Current Circumcision Practices: Canada

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Current

Circumcision

Practices:

Canada

John L. Wirth

From Syracuse, New York

ABSTRACT. Current statistics of circumcisions

per-formed in Canada are reported, by province. Statistics of

circumcisions performed in the United States 30 years

ago are also reported, by race and region. Pediatrics 66:

705-708, 1980; circumcision, statistics of, in Canada;

circumcision, statistics of, in United States.

The following appears in an editorial in the

Brit-ish Medical Journal of May 5, 1979:

Part of the North American way of life is removal of

the foreskin within a few hours of birth. Nearly two

million boys are born each year in the United States and

in some centers 80%-90% are circumcised, using vast

amounts of medical and nursing time and costing parents

equally vast amounts of money. ...Presumably most

Americans are satisfied with their present practice, and

some justify it most forcefully. Others, however, do have

misgivings, insofar as there really is no rational case for

general neonatal circumcision.’

The purpose of this communication is to report

that, although this picture of circumcision practices

is quite accurate as pertains to practices in the

United States 30 years ago, and although it may or

may not be accurate as to current American

prac-tices, the current history of Canadian practices is

different than suggested.

US STATISTICS

National statistics on neonatal circumcision in

the United States are rare. The Department of

Health, Education and Welfare’s (HEW) Hospital

Records Study excludes procedures on neonates.

The Commission on Professional and Hospital

Ac-tivities (CPHA), Ann Arbor, MI, publishes such

statistics from CPHA member hospitals; since these

hospitals may not be typical in their circumcision

Received for publication March 10, 1980; accepted April 4, 1980.

Reprint requests to (J.L.W.) 408 Greenwood Place, Syracuse,

NY 13210.

American Academy of Pediatrics.

practices there is a question as to the errors

asso-ciated with projections from them.

A set of national statistics that reports American

practices of 30 years ago is available as part of Cycle

III of the Health Examination Survey, a result of

physical examinations of a statistical sample of

12-to 17-year-old boys and girls conducted by HEW

from July 1963 to December 1965. One of the items

noted for the boys was whether they were

circum-cised. The statistics from that survey pertain mainly

to circumcision practices in the early 1950s,

al-though some of the examinees would have been

circumcised after infancy. Of the combined total of

blacks and whites examined, about 76% were

cir-cumcised-whites, about 80%, and blacks, about

45%. The percentages of whites and blacks

corn-bined circumcised in the Northeast, Midwest,

South, and West (the states included in each region

are defined by the Census Department) were,

re-spectively, about 81%, 86%, 63%, and 73%. The

percentages of whites circumcised from these

re-gions were about 83%, 89%, 74%, and 74%. The

percentages of blacks were about 68%, 52%, 31%,

and 54% (T. A. Drizd, unpublished data from

Divi-sion of Health Examination Statistics, National

Center for Health Statistics, Hyattsville, MD).

About one in 2,500 of the eligible cohort of 12- to

17-year-old boys and girls was examined. As the

variation in practice from hospital to hospital for

circumcision is no doubt greater than for any other

procedure, the errors of projection from the

statis-tical sample are no doubt greater than for any other

procedure. Nevertheless, these Health Examination

Survey Cycle III figures are probably the best

in-dication of the circumcision practices in the United

States at the midcentury. The figures derived from

the Survey suggest that the number of hospitals

where not only 80% to 90% but 90% and above of

male newborns were circumcised was, in fact,

sub-stantial.

Reliable statistics that will report current

Amer-ican hospital practices should be available shortly,

at least in some states. For Canada, comprehensive

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r-Canadian national health insurance program. (Each

Canadian province has a federally subsidized

med-ical insurance program, providing the province

agrees to conform to federal standards. One of the

federal requirements is that the program be

univer-sal; the last province became eligible for subsidy in

1972. Some small groups-federal prisoners, the

Royal Canadian Mounted Police-are covered by

other plans.)

CANADIAN STATISTICS BY PROVINCE

Statistics of circumcisions from Health and

We!-fare Canada (HWC) have been reported

previ-ously.2 Ordinarily, HWC does not release the

statis-tics of individual provinces; thus the statistics

re-ported,2 which were for three fiscal years, were

combined for the Atlantic provinces, for the Central

provinces, and for the Western provinces. Statistics

have now been obtained from the individual

prov-incial health insurance commissions. In each

prov-ince, payments for circumcisions are made under

codes according to the age of the patient; for each

province, the number of payments under the code

covering the youngest age group is shown in the

Table. None of the commissions has earlier figures

than for fiscal year 1970 to 1971.

