The furor over a proposed ban on circumcising males under age 18 in San Francisco has thrust the issue of whether the procedure's potential health benefits outweigh the pain and possible risks.
The proposal will appear on the ballot in the city's elections this November. It would make the circumcision of a male minor a misdemeanor, punishable with a maximum jail sentence of one year and a fine of up to $1,000.
California Congressman Brad Sherman has already vowed to introduce legislation that would prevent San Francisco, or any other city, from enacting such a law. And a coalition of Jewish and Muslim plaintiffs has filed a lawsuit to block the ballot measure, arguing that it violates their constitutional rights.
The law would not include a religious exception.
But opponents of circumcision argue the practice unnecessarily harms and mutilates babies. The anti-circumcision group in San Francisco collected more than 10,000 signatures on its petition to have the ban included in the upcoming vote, well above what the city requires for a measure to be put on the ballot.
The National Organization of Circumcision Information Resource Centers (NOCIRC) is a U.S.-based group that believes circumcision should "be performed only when it is absolutely medically necessary, after all non-invasive therapies have failed, or when an adult gives consent, after he has been fully informed about the risks and harm of the surgery."
The group argues that international health agencies, including the American Academy of Pediatrics, do not recommend routine infant male circumcision.
The Canadian Paediatric Society, for example, acknowledges in its 1996 position paper on neonatal circumcision that research shows health benefits, including:
- a 12-fold reduction in the rates of urinary tract infections during infancy
- a lower risk of developing penile cancer and HIV transmission
But it also cites complication rates between 0.2 per cent and 2 per cent associated with the procedure, most of which are minor.
"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," the CPS paper concludes.
The paper advocates "appropriate attention" to pain relief when the procedure is performed, and goes on to say: "When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms."
More recent studies conducted in Africa have found that circumcision reduced HIV infection rates by as much as 60 per cent, herpes infections by as much as 34 per cent and human papillomavirus (HPV) infections by as much as 35 per cent.
Dr. Neil Pollock is a British Columbia physician whose practice focuses on only two procedures: no-scalpel vasectomy and infant circumcision.
In a telephone interview with CTV.ca, Pollock, who has performed more than 30,000 infant circumcisions, said he agrees with the stance taken by the CPS, which is essentially that families should be told the procedure's potential benefits and risks and then be allowed to make a decision for themselves.
Speaking to the CPS's position that circumcision not be a routine neonatal procedure, Pollock says: "What people make the inference of is, ‘Well, you see, they don't recommend it. That means that they're saying we don't think you should do it.' And that's false. What they're saying is, ‘We don't think that there's a mandate to say everybody needs to have this done.' Most doctors agree with that."
Pollock says the argument that circumcision is painful for a baby is no longer valid in an age when a local anesthetic makes it virtually painless.
Pollock himself has developed what he refers to on his website as a "virtually bloodless, virtually painless" 30-second procedure that a child can sleep his way through.
Time for a Change?
Lloyd Schofield, the man behind the San Francisco anti-circumcision measure, is spearheading a campaign that includes a website and T-shirts that read: "Help Stop Forced Genital Cutting."
"The base of our argument is you're spending incredible amounts of money doing painful and damaging surgery to an unwilling patient," Schofield told SFGate.com late last year.
Pollock concedes that babies are not able to consent to the procedure, but argues that the procedure's health benefits make it a decision that parents consider "with the best intentions."
"I totally understand the position that this procedure is done on infants that have not been able to weigh out the pros and cons," Pollock said.
"The other side to consider is that (there are) multiple medical benefits. And that parents who decide to make this decision for their children are making similar very important decisions for their children in all types of areas of their life."
In a recent editorial in the Canadian Medical Association Journal, Dr. Noni MacDonald, a professor of pediatrics at Dalhousie University and a pediatric infectious disease specialist at the IWK Health Centre in Halifax, points out that recent studies of patients in Africa that found stunning drops in HIV and HPV rates examined only circumcised adult males.
She says the research raises the question not of whether infant male circumcision recommendations should change, but rather if circumcision should be made routine for pre-pubescent males.
"Some adult males may squirm at the very thought of routinely offering circumcision to peripubertal males, possibly because of perceived pain and discomfort," MacDonald writes. She goes on to say that "it's curious that a painful elective procedure of no major benefit to the infant until years later would ever be deemed more acceptable than the same procedure for a peripubertal boy."
MacDonald points out that the adolescent boy can make an informed choice about whether or not to undergo the procedure, a discussion that could include a broader look at ways to reduce sexually transmitted infections.
Pollock, however, cites two problems with MacDonald's argument. First of all, he says, males who go uncircumcised throughout childhood miss the health benefits of the procedure in early life, such as a lower risk of urinary tract infections. As well, the procedure done later in life carries higher risks because, for example, it needs to be performed under general anesthetic.
In addition, Pollock says, "I'm not sure that an 11- or 12-year-old is in the best position to weigh out the pros and cons of circumcision based on their immaturity and their potential lack of understanding of the issues at hand."
The Canadian Paediatric Society began a review of its position on neonatal circumcision in 2009. However, the issue has become so fraught with differing opinions and new research that the CPS has yet to issue an updated statement.
"The revision has not been released yet and the CPS stands by its recommendations until the revision is published," Andree Dion, the society's media relations co-ordinator, told CTV.ca in an email statement. "At this time, we don't know when the revision will be published or what it will say."
