Canadian urologists reject routine circumcision

In a major statement based on a comprehensive survey of the medical literature in January 2018, the Canadian Urological Association has concluded that routine prophylactic circumcision of male infants and boys is not justified as a preventive health measure. The statement is of particular interest because it reaches this conclusion on the basis of a very narrow calculation of medical benefits, costs and risks, pays little attention to the harms of circumcision (such as effect on male sexuality, moral harm of denying choice etc) and largely ignores bioethical and human rights issues. The statement emphasises that the results of clinical studies in underdeveloped regions with acute health and social problems cannot be mapped onto developed nations with quite different epidemiological and social environments, and point out that “The effect of MC has to be analyzed at the individual and societal level.” The statement is at pains to point out that the evidence as to the benefits and risks of circumcision is contradictory and inconclusive, and that much of it is of poor quality, especially studies claiming to show that circumcision has little impact on sexual sensation and function. The final conclusion is that while circumcision does offer some advantages, they are small, can be achieved by other, non-surgical means, and are outweighed by the risks and harms. This being the case, routine circumcision is not justified as a health measure and cannot be recommended.

INTRODUCTION “Circumcision is the oldest planned operative procedure in the history of the human civilization but there continues to be a lack of consensus and strong opposing views on whether universal neonatal circumcision should be adopted as a public health measure. … A review of the literature on MC shows evidence of a vehement debate, often clouded by strong personal biases and lack of high quality evidence. Creation of a guideline specific to the need of Canadian infant males is therefore difficult given the level of evidence provided for each potential benefit, the lack of data directly applicable to the Canadian population, the inability to quantify the true complication rate of routine circumcisions accurately, uncertainty about the health benefits of a circumcision compared with other health interventions, the ethical issues and acceptability of a surgical procedure done by parental consent for future benefits, and the costs of training and implementation of any universal neonatal circumcision policy in Canada.”

In its conclusion the statement emphasises that the results of clinical studies in underdeveloped regions with acute health and social problems cannot be mapped onto developed nations with quite different epidemiological and social environments, and point out that

“The effect of MC has to be analyzed at the individual and societal level. For the individual Canadian neonate, there are definite advantages of a circumcision, but the exact estimates of the effect are unknown, the protection provided is not comprehensive, accrue over a life-time and can be achieved by other preventive health measures. … There are also clear risks associated with this surgical procedure and parents will continue to have to weigh the potential benefits and risks of neonatal circumcision. In an overall societal perspective, given our health care system and the socio-economic and educational status of our population, universal neonatal circumcision is not justified based on the evidence available."

Source: Sumit Dave, Kourosh Afshar, Luis H. Braga, Peter Anderson. CUA guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants. Canadian Urological Association Journal 2017 Dec. 1; Epub ahead of print. http://dx.doi.org/10.5489/cuaj.5033.

Earlier policies and policies issued by the various provincial medical bodies and the Canadian Pediatric Society are available from CIRP.