Canada: Circumcision questioned following plastibell death

Opposition to circumcision in Canada is growing rapidly following the death of a baby in the province of British Columbia. The boy bled to death after being circumcised (using the plastibell device) in August 2002.

The recently-released report of the BC coroner found that the baby, Ryleigh Roman Bryan McWillis, aged one month, was circumcised in the Penticton Regional Hospital on 20 August 2002. He was released from the hospital into the care of his parents; suffered extensive bleeding from the wound; was returned to Penticton Hospital; and was subsequently transferred to the B.C. Children's Hospital, where he died less than 48 hours after the operation. The Coroner concluded that the death was due to "multiorgan hypoxic/ischemic injury due to hypovolemic shock as a result of massive hemorrhage from a circumcision site." Tragic though it is, there is nothing extraordinary in this outcome: bleeding and death are well-known complications of circumcision. A similar case was reported by the Miami Herald in 1993, a case occurred in Ireland in 2003, and cases have also been recorded in Australia.

The Coroner further showed that the doctor at Penticton Hospital performed the circumcision in the absence of any medical indication or need, but at the request of his parents. This practice – needless circumcision at parental request – is thus shown to be hazardous to children's lives. As Dr Greg Watters and Stephen Carroll have shown in their study of parental attitudes in rural New South Wales, parents rarely appreciate the risks associated with the excision of an infant's prepuce, and are ill-equipped to make decisions that should properly be made after expert paediatric advice or left to the boy himself.

Circumcision under attack following baby boy's death

CBC News British Columbia, 11 February 2004

PENTICTON, B.C. - The report on the death of an infant following a routine circumcision has triggered renewed calls to ban the procedure in B.C.  Ryleigh Roman McWillis was a month old when he bled to death following the operation in Penticton in August, 2002.

A coroner's report released this week makes no recommendations for change, which dismays his parents.

Brent McWillis had hoped the coroner's report into the death of his son Ryleigh would help prevent a similar tragedy in future.

"It was a very unfortunate and nightmarish thing that happened to us," he says. "The only thing I want to see is that it doesn't happen to anyone else's child." Ryleigh's parents say they'd like all hospitals to adopt better standards to care for infants following a circumcision.

Meanwhile, other groups opposed to circumcision, are calling for an internal review by the B.C. College of Physicians and Surgeons. "This surgery is not necessary, and if the surgery is not therapeutic, the risk cannot be undertaken," says John Geisheker, the lawyer for the group, Doctors Against Circumcision.

Dr. Eugene Outerbridge of the Canadian Pediatric Society says a study last year, showed male circumcision exposes children to risk, with no real medical benefit.  But Outerbridge says an outright ban would violate the rights of religious minorities.

Comment: "Wait until their sons can make the decision for themselves"

CBC Radio (British Colombia), Friday, February 20, 2004

From Ottawa journalist Thom Barker, a clear and powerful statement calling for a ban on routine infant circumcision in Canada. A year and a half ago a baby in British Columbia bled to death after he was circumcised. Last week a coroner's report made no recommendation on the future of the practice. Thom Barker is a freelance writer in Ottawa. On Commentary he has a suggestion.

Last week we were horrifically reminded that circumcising baby boys is not without the highest risk. It can and occasionally does lead to their deaths. But the articles I've seen on it recently didn't focus on how unnecessary it is; they discussed how circumcision should be done more safely. So with safety in mind here's my advice. Ban it! Stop mutilating infant boys for no good reason.

For nearly 30 years now the Canadian Paediatric Society has officially stated that circumcision is medically unnecessary. Long term statistical evidence has proven that the risks of doing it outweigh the risks of not doing it, and medical ethicists almost universally decry it.

So why do we continue to circumcise about one out of every five boys born in this country? Why do we continue to leave it up to the parents and doctors to decide?  The first reason is familiarity. Circumcision has been and remains such a common practice - to make baby look like daddy - that we're reluctant to recognize it for what it really is: genital mutilation. To do so would be to condemn our parents, our friends, our siblings and possibly ourselves as guilty of criminal assault.

More problematic is the religious justification. Childhood circumcision of boys is an integral aspect of the Jewish and Muslim traditions and cultures. But similar arguments based on tradition did not stop Canada in 1997 from banning female genital mutilation. It did not stop us because it was viewed as a human rights issue. In fact, as a society, we routinely override the rights of parents to protect children from perceived harm. So why doesn't this protection extend to infant boys?

