[Recorded by Electronic Apparatus]
Tuesday, November 19, 1996
.1110 
[English]
The Chair: We're back on Bill C-27. We have highly specialized witnesses today.
We welcome, from the Society of Obstetricians and Gynecologists of Canada, Dr. André Lalonde, president, and Dr. Gillian Oliver, head of pediatric and adolescent gynecology at the Hospital for Sick Children.
We'd like you to present your brief before we go to questions.
Dr. Lalonde, I understand you're going first.
Dr. André Lalonde (Executive Vice-President, Society of Obstetricians and Gynecologists of Canada): Madam Chair, I have a slight correction. I'm the executive vice-president of the society, not the president.
The Chair: We were so impressed with you we promoted you.
Mr. Rideout (Moncton): We're always elevating people.
The Chair: That's right. They elevate everybody around here but me.
Dr. Lalonde: Ladies and gentlemen, the Society of Obstetricians and Gynecologists of Canada is pleased to appear in front of this committee to discuss two bills, Bill C-235 and Bill C-27. The SOGC studied this issue and issued a statement in September 1992, which I will share with you in a few moments.
Female genital mutilation is a serious international problem. It results more often in child abuse and is unfortunately still widespread in the world. However, in Canada, fortunately, we usually see the results of female genital mutilation undertaken in other countries, and there have been no reported cases in Canadian hospitals of complications of female genital mutilation undertaken in Canada.
Briefly, I will mention the types of genital mutilation. There are various types, from a small incision into the vulva-vaginal area to major amputations. The first type is usually a small incision of the labia and/or clitoral area. Secondly, it can be a full excision of the prepuce of the clitoris, or the complete excision of the clitoris with or without the labia minora. The third type is the infibulation type, in which the whole clitoris is excised together with the labia minora and the internal surface of the labia majora.
Complications are very well known and can lead to serious infection, including septic shock and even death. Long-term complications are numerous and may include any of the following: anaemia; difficulty with micturition; recurrent urinary tract infection; urinary incontinence; chronic pelvic infection; infertility; vulvar abscess; keloid formation; dermoid cyst; neuroma; calculus; fistula; sexual dysfunction; menstrual dysfunction; problems in pregnancy and childbirth; and even HIV transmission.
The physical complications are accompanied by tremendous psychological damage and consequences that can include loss of trust and confidence in caregivers, anxiety, depression and behavioural problems.
In this first slide you can see the vulvar-vaginal area. There should be an opening. You should be able to see the vagina. Up here is usually the prepuce and then the clitoris.
As you can see, there is a complete excision. There is no more clitoris, no more prepuce, no more folds at each side of the clitoris. The vagina is closed until this very small opening at the bottom. This is usually the major type, a complete excision of everything.
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This slide illustrates the small opening. The rectal area would be here. The clitoris area should be here.
This is a surgical instrument inserted underneath here, because we'll have to do an incision to open up the vagina and the urethra. Once these parts have fused, they cannot void normally. They void but it goes down underneath this new area and comes out in a small hole at the opening just over the anus. Menstrual flow also comes out there.
Complications are urinary tract infections, but you can imagine, if this small opening does not occur, or if there is fusion of that small opening, then it's a serious problem for both urination and when the first menses come. Since these women have this done when they're children, when the first menses come, if this opening is not wide enough or is not even there, it has serious consequences that can lead even to death.
Surgically, as shown previously, the scissors were in here, and it opened up completely. It's a bit difficult for you to realize, but again, there is the anus area. There is a small opening at the beginning and now there is a major opening surgically to correct this.
Now that it's open, it leads right up to the urethra. Each side are what we call the ``flaps'', because the labia have disappeared.
Other frequent complications.... Again, we're looking at the perineum area. We have here the anus, and then the start of the vaginal opening. You can see this tremendously big cyst. This is a case history of a 22-year-old woman in Canada who presented this many years after having had the procedure done in her country.
This measured approximately 10 centimetres. You can see the small opening only of the vagina and the huge cyst that will have to be excised.
They present here in Canada most often because they have menstrual problems or because they want to have vaginal intercourse either before or when they're going to get married, or else they are pregnant.
That was the cyst that was removed. As you can see, it measured 10 centimetres.
Finally, in terms of repair, as you can see, it causes a lot of scar tissue. This shows the opening of the urethra to the exterior. That's the repair and some of the scar tissue that's left.
It does, however, give good results. This is the final result. The vagina is open, and it's now created a small, artificial labium on each side. When we suture each side, it recreates that zone or that area. Usually this catheter in the urethra is used only for the surgical procedure. It is a relatively minor procedure to repair this in Canada.
