Toronto Star, March 12, 1999

Is circumcision really necessary?

Medical experts continue to debate the 5,000-year-old surgical practice

By Nicholas Keung
Toronto Star Life Writer

His mother says he has no choice.

His doctor says anesthetic is not required because there is no pain.

And in just another two minutes of his one-month life, Francis Kwafo Jr. will have no foreskin covering his penis.

Waking up from a sound sleep in the mid-afternoon, the Mississauga boy finds himself draped on an examination table in Dr. Aaron Jesin's clinic in North York.

He starts wailing as his mother Sarah Kwafo undresses him for an operation she describes as necessary ``to help him not be stigmatized by his peers when he grows up.''

``If we don't have him circumcised, he would be teased by other boys in the locker room because his penis looks different,'' says Kwafo, 33.

``His father is circumcised. His 8-year-old brother is circumcised. This is all for cultural and social reasons.''

While a nurse is holding Francis' legs on the table, Jesin takes out a green pouch of surgical tools, including a clamp, a blade and a pair of scissors.

The doctor carefully clamps the fold of skin, shaves it off and quickly puts a yellow powder called bismuth subgallate on Francis' penis to control the bleeding.

Peeking out from behind the nurse, the mother quickly steps in and sticks a bottle of milk into the boy's mouth. He stops howling immediately.

Although reports from Toronto's Hospital for Sick Children and the University of Alberta indicate circumcisions performed without pain medication could leave boys more susceptible to pain throughout their lives, Jesin believes babies won't "have any recollection of it at all.''

Like other proponents of the procedure, Jesin, who has circumcised more than 10,000 boys since 1977, says the practice - which can be traced back to Abraham - decreases the risk of urinary tract infections, cancer of the penis and sexually transmitted diseases, including HIV, the virus that causes AIDS.

Since its general acceptance in the Victorian era as a way to curb masturbation, a behaviour then thought to be immoral, non-ritual circumcision has been a subject of controversy.

Although it is estimated about a quarter of Canada's male infants are still being circumcised each year, health authorities maintain the procedure isn't medically necessary.

``With the benefit of additional medical research, we agree there are potential medical benefits but they are not compelling,'' says the recent American Academy of Pediatrics position statement on circumcision.

For the first time, it also recommends babies undergoing the procedure be given pain relievers because they suffer when their foreskins are removed.

The findings are consistent with the position statement issued by the Canadian Pediatric Society in its 1996 report on circumcision.

But at a review meeting last Saturday, the society's 13-member Fetus and Newborn Committee restated that it is up to the parents to decide whether to have their infants circumcised.

``We'll focus more on educational programs to help parents make an informed decision, but we won't take away their capacity to make a decision,'' says committee chair Dr. Doug McMillan, a professor of pediatrics at the University of Calgary.

Critics of circumcision are calling for the medical profession to make a clear statement condemning the still-common practice.

At issue is whether it's ethical for doctors and parents to circumcise a newborn baby when the procedure is not medically required to save a child from any imminent health risks.

The pediatric society is confronted with ``a mess,'' says John Antonopoulos, president of Montreal-based Circumcision Information Resource Centre.

``They're now faced with a practice that does not jive with modern medical ethics, something that was introduced in medical practices long before the advent of modern medical ethics.''

He argues male circumcision is no different from the barbarity of female circumcision, which has been banned in Canada and many other western nations.

``If the practice is not a positively proven good thing, we should not be doing it. There's simply no middle ground,'' says Antonopoulos, who is an educator and an editor of medical publications.

The infant circumcision rate in Canada has dropped almost by half, compared to 48 per cent in the 1970s and, because of financial cutbacks, most provinces no longer cover it in their health plans.

Manitoba is the only government that still covers non-therapeutic circumcision, provided it is done within 30 days of a child's birth. In other provinces, physicians charge anywhere from $100 to $200 for the operation.

Dr. Robin Walker, co-author of the Canadian Pediatric Society's 1996 review, says circumcision is an emotional subject.