Male circumcision is hardly universal even among practising Jews and Muslims. In fact, there are significant numbers of both, including religious leaders, who advocate discontinuing the practice because it's contrary to more fundamental principles of their faiths, most importantly respect for human life.  So even in the religious context it seems that parents have some freedom of choice.  I was born Catholic. At about the same time that I might have had my foreskin removed, I was baptized instead. When I later renounced my Catholicism I resented having been baptized against my will. But fortunately I didn't have an irreversible physical deformity to forever remind me of it.

Would it be so egregious to make parents wait until their sons can make the decision for themselves? There's no end to the legal protection adults have to damage themselves.

For Commentary, I'm Thom Barker in Ottawa.

Boy dies after Plastibell circumcision

Mark Brennae, CanWest News Service, Published: Wednesday, June 13, 2007 canada.com

OTTAWA — A one-week-old Ontario infant died from complications after undergoing a circumcision in a provincial hospital.

Information about the case was published in the April 2007 edition of Paediatric Child Health. The baby, whose name has been withheld by the parents, passed away after his kidneys [no, bladder] became enlarged to seven times their [its] normal size.

The child was born at an unidentified Ontario hospital “sometime in the last three years,” said Dr. Jim Cairns, Ontario's deputy chief coroner. “The family wants to keep this anonymous.” No charges were ever laid and no legal action was ever taken in the case.

According to the Paediatric Child Health article, the boy was “bottlefed and was reported to be doing well when he was circum[cis]ed.”

Five hours later, the parents returned to their family doctor with the infant, who had become “irritable and had blue discolouration” below the belly button. Doctors noticed the discolouration and slight swelling of the penis, but sent the child home. Fourteen hours after the circumcision, according to Cairns, the child was brought to another hospital where doctors noted he was extremely irritable with marked swelling of the penis and bruising to the scrotum.

The child was then transferred to a paediatric centre, where his bladder was diagnosed, Cairns said, to “seven or eight times its normal size.”

The PlastiBell ring, which is used to hold back the foreskin after circumcision, was removed and drained and the child went into shock.

“If the PlastiBell had been taken off five hours after he got there, he would be alive,” said Cairns

[Perhaps. If the PlastiBell had never been used in the first he would certainly be alive.]

The child's death was attributed to septic shock — “an overwhelming infection, leading to multi-organ failure,” Cairns said. “Death is rare after circumcision,” said Cairns. “But complications can happen.” The case was brought to Cairns' attention because the circumstances of every death of an Ontario child under five years of age must be reviewed by the provincial coroner's office.

Another Canadian boy bleeds to death after circumcision

Ontario newborn bleeds to death after family doctor persuades parents to get him circumcised. National Post, 25 October 2015

TORONTO — An Ontario doctor has been cautioned after a 22-day-old baby bled to death from a circumcision gone horribly wrong, underscoring the heated debate over a simple yet contentious procedure. Another physician involved in the case was urged by a medical governing body to be “mindful” of the operation’s dangers. But Ryan Heydari’s parents say the regulators who handled their complaints have shed little light on what led to Ryan’s death – or how to prevent similar tragedies in future. They say they did not even want the newborn circumcised — a view in line with longstanding recommendations from the Canadian Pediatric Society — but were persuaded to do so by a family physician. “We are so shocked that we will not have an answer to bring us some peace for our broken hearts, to prevent other cruel deaths like Ryan’s and to ensure that doctors take proper care of their patients,” mother Homa Ahmadi told the National Post.

In fact, the case only became public because the couple appealed the original Ontario College of Physician and Surgeons rulings, which were rendered in secret. An appeal tribunal upheld this month a decision by the College to caution the doctor who saw Ryan in the emergency department hours after his circumcision, his diaper stained red with blood. The Health Professions Appeal and Review Board also confirmed the college’s separate advice to the pediatrician who conducted the procedure to be aware of its potential hazards, and document his efforts to get informed consent. The pediatric society said in a recent report that death from bleeding caused by circumcision is “extremely rare,” though it’s not completely unheard of. A five-week-old B.C. baby bled to death after being circumcised in 2003.

Ahmadi gave birth on Jan. 3, 2013 to a boy who loved attention, cried relatively little and seemed to actually smile. “He gave us the most amazing moments of our life,” says Ryan’s mother. She and husband John Heydari, who immigrated from Iran about 12 years ago, opposed having him circumcised, convinced that “mother nature created us the way she intended us to be.” But their family physician persuaded them it was a good idea for medical reasons, despite contrary advice from pediatric specialists.