The Table gives (except in the cases of Ontario

and the starred provinces-see below) the number

of procedures compensated by the provinces by

fiscal year (April 1 to March 31). The percentages

in parentheses are the number (times 100) of

pro-cedures compensated under the code divided by the

number of live male births in the province during

the calendar year most nearly corresponding to the

fiscal year-the calendar year most nearly

corre-sponding to fiscal year 1970 to 1971, for instance, is

1970. For this reason, and because some provinces

include circumcisions on infants up to 1 year old

under the code, the percentages are not exactly the

fractions of male infants born during a calendar

year who were circumcised. However, since

accord-ing to HWC it takes an average of 60 days to process

a claim, the percentages are very nearly these

frac-tions.

The statistics for Ontario show the number of

procedures performed, rather than compensated,

during each fiscal year and the percentages the

number (times 100) divided by the number of male

births during the corresponding calendar year.

Since Ontario’s code 5570 includes only

circumci-sions on infants up to 10 days old, it is certain that

the number of circumcisions given for a fiscal year

occurred over a period of three months later than

the corresponding calendar year.

For the starred provinces (Table), the statistics

show the number of procedures performed during

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the calendar year and the percentages the number

(times 100) divided by the number of live male

births during the same calendar year. For this

rea-son, and because circumcisions on neonates only

are included under the codes for these three

prov-inces, the above reservations do not apply to the

percentage figures for these provinces.

No statistics are readily available from the

North-west Territories.

Except for Quebec, the number oflive male births

in the provinces in each calendar year from 1970 to

1974 has been taken from Statistics Canada’s Vital

Statistics Preliminary Annual Report 1974, Table

4B; the printouts of the final figures for 1975 to 1978

have been supplied by the Vital Statistics and

Dis-ease Registries Section of Statistics Canada. The

figures for Quebec for 1971 to 1973 have been taken

from the Quebec Ministry of Social Affairs’

R#{233}vi-sion des naissances vivantes annuelles, Qu#{233}bec,

1950-1974, Table D.02. The Ministry has supplied

a further revision of the figure for 1974 given in this

document, figures for 1975 and 1976, and the

prelim-mary figure for 1977.

Alberta

In the fiscal years 1970 to 1971 through 1976 to

1977, respectively, 389, 82, 263, 203, 252, 300, and

209 circumcisions were compensated for patients

whose age was not reported.

British Columbia

The fact that the percentage figures show an

increase for fiscal years 1974 to 1975 through 1976

to 1977 and an abrupt drop in 1977 to 1978 is in

part the result of decreases in the time taken to pay

claims and variations in the number of times

(usu-ally 24) during the fiscal year that payments were

made. According to the British Columbia Medical

Services Plan, the respective number of procedures

for 1974 to 1975, 1975 to 1976, 1976 to 1977, and

1977 to 1978 should be adjusted as follows: -3%,

-5%, -5%, +4%.

New Brunswick

According to the Department of Health, the

re-porting system used prior to April 1, 1976, led to a

possible underreporting of circumcisions.

Newfoundland

The flgurs given are for circumcisions performed

by fee-for-service physicians. Not included are the

circumcisions performed by the 33% of the

physi-cians of the province who are salaried. Estimates

have been given that fee-for-service physicians

serve 55% and 70% of the population. For each year,

by using these two estimates, two values have been

calculated for the percentage of male infants,

deliv-ered by fee-for-service physicians, who were

circum-cised. The two values are given in the Table as the

limits of a range of values within which the actual

value probably lies. If it is assumed that the practice

of the salaried physicians does not differ

substan-tially from that of the fee-for-service physicians, the

range can be taken as that within which the

per-centage of all male neonates circumcised probably

lies.

Saskatchewan

The number of circumcisions from the Swift

Cur-rent Medical Region, through which approximately

5% of the province’s population receives services,

are not included. Since the number of live male

births includes the number for this Region, the

percentage figures for circumcisions should be

ad-justed upward, by 2.7% or 2.8%.

Yukon

The data for the last quarter of fiscal year 1977

to 1978 are incomplete and the figure for that fiscal

year is partly estimated.