``If you're not totally opposed (to) or for circumcision, then you're in trouble with both ends of the spectrum,'' notes Walker, chief of neonatalogy at the Children's Hospital of Eastern Ontario in Ottawa.

``We know that most influence is from parents, the circumcision status of the father and it has got nothing to do with medical needs.''

Circumcision is a cultural practice essentially confined to North America and that's why the percentages of circumcised boys and men in Canada vary widely from roughly 50 per cent in Ontario to less than 20 per cent in the Maritimes, he explains.

Worldwide, only about 23 per cent of men are circumcised, according to the Circumcision Information Resource Centre.

``It really does depend on where you grow up, your social life and what you see the cultural norm and expectation are,'' Walker adds.

He says circumcision is nothing more than a cosmetic procedure but ``legally'' physicians who believe it's an appropriate procedure do have the right to do it with the consent of the parents.

``If a procedure is not inappropriate, it is really wrong to say that a physician is unethical because his or her opinion doesn't correspond to what the (pediatric society's) statement says,'' Walker notes.

``I think a physician is entitled to make his or her own judgment of what the scientific standing of the situation is.''

Dr. Murray Katz, of Montreal's Tiny Tots Medical Centre, agrees.

``Circumcision is like parents having their kids' ears pierced or other cosmetic surgeries done. Are we saying that parents have no right to do that? I don't think so,'' he notes, adding that the procedure's potential benefits are often overlooked.

Dr. David Alwin, an internist at Anna-Laberge Hospital in Chateauguay, Que., and a member of Doctors Opposing Circumcision, bluntly says it's ``simply unethical to remove a normal body part for a cultural reason. It's like filing down the teeth of some native people or binding the feet in China.''

The doctors' group has chapters in all Canadian provinces and territories, in every U.S. state and in nations on six continents. Its aim is to stop the practice on infants and children.

``Circumcision is difficult to understand and you wonder why normally rational physicians suspend the usual ethical and scientific standards to justify this procedure,'' Alwin says.

He concedes that today circumcision remains a taboo subject among medical professionals.

``Most people try to avoid getting into the debate of circumcision because it would just open a can of worms,'' he notes.

Under tremendous social pressure, some U.S. health insurance companies are compelled to cover the practice for fear of losing out in the competition, Alwin says.

Until the past decade, little was known about the functions of foreskin.

Dr. John Taylor, a retired Winnipeg pathologist and an expert on the subject, says the fold of skin is rich with specialized sexual tissues responsible for initiating sexual reflexes and ejaculation.

``Circumcision is a mutilation, an abuse of human rights. It's like removing your eyelids and lips, a part of your body that you really need,'' he says.

``The differences between circumcised and uncircumcised are like black and white, days and nights, as far as sexual experiences are concerned . . . Once it's off, it's off and you can never replace that sensation.''

That's what drove Don Kettle, a Toronto computer technician, to form the city's first foreskin restoration support group last November.

``Most circumcised adult men who come to our meetings are angry and outraged, feeling violated for a decision they had no control of as infants,'' says Kettle, 43.

So far, his group has eight members and Kettle says he has received more than 60 inquiries from concerned men.

``They're deprived of sexual stimulation because a most important part of their sexual organ is missing.''

Although most people, including Kettle, suggest parents should leave children to decide in their adulthood if they want a circumcision, Katz says the medical risks and costs of the procedure increase as men age.

``I don't think we should circumcise baby boys just to prevent one from getting infected,'' Katz says.

``But if a parent asks me to perform the procedure for their kid, I'll ask them why and say to them: `Fine, I'll do it.' ''

Correction - Doctor's views were misstated

Dr. Aaron Jesin endorses a Canadian Pediatric Society position that it's up to parents to decide whether to have infants circumcised. Also, when interviewed for a feature yesterday in the Life section, he didn't say babies feel no pain from the procedure.

The Star regrets the error.

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