So the complications are numerous. When they're done, obviously they're usually not done by physicians, and therefore they're not done under aseptic conditions. This leads to major problems of infection and haemorrhage. As you know, around the clitoris there are major arteries. If the dorsal artery of the clitoris starts bleeding it can lead to haemorrhage and even death.
In terms of medical treatment, physicians in Canada have received instructions on how to deal with the physical aspects of female genital mutilation. We have had articles in the SOGC journal, in pediatric journals, in the Federation of International Gynecology and Obstetrics journals and in the CMA journal. So our members are pretty well aware of what has to be done.
Many gynecologists in the country have experience with repairs, mostly in adult women and women who are planning to have vaginal intercourse or who are already pregnant. Although the surgical techniques are well known and in place to respond to these mutilating procedures, very few programs in Canada address the psychosocial aspect of this problem.
I now would like to present the policy statement adopted by the Society of Obstetricians and Gynecologists of Canada on September 1992. The SOGC reviewed information regarding female genital mutilation, including female circumcision, excision and infibulation.
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The SOGC board council unanimously passed the motion that female genital mutilation is never medically indicated. Its practice in Canada by a physician is inexcusable. The SOGC condemns this procedure as being a violation of the female body. The SOGC recommends that physicians performing this procedure should be reported to provincial licensing bodies.
Women who have been subjected to any of these procedures should be treated with understanding and compassion. Guidelines should be developed to assist physicians in dealing with these women during examinations and vaginal birth.
I would like to briefly comment on the bill that is being proposed. The SOGC has reviewed both bills and commends the government and members of Parliament in their effort to address this important issue.
SOGC has taken the stand that makes any act of female genital mutilation incompatible with the practice of medicine, thereby exposing physicians and other health professionals to severe sanctions if they participate in these procedures.
The only difficulty we see with proposed section 268 of the bill is the last few lines where surgical procedures are permitted for ``the physical health of the person or for the purpose of that person having normal reproductive functions or normal sexual appearance or function''. We understand the reasons this was put there. We are, however, concerned that someone could act for such a procedure because they feel this is a normal sexual appearance or function according to their culture, and that being the culture of the physician and the culture of the patient. We believe this would then create a possible loophole.
The SOGC would strongly recommend that an amendment be added to the bill stating that female genital mutilation is never medically indicated. This covers all eventualities. Even if someone wishes to have this procedure done for cultural reasons, the physician would still be prohibited from doing such a procedure.
The second area of concern is that we would like to include the word ``vagina'' when we talk about the clitoris labia majora and labia minora. Again, this could be a loophole where someone, for example, after the delivery of a baby would proceed to close the labia majora or the entrance of the vagina. This has been requested by some cultural groups. For this reason, we believe we should add the word ``vagina'' and therefore close that possible loophole.
In conclusion, the SOGC is pleased that Parliament will outlaw this reprehensible act. Although the bill appears to answer most of our concerns, we believe the wording should be clear that female genital mutilation, including female circumcision, excision, and infibulation, is never medically indicated in Canada.
Thank you.
The Chair: Dr. Oliver?
Dr. Gillian D. Oliver (Head, Pediatric and Adolescent Gynecology, Hospital for Sick Children; Society of Obstetricians and Gynecologists of Canada): Good morning. Thank you for allowing me to participate in the formulation of Bill C-27, addressing female genital mutilation.
I believe my role here today is to provide medical expertise pertaining particularly to proposed subsection 268.(3). Furthermore, it is to ensure that the bill is not prohibitive to providing appropriate surgical reconstruction of female genitalia, where the goal is to maximize the child's anatomic, psychologic and reproductive health.
Rather than attempting to give a complex lecture on developmental embryology or gynecologic pathology, I thought it would be best to show you by way of a very short slide presentation some examples of congenital and acquired abnormalities of genitalia so that you can appreciate the need for this proposed subsection in Bill C-27.
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I thought I would just start with a picture of a circumcised female, again emphasizing what Dr. Lalonde just said.
This is the opening of the urethra. The clitoris has been removed and the labia minora, or the small lips, have been brought across.
Here you can just see the back of the hymen, the opening to the vagina, which is all that is allowed for egressive menstrual products.
What's important is that these women often present themselves to a physician and request that this procedure be reversed, so the bill has to allow a physician to reverse this procedure.
This is an example of more my area. This is a female child born with a condition called congenital adrenal hypoplasia. The clitoris is markedly enlarged. The labia majora are naturally fused together in the midline. This child has an entirely normal reproductive potential if she can undergo reconstructive surgery. It's very important that this bill does not prohibit us from operating on these children.
