Circumcision rates dropping, but infant death highlights ongoing debate

The post-circumcision death of an infant boy in Ontario has highlighted the ongoing debate about circumcision in Canada, where about a third of parents still choose to circumcise their newborn boys.

Ryan Hedari’s parents say their physician urged them to circumcise their son despite their wish not to, and in 2013 the boy died seven days after the procedure due to shock from blood loss.

Earlier this month an appeal tribunal of the Ontario College of Physicians and Surgeons cautioned the doctor who saw the baby in an emergency room hours after the circumcision procedure, and urged the performing doctor to be mindful of the risks of the procedure and to receive informed consent from patients.

Though the numbers are declining, about a third of Canadian parents still choose circumcision for their sons. That’s despite recommendations from the Canadian Paediatric Society (CPS), updated last month, saying that circumcision should not be routine for newborn boys.

A study published in Canadian Family Physician in 2013 put the infant circumcision rate in Canada in 2013 at 32 per cent, though the CPS recommends against it as a routine procedure and the number of physicians who will perform circumcisions continues to drop.

“While there may be a benefit for some boys in high risk populations and the procedure could be considered as a treatment or to reduce disease, in most cases, the benefits of circumcision do not outweigh the risks,” Dr. Thierry Lacaze, chair of the CPS Fetus and Newborn Committee, said in a statement about the updated recommendations.

The CPS statement also recommends that parents choosing circumcision should be referred to a practitioner trained in the procedure, and that neonatal circumcisions should be performed by trained practitioners with strict adherence to hygiene and analgesic best practices.

Toronto’s Hospital for Sick Children has staff who perform circumcisions but doesn’t have an official position on the procedure, pro or con.

“We don’t think that the evidence for or against is enough to [state a position], and hence we offer as much unbiased information as possible so the family can weigh the risks and benefits,” Dr. Martin Koyle, the hospital’s professor of surgery and chief of pediatric urology, tells Yahoo Canada News.

The hospital’s role is to give parebnts the information they need to weigh their own considerations — including religion, family history and culture — and to perform the procedure, when requested, in a safe environment with trained practitioners, he says.

Reasons behind circumcision

One reason given by some parents who choose circumcision is that the child’s father is also circumcised. One study from the University of Saskatchewan surveying 230 parents in prenatal classes in the Saskatoon found that 56 per cent of parents would consider circumcision if they had a son — a number that jumped to 82 per cent if the child’s father was circumcised and dropping to just 15 per cent if not.

Others choose circumcision for religious reasons. Many Jews and Muslims, and some Christians, circumcise male infants because of texts found in the Old Testament of the Hebrew Bible. The World Health Organization estimates that more than 70 per cent of the one-third of males aged 15 or older who are circumcised are Muslim.

The Canadian Maternity Experiences Survey, released in 2009, found the main reasons given for choosing circumcision were health or hygiene (44.4 per cent), to be like the child’s family or peers (35.6 per cent), and religion (17.3 per cent).

In Canada, overall circumcision rates continue to decline. The CPS estimated the national rate at 48 per cent in 1970. And rates of circumcision vary considerably across the country. The Canadian Maternal Experiences Survey found that in the 10 Canadian jurisdictions where at least five circumcisions were reported, the proportion of women who reported circumcising their male babies ranged from 44.3 per cent in Alberta and 43.7 per cent in Ontario to 9.7 per cent in the Northwest Territories and 6.8 per cent in Nova Scotia. And in Newfoundland and Labrador, Nunavut and Yukon, less than five respondents reported choosing circumcision so a percentage couldn’t be calculated.

In the United States circumcision rates have dropped in recent decades but remain much higher than the Canadian rates. Research reported in Mayo Clinic Proceedings in 2014 found that the circumcision rate for American male infants was 77 per cent in 2010, versus 83 per cent in the 1960s.

In 2013 the American Academy of Pediatrics released a statement saying that while the final decision lies with parents the health benefits of circumcision outweigh the risks, differing from a past policy that deemed circumcision unnecessary for the health of newborn boys.

In terms of the potential benefits, there is some evidence that circumcision can provide protection against urinary tract infections, penile cancer and transmission of some sexually transmitted diseases, including HIV and HPV. However, urinary tract infections in male infants are relatively uncommon, says Dr. Koyle, and penile cancer is very rare.

Potential complications

For some infants, these benefits are far more pronounced — for example, those with an underlying urologic abnormality. And the risk of complications from circumcision in infancy is about a quarter what it is in young adulthood and adulthood, Dr. Koyle says.

But like any surgical procedure, however minor, there are risks involved. Those include bleeding, hemorrhage, infection, inflammation and tightening at the tip of the penis.

“The most severe risks are bleeding and infection,” Dr. Koyle explains. “Most of them tend to be mild but some can be catastrophic. I’ve seen the whole spectrum from good to bad.”

There is also a small risk of about two to three per cent of penis scarring, he says, even in procedures that are free of complications. Other potential side effects of circumcision include poor healing, cosmetic issues, skin bridging and fistula due to holes in the urethra.

“The most important thing is not taking it for granted,” Dr. Koyle advises. “It’s a procedure.”

Families should ensure that they are well informed on the risks and benefits, and if they do choose circumcision it should be done by a medical professional who has a long and positive track record with the procedure. They should also receive information on potential complications to watch for, and how to get medical help if they occur.

“The family really has to be informed of the complications and really have specific instructions,” Dr. Koyle says.