The Canadian Paediatric Society didn't elicit huge fanfare when it released its long-awaited update to its position on newborn male circumcision earlier this month.
That's understandable, considering the document doesn't depart in any significant way from the organization's previous guidelines on the topic: that circumcision is not medically necessary for most babies and the procedure should not be routine at birth. For that reason, provinces no longer cover the cost of circumcisions through their health plans. But some parents will still choose to have their sons circumcised, so the CPS set out some best-practice guidelines designed to lower the potential risks.
Those recommendations sound reasonable, including the one that says circumcisions should be performed by a trained practitioner "whose skills are up to date and strictly adhere to hygienic and analgesic best practices."
But on the ground, what happens is often much different from what the guideline recommends – something parents should find alarming.
Male circumcision, or the surgical removal of the foreskin from the penis, has been performed for thousands of years, and became popular in Britain and the United States in the 19th century, according to the Canadian Paediatric Society. Although the procedure has cultural and religious significance in the Jewish and Muslim faiths, many parents had their sons circumcised to improve hygiene and lower the risk of disease.
But in recent years, circumcision rates have been dropping in countries such as Canada, particularly as more evidence shows the potential risks. For instance, studies show that more than 100 boys have to be circumcised to prevent one urinary tract infection – a problem that is easily treated with medication.
More recently, studies have suggested circumcision can prevent transmission of HIV. However, the research has primarily been conducted in Africa, and the CPS document notes it's not clear whether those results can be applied to countries such as Canada, where HIV infection rates are lower.
It's difficult to know how many circumcisions are performed in Canada, as most are done in doctor's offices or clinics and data aren't tracked. But the Canadian Institute for Health Information (CIHI) has records of circumcisions performed in hospitals and in day surgery for every province except Quebec. In 2004-05, there were nearly 15,600 circumcisions performed, according to the CIHI data. By 2014-15, that figured dropped to fewer than 8,500. The CPS estimates that roughly 30 per cent of newborn males are now circumcised.
Few, if any, jurisdictions in Canada require physicians to undergo formal training before performing circumcisions. In many cases, doctors learn the procedure from watching or talking to a colleague, says Dr. Jorge DeMaria, a pediatric urologist and professor in the department of surgery at McMaster University in Hamilton. He has been one of the leading voices calling for standardized training and formal education requirements to improve safety and lower the risks associated with the surgery.
In 2013, Dr. DeMaria and his colleagues published a study that revealed just how great the disconnect is between best practices and reality. They surveyed a group of 62 physicians and surgeons in southwestern Ontario who perform circumcisions. None of the respondents said he had learned how to perform circumcisions in a structured training course. Nearly half of the non-surgeons said they learned how to do the procedure from a colleague. About one-third said they would perform a circumcision on an infant with a concealed penis – a condition in which the penis is hidden beneath excess skin – despite the fact the surgery is not recommended in those babies.
But according to the Canadian Paediatric Society's own document, the complication rate linked to circumcision is relatively low – a median of 1.5 per cent, according to one study – so the absence of formal training doesn't appear to be taking a major toll, right?
Not necessarily. The true rate of infections, bleeding, skin adhesions and more serious complications may be higher than believed because the few studies that have looked at this area may underestimate the number of adverse events. For instance, some studies may look only for complications a few days postprocedure, while it could take longer for problems to appear. In some cases, parents aren't happy with the cosmetic appearance after the surgery, which likely wouldn't be counted as a complication, but may well be in the eyes of the family.
In 2013, the CBC reported on a Montreal doctor with more than 30 complaints made to the provincial medical regulator relating to botched circumcisions. The doctor in question still advertises his services online, with a website that states he has travelled throughout North America to identify the best way to perform circumcisions.
According to the American Academy of Pediatrics' 2012 guidelines, "the true incidence of complications after newborn circumcision is unknown," adding that "it is imperative that those providing the service have adequate training in the method used and resources for and practice of adequate analgesia and infection control."
No surgery will ever be risk-free, of course. But considering how many circumcisions are still performed, and the fact they make a permanent alteration to a very important body part, it's unacceptable that training remains so unstructured and informal. There could be a relatively easy fix: Regulatory colleges could require doctors to complete a continuing medical education program before performing circumcisions.
So what can parents do? In the absence of training requirements, the best bet may be to become as informed as possible about the risks and benefits and asking your doctor about his or her level of experience, training and complication rate. It may not be a surefire solution, but it may help in the confines of the current system for those considering the procedure for their newborn boy.
Carly Weeks