February 20, 2002.

TO: Members of the College

FROM: Registrar

RE: Caution Against Routine Circumcision of Newborn Male Infants

The practice of medicine is increasingly becoming evidence based. There is a strong and growing consensus that medical intervention should be based upon sound evidence of expected benefit that outweighs the potential risk of any such intervention.

Where there is little evidence of expected benefit from a surgical procedure, but well recognized risk of surgical complications that may cause harm, it would generally be considered imprudent if not improper for a surgeon to perform such a surgical procedure.

Notwithstanding these fundamental principles, 27.6% of newborn males were circumcised in this province in 2000-2001, in spite of the fact that the Canadian Paediatric Society (CPS) has for two and a half decades explicitly cautioned against routine circumcision of newborn male infants.

Since August 1996, infant circumcision has not been a publicly insured service in Saskatchewan. The decision to de-insure the service was based partly on the lack of valid medical indications for the procedure.

Even though citizens must now personally pay for this service, the incidence of routine male circumcision has dropped only moderately over the past five years.

The relatively high rate of newborn male circumcision in Saskatchewan stands in very sharp contrast to that in some other regions of the country. For example, in Nova Scotia the rate has dropped to 1.5%, while in Newfoundland/Labrador it has dropped to 0.6%.

Such high infant circumcision rates in Saskatchewan in the face of an explicit caution from the CPS is of great concern to the College of Physicians and Surgeons, and ought to be a concern to all physicians who perform the procedure.

Is it possible that so many Saskatchewan physicians are totally unaware of the position of the CPS, and the research evidence that supports that position?

If physicians are unaware [sic] of the evidence against routine newborn circumcision, why do they continue to practice in a manner that ignores this evidence?

In my dialogue with Saskatchewan physicians about this issue, I’ve encountered many who claim to be “neutral” in their opinion about routine circumcision, but perform the procedure strictly on the basis of parental preference.

On the surface, that approach might seem commendable as it seems sensitive and responsive to parental values. However, it begs the question as to whether the parents are appropriately informed about the benefits and risk of this procedure. Even more importantly, it begs the question as to whether physicians are providing accurate and adequate information to parents that is likely to yield a truly informed decision on their part.

Informed consent to any surgical procedure relies on an assumption that the decision maker possesses full and accurate information about both the benefits and risks of the procedure. The onus is cast upon the surgeon, who might perform the procedure, to ensure that such information is not only conveyed to the decision maker, but is understood by the decision maker.

It is difficult to identify any other domain of medicine in which physicians would feel comfortable playing such a passive role in a decision pathway culminating in surgery. It is also difficult to identify any other domain of medicine in which practice patterns stand in such stark contrast to research evidence.

When the Council of the College of Physicians and Surgeons reviewed this issue at its last meeting, it directed the Registrar to initiate an effective educational strategy to raise professional and public awareness of this issue. The first step in that strategy is this memo, which is directed to all members of the College who perform circumcisions, or are likely in a position to influence parental decision making on this issue.

These are my recommendations to you:

(1) First, be sure that you are fully and accurately informed about the research literature on this subject, which serves as the basis for the CPS position against routine circumcision of newborn male infants.

You can obtain a copy of the CPS Position Paper, and a succinct summary of the relevant research evidence by logging on to the CPS website at www.cps.ca.

If you are not able to access this information from the CPS website, please give Ms. Jo-Anne Wolan a call at the College. We will be pleased to send you a written copy of the CPS position paper.

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

(3) 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 can, and should, respectfully decline to perform the procedure just as you respectfully decline to carry out other requested medical acts that you regard to be inappropriate.

(4) 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 of a consent document which clearly stipulates that the circumcision in question is not medically indicated and is being performed in accordance with parental religious practices.

In such cases, physician would be prudent to consult with and seek advice from the Canadian Medical Protective Association before proceeding.