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September 10, 2004
Doctors revisit circumcision
B.C. college determines that potential negative effects negate
benefits.
PAT JOHNSON SPECIAL TO THE JEWISH BULLETIN
The College of Physicians and Surgeons of British Columbia has
issued a new policy for doctors, reconsidering past practices about
male infant circumcision. The policy states that the procedure was
once considered a preventive health measure but that potential side-effects
effectively negate potential health benefits and that, as a general
rule, routine circumcision is not recommended.
The policy report does give a nod to the religious significance
of the process.
"From a religious standpoint, infant male circumcision is acknowledged
to be an important ritual and an integral part of Jewish and Islamic
religions," states the document, which was approved by the
college in June. But it also states that "Routine infant male
circumcision performed on a healthy infant is now considered a non-therapeutic
and medically unnecessary intervention," and the college calls
for wider societal discussion on the topic.
Dr. Morris VanAndel, registrar of the College of Physicians and
Surgeons of B.C., said the religious imperative to circumcise a
child is a matter for parents, but the purely medical considerations
suggest the procedure not be done routinely.
"Our point of view is we're not going to get into the cultural
niceties of this, but the current evidence says that, from a medical
point of view, with rare exceptions, routine circumcision has no
medical indication," said VanAndel.
"This was discussed at great length by our ethics committee
and the ethics committee looked at all the current evidence and
current feeling and came up with a report," he said.
The new guideline for doctors reflects an attitude change that has
been evolving for several years.
"Circumcision for many, many years has been an accepted procedure,"
said the registrar. "In fact, up to some years ago, [circumcision]
was almost considered routine." The thinking on that has changed.
"People took a fresh look at this and said, is this still a
procedure that should be done routinely, or should people be in
a position to provide an informed consent so they can decide on
their own basis whether it should be done or not?"
Though he has not heard of any controversy around the new guidelines,
he acknowledged there is a degree of politicization around the issue.
"As usual, 99 per cent of people are in the middle of this
and there are extreme positions on both sides," said VanAndel.
"There are individuals who feel that circumcision is totally
unethical and it should never be done, it's horrendous, et cetera,
et cetera.... There are those on the other side who say get out
of my life, I'll make my own decision."
A lack of evidence
According to the college guidelines, the foreskin is "rich
in specialized sensory nerve endings and erogenous tissue."
Circumcision, like all surgical procedures, carries with it some
risks, the policy notes, from minor infections to more serious hemorrhaging
leading to death, however rare.
On the other hand, there has been a long-held assumption that circumcision
carried with it medical advantages, such as the reduced likelihood
of sexually transmitted diseases and urinary tract infections.
"Current consensus of medical opinion, including that of the
Canadian and American Pediatric Societies and the American Urological
Society, is that there is insufficient evidence that these benefits
outweigh the potential risks," the guideline states. "That
is, routine infant male circumcision, i.e. routine removal of normal
tissue in a healthy infant, is not recommended."
The policy also warns of legal complications, based on the view
that parental consent on behalf of minors could be determined by
a future court decision to extend only to diagnosis and treatment
of medical conditions and not for non-therapeutic procedures.
The policy succinctly describes the human rights considerations
for and against circumcision.
"Many adult men are increasingly concerned about whether their
parents had the right to give consent for infant male circumcision,"
states the guideline. "They claim that an infant's rights should
take priority over any parental rights to make such a decision.
This procedure should be delayed to a later date when the child
can make his own informed decision. Parental preference alone does
not justify a non-therapeutic procedure."
On the flip side, it considers religious rights.
"Others argue that this stance violates the parents' right
to religious or cultural expression, and that adherence to their
religious and cultural practices would be in the best interests
of the infant."
A doctor's right not to perform the procedure, along with her or
his obligation to a patient, is laid out in the policy.
"You are not obliged to act upon a request to circumcise an
infant, but you must discuss the medical evidence and the current
thoughts in bioethics that dissuade you from performing this procedure,"
says the policy. "You must also inform the parents that they
have the right to see another doctor."
The Canadian Pediatric Society (CPS) policy closely reflects the
new guideline from the College of Physicians and Surgeons of B.C.