Once carried out on most Canadian boys and still common as a religious rite for Jews and Muslims, circumcision has generally fallen in popularity, rates hovering around 32 per cent. The pediatric society has long held that its risks – including pain to a small baby, bleeding and the chance of disfigurement of the penis – outweigh its benefits. But its report still recommended against routine circumcision of every newborn male, saying that it may make sense in certain cases. For those who have the procedure, “close follow-up in the early post-circumcision time period is critical,” the society warns. One urologist says he has encountered a few cases where circumcised babies had to undergo transfusions because of dangerous bleeding, and sees less-serious complications routinely. Dr. Jorge DeMaria of Hamilton’s McMaster University believes regulators should require doctors to prove they have undergone proper training before doing circumcisions. He also questions circumcising newborns for preventive-health reasons, in a country with low levels of HIV and wide availability of condoms. “In our setting, in North America, really it’s not necessary.”

Ahmadi says she and her husband knew almost immediately after their son’s procedure that something was seriously wrong. The previously unfussy baby “was crying so much, so hard, and he wouldn’t stop,” she recalled in written answers to questions. “He was bleeding, and it only got worse over just hours … It was so obvious from the blood his tiny body had lost that he was in danger.”

The pediatrician who did the circumcision told the College he conducts many of them, that Ryan’s was uneventful and there was no bleeding when he checked the dressing before the family left. The parents called about bleeding later that day, though, and he advised them to take Ryan to Toronto’s North York General Hospital, which they did. “We … waited for care that could have saved his life, but that level of care never came,” says Ahmadi. A sparse outline in the board’s decision says Ryan was eventually transferred to Sick Kids hospital, but died there seven days later. Pathologists said he succumbed to “hypovolemic shock” caused by bleeding from the circumcision, which emptied his body of 35 to 40 per cent of its blood. The doctor at North York General — whose name has been withheld according to College policy — was cautioned for failing to recognize the seriousness of the boy’s condition or treating “compensated shock” – the first stage of the condition.

Too many circumcision complications in Canada hospitals

In a study published in the August 2013 issue of the Canadian Urological Association Journal urologists report a disturbingly high incidence of complications and other adverse outcomes from circumcisions performed on infants by surgeons in Ontario hospitals. The authors found that “most physicians performing neonatal circumcisions in our community have received informal and unstructured training. This lack of formal instruction may explain the complications and unsatisfactory results witnessed in our pediatric urology practice. Many practitioners are not aware of the contraindications to neonatal circumcision and most non-surgeons perform the procedure without being able to handle common post-surgical complications.” In other words, even under the most favourable conditions - qualified medical personnel, modern hospitals and the latest equipment, an advanced Western society - circumcision of infants still cannot be safely performed.

Although they are not aware of it, the authors confirm the conclusion of Hugh Young's study of circumcision techniques, that no fully satisfactory and entirely safe method has ever been devised and - given the complex and variable anatomy of the foreskin - none is ever likely to be. Unlike a finger, an arm, the gall bladder, or the appendix, the foreskin is not a discrete or self-contained member or organ that can easily be detached from the rest of the body. Since it is an extension of the penile skin system, there is no agreed point at which the “foreskin” ends and the rest of the penis skin begins, and thus no clearly-defined point at which the operator should start (or stop) cutting. As Young concludes, the structure of the foreskin does not lend it self to neat amputation, but is highly vulnerable to complications and messy cosmetic outcomes.

Abstract A survey of circumcision methods and instruments is presented from an evolutionary perspective. Instruments for circumcising have evolved, but not in any coherent or consistent manner. Nor, after more than 4,000 years, has any consistent (“best”) method emerged for circumcising. This underlines fundamental problems with the operation. The instruments have been fetishized along with the operation.

The article concludes: Unlike the hurricane lantern, they did not find the best method and stick with it; unlike the scissors, there was no great leap forward; unlike the car door handle, there was no smooth progression, from linear to annular to disposable, Instead, inventors have jumped back and forth, apparently having some nostalgia for the linear barzel, and perhaps some dislike of the necrosis of the Plastibell. It took the designers of the devices thousands of years to work out how to compress in a circle. They still have not accommodated the frenulum because the frenulum intractably complicates the cutting. And though it is common knowledge that the frenulum, the last remnant of Taylor’s ridged band, is the male G-spot, circumcisers have not yet formulated a consistent policy towards it and hence their devices do not treat it consistently. What this exposes is that no way of circumcising is without problems because the foreskin has not evolved in a way that lends itself to being removed.

Sources:

Hugh Young. Evolution of Circumcision Methods: Not “Just a Snip”, in G.C. Denniston et al (eds), Genital Cutting: Protecting Children from Medical, Cultural, and Religious Infringements. Dordrecht: Springer 2013.

Jorge DeMaria, Alym Abdulla, Julia Pemberton, Ayman Raees, Luis H. Braga. Are physicians performing neonatal circumcisions well-trained? Canadian Urological Association Journal, Vol 7, August 2013