This is a male child, born with a condition called bladder ecstrophy in which the bladder and midline wall is not developed. As a result, because of this fusion defect, all the anatomy for a male child does not fuse.
I think you can appreciate that this child has no reproductive potential as a male. These children have to be raised as females from birth. They need to undergo reconstructive surgery, so that although they will not have a reproductive potential, they will have normal external genitalia and normal sexual function. This bill must allow us to do this operation.
This is a genetically normal female presenting with no vagina. I don't know if you can appreciate this, but here's the front, the clitoris is hidden behind, the urethra is just tucked behind, and there's no vaginal opening. The bill must allow us to be able to reconstruct the vagina for this female so that she can function sexually.
There is an offshoot of this condition. There is a uterus behind this, and if we hook up to it, this person will have normal reproductive potential. The bill must let us be able to operate on these people.
Going away from congenital defects, this is a child with what we generally call a ``straddle injury''. Here is the normal urethra and vagina and the hymen's intact. But she fell on a horseshoe stake and she has a penetrating injury to the labia minora and majora. The bill must allow us to operate and fix that to try to attempt to reconstruct a normal anatomy.
This is an older adolescent victim of rape. This is called a vulva hematoma. In this situation it's expanding and it needs surgery because there is increasing blood flowing by the hour. We have to be able to operate on this labia majora and minora to fix this problem. There is a catheter tube to allow her to pass urine, so it gives you an idea of how much swelling there is.
This is a little more difficult slide. This is a child who was a victim of sexual assault with a burn injury into the vagina. All the anatomy has been destroyed by the burn. This area will scar down and stenose and this child will eventually have numerous complications. Again, we need to be able to operate to correct this.
And lastly, acquired things. This is a child with what's called a lymph angioma, which is a benign growth. We can have a cancerous growth developing in children on the genital region. Again, we need to be able to operate on the genitals to remove these. Left unchecked, this will just grow and grow, to the point where she won't be able to walk.
Finally, I'd like to emphasize that there's an important reason for that proposed subsection 268.(3). It allows normal and appropriate medical care to be carried on. There are very clear distinctions and guidelines within the medical literature that would prohibit a physician abusing the bill and using it as an excuse to perform an infibulation.
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It's important that we as lawmakers do not prevent what is normal medical practice, and allow medical practice to clearly define the line, which has already been clearly defined, between an appropriate operation and a mutilation.
Thank you very much.
The Chair: Thank you. Madame Gagnon.
[Translation]
Ms Gagnon (Quebec): It is nice to meet you this morning. You have raised some important points on this bill. You know that I am rather concerned by this bill. I even introduced one myself and pressured the minister a little because he did not seem to see the importance of such a bill. Like you said, in Canada, it is quite difficult to find reported cases of excision.
In my bill, I wanted to send a clear message to practitioners, judges and all people concerned by the issue so that there is no ambiguity in the minds of the groups involved. This is a cultural practice that is inadmissible in Canada and elsewhere. Extraterritorial reach is of utmost importance. When these people leave the country, they leave with young Canadian girls and boys. They are now Canadian citizens and practice something that is intolerable in Canada.
That is more or less the objective of the bill and the objective I sought. The minister introduced the bill and we are happy. At least there is a bill that we can work on and perhaps improve. However, I see a problem with one of the clauses, the one dealing with consent that could be given at age 18.
The Quebec Bar as well as the Canadian Bar Association appeared before us. They believe that this bill sends out an unclear message. I would like to ask you if you share that point of view.
My second question deals with the clause that could allow certain surgical procedures. I would have liked to have proposed an amendment. In a bill like this, certain things do not need to be clarified, and I am afraid that it could open the door to certain practices that could, under the guise of... I would like you to clarify that a little and tell me if you also see it as an opening to authorize certain surgical procedures.
Dr. Lalonde: We raised the same concerns regarding consent at age 18. We understand more emphasis being placed on young persons under the age of 18. It should perhaps be added that young persons under the age of 18 will not be able to obtain consent from their parents or any other person. We are not lawyers and we have to rely on the Bar Association or on people who are more familiar with the legal issues.
My colleague will comment on surgical procedures. It is clear that we cannot draw up a list. Some people are born with certain anomalies that are not visible. That is why we said that the first phase was quite clear. I do not think that the experts, pediatricians, gynaecologists or others, would have trouble differentiating between a mutilation and the correction of a congenital deformation.
