalism demands that physicians decline to become little more than robots who perform an array of medical interventions on demand. No physician should be coerced to perform a medical procedure that is contrary to his/her professional judgement.

When physicians receive requests for infant male circumcision, it is important that physicians take ample time to gain an understanding of the basis for the request, to provide accurate detailed information to parents about the potential benefits, risks and alternatives, and to gauge their understanding of that information.

If parents persistently request circumcision of a newborn male infant after a thorough dialogue about benefits, risks and alternatives, a physician is not obligated to perform the procedure if he/she does not regard the procedure to be medically indicated and appropriate. Physicians may respectfully decline to perform this medical procedure, just as they respectfully decline to prescribe medications that are not medically indicated, and as they decline to offer medical opinions contrary to their best professional judgement.

Where infant male circumcision is requested for religious rather than medical reasons, there is a high probability that the procedure will be performed by someone other than a physician if the option is not made available through a physician. Where a physician is confronted with a request for infant male circumcision based upon religious rather than medical reasons, and where physicians may be inclined to comply with such a request as the "lesser of two evils," even though contrary to his/her medical judgement, the College recommends that physicians obtain advice from the CMPA about appropriate documentation of the consent process, so that it explicitly defines the conditions under which the procedure is performed. 334 Obtaining informed consent for any procedure requires disclosure of all relative benefit and risks of the anticipated procedure, as well as alternatives to that procedure. A prudent physician will make a reasonable effort to achieve understanding of the information that is shared with parents/guardians.

To formulate and certify a professional opinion that a patient has understood the nature, effect, risks and alternatives of a contemplated medical intervention requires more than one way disclosure of risks to the patient. It requires two way dialogue through which the physician has reasonable potential to gauge the understanding held by the patient or guardian.

The Canadian Paediatric Society has concluded that the overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommended circumcision as a routine procedure for newborns. Infant male circumcision is often treated as a minor procedure with virtually no risk or significant complications. That is not true. Infant male circumcision may lead to complications that range from minor to severe. A study reported in the British Journal of Surgery (1993) suggested that complication rates range between 2%-10%.

In many countries, including Canada, citizen groups are gaining a higher profile and more credibility among the general public. They are bringing to light new evidence that the male prepuce may play an important physiological and psychological role in adult male function, which has to date been largely ignored in any consideration of harm associated with infant male circumcision. As a consequence of the public awareness raised by these groups, a growing number of adult males and/or their parents are now expressing strong resentment against physicians who performed infant male circumcision many years ago at their request. The retroactive anger towards these patients is generally based upon arguments that parents were given woefully inadequate information about the potential adverse impact on adult male function, and inadequate information about normal infant penile development and hygiene. While the College's primary mandate is public protection, we encourage physicians to give careful thought to the long term risks that may occur by taking an inappropriately casual approach to infant male circumcision driven exclusively by parental preference without valid medical indications for the procedure.

(File revised 14 October 2006)