FEBRUARY 28, 2006


Canada cuts back on circumcision

Au naturel's so in, even an artificial foreskin will do

Circumcision is going out of style. The rate of male infant circumcision in Canada has dropped significantly from roughly 48% in 1970 to 13.9% in 2003, with provincial rates varying widely. But it's still a touchy subject, leaving physicians caught in the crossfire of a debate charged with medical, psychological and cultural implications. And all the while, a new trend is emerging in its place: more and more men are seeking to restore what someone else decided should be cut away. For these males, foreskin restoration is the order of the day.

As far back as 1975, the Canadian Pediatric Society (CPS) issued a position statement advising there's no valid medical indication for neonatal circumcision. In 1996, the CPS decried the procedure "should not be routinely performed."

"Doctors are under no obligation to circumcise a child at the request of parents," explains Dr Walker. He says the ranks of those who'll do it are dwindling.

Still, doctors remain free to do as they see fit. In fact, in the only two provinces where the College of Physicians and Surgeons has formally advised doctors not to perform the operation — Saskatchewan and British Columbia — rates remain well above the national average, at 16.7% and an estimated 20% respectively.

The CPS guidelines aren't the only impetus for circumcision's fall from grace. By 2004, every provincial health insurance board — save Manitoba's — had de-listed the procedure. So if parents still want the snip, they've got to foot the bill themselves. "We didn't see a big change initially," says Dr Walker, "but it's happening gradually."

That's encouraging news for human rights groups who have argued for years that circumcision is tantamount to female genital mutilation, which is outlawed by the Criminal Code of Canada.

Still, there are those who maintain circumcision prevents disease. Evidence that circumcision reduces the risk of penile cancer, HIV and urinary tract infections (UTIs) can indeed be found in the medical literature, but Dr Walker says that evidence has to be put into context. "Cancer of the penis has an incidence of one in several hundred thousand males over 70, and it isn't lethal," he explains. And while studies have shown the relative risk of HIV infection is lower in circumcised males, Dr Walker says the evidence is questionable and argues that whether circumcised or not, the only way to avoid HIV is never to have unsafe sex. As for UTIs, "the rate of infection in circumcised infants is lower, it's still less than one percent in those who aren't," he says.

The reality is that circumcisions are primarily performed for cultural or religious reasons. The brit milah — the covenant of circumcision — was God's first command to Abraham and the defining mark of his chosen people. And the ritual remains widely practiced in both the Jewish and Muslim faiths. But regardless of personal religious beliefs or medical fact, the choice of whether or not to circumcise an infant is legally the parents' to make.

That's a problem for a growing number of men who resent not having had a say. Others complain that the prepuce, or foreskin, is a sensory organ that enhances sexual pleasure. Still others want to regain their "natural status" for physical and emotional wholeness or aesthetics. These men are taking matters into their own hands and "restoring" their foreskin — either surgically or by gradually stretching the leftover skin. But it's never quite the same.

"Once you cut off nerves and blood supply, you can't get it back again," says Adam Greenberg, coordinator of the Toronto chapter of the National Organization of Restoring Men (NORM). "We try to restore those emotional and physical scars."

Founded in 1989 in San Francisco, NORM is a non-profit support group for men to share advice about non-surgical restoration techniques. The gay community was targeted for this outreach, since the founders felt that they tended to be more open about matters concerning sexuality. And though homosexuals still represent the majority of NORM's membership, heterosexuals are catching on.

"You can work with what you have and expand it," says Mr Greenberg, who's been working on his own restoration for 32 months, "you just have to be patient." Non-surgical restoration is based on the principle of tissue expansion: maintaining constant outward tension on the shaft of the penis to induce the skin to grow. Tape and weights, elastic straps or manual stretching can all be used — an impressive selection of devices are even available online.

Dr Robert H Stubbs is a Toronto plastic surgeon who's performed both adult circumcisions and restorations. "Surgical restoration is highly risky because penises are attached to men, and they never comply," he says. "I usually try to talk them out of it." But he will perform the five-hour, $10,000+ multi-stage operation if there's enough donor tissue — which is taken from the scrotum — and he feels the patient's on board.

Ultimately, the circumcision decision is the most personal choice a man can't make. But bringing the trend towards restoration out of the shadows may eventually give them the voice they've never had.



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