SUMMARY OF TABLE

Disregarding the Northwest Territories, for

which figures are not available, the highest

mci-dence of neonatal circumcision is in the

Yukon-about 70% in the last few years. In the four Western

provinces plus Ontario and Prince Edward Island,

the rate in the last period reported is about 50%.

The latest rates computable are 30% and 22% in

New Brunswick and Nova Scotia, respectively. The

latest rate reported in Quebec is 13%. In

Newfound-land, the rate is 2%, far lower than in any other

province.

Except in the Yukon and Saskatchewan, a fairly

rapid decrease in the rate is evident-one which if

extrapolated over the next 20 years or so would

result in a low rate. In 1975, a statement by the

Canadian Paediatric Society3 speaks of “a society

with a rapidly diminishing demand for

circumci-sion” (no statistical evidence was advanced to

sup-port this comment). This is a fairer characterization

of Canada in its circumcision practices than that

found in the British Medical Journal.’ In

New-foundland, neonatal circumcision may be less

corn-mon than in Britain.

COMMENTS

The British Medical Journal editorial’ gives the

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cir-708 CIRCUMCISION PRACTICES

cumcised in Britain as 6%. It remarks that this is

“probably about the correct proportion in a

West-em country today,” ie, the proportion for which

circumcision is medically indicated. It also

recom-mends that medically indicated circumcisions be

performed between the ages of 3 and 5 years and

states that “unfortunately only one third of the

operations in England and Wales are done before 5

years.” The basis for these statistics is given as one

of the Hospital Inpatient Inquiry reports of the

Department ofHealth and Social Security (DHSS).

As to circumcisions, however, these reports are

almost certainly incomplete, for three reasons: (1)

Like the similar government reports of “hospital

morbidity statistics” of the United States and

Can-ada, they do not include procedures on neonates.

“Newly born babies are not included as patients in

their own right in NHS [National Health Service]

hospitals unless they are nursed in a special care

unit and/or pediatric department.”4 (2)”. . .[DHSS]

statistics for the numbers of circumcisions refer

only to those which were medically necessary and

do not reflect the number of circumcisions

per-formed for religious, ethnic or hygienic reasons.”5

Unlike the Canadian national health insurance

pro-gram, the National Health Service does not

corn-pensate routine circumcisions. (3) “Since the

Hos-pital Inpatient Inquiry gives only the primary

rea-son for requiring treatment [and circumcision may

be a secondary reason], we have no figures for the

total numbers of circumcisions performed each

year.”5

A decrease in the circumcision rate in the United

States similar to that in Canada, although

uncer-t,ain, is suspected.

ACKNOWLEDGMENTS

The author thanks Mr T. A. Drizd for supplying data

from the National Center for Health Statistics; Mr D.

Nagnur of Statistics Canada and Mr W. A. Mennie of

Health and Welfare Canada for their response to several

requests for statistics; and to the provincial health

insur-ance commissions for supplying their statistics for

publi-cation.

REFERENCES

1. The case against neonatal circumcision, editorial. Br Med J 1:1163, 1979

2. Wirth JL: Statistics on circumcision in Canada and Australia. Am J Obstet Gynecol 130:236, 1978

3. Circumcision in The Newborn Period: Supplement to the

CPS News Bulletin, Sept/Oct 1975. (Copies of the English/

French text are available on request from the Society at the

Department of Pediatrics, Centre Hospitalier Universitaire,

University of Sherbrooke, Sherbrooke, Quebec J1H 5N4.)

4. Mann JDW: Letter. Statistics and Research, Dept of Health

and Social Security, Dec 16, 1976

5. Robinson EJ: Letter. Dept of Health and Social Security,

May 12, 1977

BELIEFS AND BIASES

It is often the fashion that upon entering medical school the student is

exposed to patients when he does not yet know how to differentiate between

the gluteus maxirnus and the olecranon. The presumed purpose of this early

exposure to patients is to make medical school more meaningful to the novitiate

medical student. In my view, however, these “show and tell” sessions are the

rankest waste of time and will never replace the “6Rs” of medicine-anatomy,

physiology, biochemistry, microbiology, pathology, and pharmacology.

More-over, rearranging basic science courses in various combinations and

permuta-tions, whether by subject matter or by systems, does not always result in better

course offerings; on the contrary, much tends to fall between the cracks.

From Petersdorf RG: The Pharos, Spring 1980, p 11.

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1980;66;705

Pediatrics

John L. Wirth