"It was estimated in 1970 that 69 per cent to 97 per cent of
all boys and men in the United States had been circumcised, in comparison
with 70 per cent of those in Australia, 48 per cent of those in
Canada and 24 per cent of those in the United Kingdom," states
a pediatric society report on the subject. "The procedure is
uncommon in northern European countries, Central and South America
and Asia.... The overall evidence of the benefits and harms of circumcision
is so evenly balanced that it does not support recommending circumcision
as a routine procedure for newborns. There is therefore no indication
that the position taken by the CPS in 1982 should be changed. When
parents are making a decision about circumcision, they should be
advised of the present state of medical knowledge about its benefits
and harms. Their decision may ultimately be based on personal, religious
or cultural factors."
The health advantages
Dr. Victor Dirnfeld, a Vancouver-area physician and a former head
of both the B.C. Medical Association and the Canadian Medical Association,
insists emphatically that there are health advantages to circumcision
and that medical assertions that non-circumcised men are as healthy
as circumcised men are based on sometimes flawed assumptions about
degrees of personal cleanliness.
Dr. Neil Pollock, a Vancouver mohel and a medical doctor whose practice
is now focused entirely on circumcision and vasectomy, performs
about 4,000 procedures per year, about half of those are circumcisions.
(To give perspective, about 10,000 boys are born in the Lower Mainland
each year.) As a mohel, Pollock pioneered a "painless, bloodless"
circumcision that caught the attention of the medical community,
which now has hundreds of physicians referring their patients to
Pollock.
When an experienced doctor or mohel performs the procedure, Pollock
explained, the risks involved in circumcision are minimal, which
should alleviate some of the concerns parents may have. On the other
hand, Pollock thinks the benefits of circumcision have been well
documented in highly respected medical journals.
Circumcised boys and men are significantly less likely to develop
urinary tract infections, which can lead to kidney damage, are at
reduced risk of cancer of the penis and have significantly less
likelihood of transmission of sexually transmitted diseases; and
infant circumcision precludes the need to do the procedure later
in life when a small, but not insignificant, number of adult men
require circumcision due to recurrent infection or other complications.
Some studies also indicate circumcision reduces sexual dysfunction
in later life, he said. As well, partners of circumcised men are
less likely to develop cancer of the cervix.
While he believes there are valid medical reasons for circumcision
– beyond the religious imperative for Jews – the guidelines
set by the doctors' college are legitimate and fair, Pollock said.
On occasion, when grandmothers have brought their grandsons to Pollock's
office, they have told him that when their own sons were born, the
babies were taken away and circumcised as a matter of course, a
procedure as routine as cutting the umbilical cord. Those days are
gone and rightly so, said Pollock, who agrees that parents should
be informed of potential risks and benefits. Like any other surgical
procedure, he said, it is imperative that physicians inform parents
of the risks and benefits so that they can make an informed decision
as to what they believe to be best for their child.
Pat Johnson is a Vancouver journalist and commentator.
New mohel on the block
Rabbi Ilan Acoca, spiritual leader of Beth Hamidrash, British Columbia's
only Sephardi shul, recently returned from Israel, where he became
a mohel. Acoca trained at as many as 10 brit milah a day with the
head of the beit din in B'nai Brak and has returned to Vancouver
ready to perform the ritual that signifies the covenant of the Jewish
people with God.
"It means to me that I'll be a vessel to perform what God commanded
us in the Torah, as he told Abraham, to do the brit milah as a covenant
between God and the Jewish people," said the rabbi.
"It will be an honor and pleasure for me to serve the community
as a mohel," said Acoca.
Most of the practices around the brit milah are similar in Sephardi
and Ashkenazi congregations, though the celebrations around the
mitzvot can differ. "The songs that we sing are different.
The blessing that we say is the same," explained Acoca.
On the issue of British Columbia's medical community debate over
the issue of circumcision, Acoca said the question is moot for Jews.
"As Jews, we don't do it as a health issue or not," he
said. "It's a question of what God commanded us to do."
Even the most tenuously observant Jews recognize the significance
of the brit milah, said the rabbi.
"Sometimes people are not connected at all, but it doesn't
make a difference because, when it comes to brit milah, most of
them will do it. It's something that we have to do. It's part of
the Jewish tradition. Orthodox or not Orthodox, Reform or Conservative,
connected or not connected, observant or not observant. It doesn't
make a difference. A brit milah is something that you have to do.
It's our tradition. It's our belief. It's our covenant with God."
– PJ
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