So perhaps mutilation should be mentioned. There is no problem defining the word "mutilation", whereas it is quite difficult to define the word "normal". The text reads:
- ... for the purpose of that person having normal reproductive functions or normal sexual
appearance or function.
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That is why we said that at the very least, the bill must include the principle that mutilation will never be accepted. We also said that it was important to realize that if the word "normal" were used, we would be opening the door to various interpretations.
[English]
Dr. Oliver: Forgive me for answering in English, but I'll understand myself much better.
I have a few points here. First, addressing the word ``normal'', I think that in the medical literature ``normal'' implies what is meant to look natural. It is very clear in the medical literature that any surgeries done in an effort to restore what should naturally happen.... Therefore, any type of mutilation, which is the exact opposite, implies taking away from what should happen naturally.
Going back to your first few points, it is important that you understand that it is very clearly delineated in the medical literature and very well understood what the line is between surgery that contributes to a positive outcome and surgery that would be considered mutilation. I think that in any court in Canada, it would be very easy to demonstrate and to criticize any physician who stepped over that line, and to find that doctor guilty of misconduct. So in the medical terminology this is a very clear point; it's not an issue of debate among doctors. I think the physician who took on that responsibility would be very much in danger of losing his licence from the medical point of view.
Second, on your concern about international children and Canadian children going abroad, certainly that has happened. There has been precedent. In my own experience, when there was concern that the children were being taken back to their home country under the guise of a vacation with the actual intent of performing a circumcision, the Children's Aid Society did step in and prohibit them from travelling outside the country. While we cannot police everywhere, if there is any concern by an active person, all they would have to do is call the Children's Aid Society to raise that issue.
Third, regarding consent, we have to be very careful not to violate the individual choices of an adult, particularly when you're dealing with sexual practice. It's very common in our society today to mutilate the genitals as part of sexual practice. Items such as earrings in the labia and tattooing are very, very common in women today. We have to be careful. While one might perceive that as mutilation, another might see it as their freedom. You have to be careful to introduce anything that violates an adult decision. Whether that should be age eighteen or sixteen - that is not a doctor's domain. Whatever age you set, I think you have to recognize that adults may be free to do whatever they choose.
This recognizes that if you go to a doctor for a return to a mutilation - and some women do come seeking a repeat circumcision - it's very clear among physicians that this is not acceptable. A physician who performed that procedure would certainly be challenged by colleagues. So again, that is a dead end for the patient.
I believe I've answered all your points.
The Chair: Thank you. Ms Torsney.
Ms Torsney (Burlington): I have to say that you reminded me of two things: one, why I never wanted to be a doctor, or couldn't be a doctor actually - the will may have been there - and also just how much respect I have for the work you do. Thank you for that.
I'm a little confused from your two presentations if you're not somehow in conflict. I wonder if I'm just not understanding or if you could clarify.
Dr. Lalonde: I don't think so. I don't view it as a conflict really. We look at it as a whole society, apart from the caution in terms of permission to do the operation, the culture, the norm, a definition of normal. We felt that it would be good to have stated somewhere that it's not a medical act in Canada.
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It would also be important to give this as a message internationally. We do have contact with a lot of countries and our physicians work in these countries, and it's good for them to be able to say that in Canada this is not a medical act. I think that comes from the meeting they had in Cairo, an international meeting on women's health.
So I don't think we are disagreeing. We haven't met before.
Dr. Oliver: Perhaps it's just that Dr. Lalonde wants to emphasize that the term ``mutilate'' is not acceptable and what the definition of mutilation is. I interpreted that it could be much broader in that a lot of the surgery I do is, in a sense, a mutilation of the tissue there. I'd like to think of it as different, but it could be interpreted that way, that I am changing and altering. It depends on your definition of mutilate. I think he felt that it would be better if we defined mutilation in terms of female circumcision, that this is not acceptable, and make that a much stronger statement.
Ms Torsney: I gather, Dr. Lalonde, that you are asking for things to be narrowed slightly. You, Dr. Oliver, were suggesting that it doesn't need to be narrowed because if we did that, some of the work you do could cause you to be in conflict with the law. Am I wrong?
Dr. Oliver: No, I don't think we're that much in conflict. I think he just wants to state it more strongly than the wording here.
Dr. Lalonde: Yes.
Ms Torsney: And you could live with those changes?
Dr. Oliver: Yes.
Ms Torsney: Not necessarily that this deals with Bill C-27 or Bill C-235 directly, but I was interested in what you said, Dr. Oliver. How does the CAS manage to find out that children are being taken out?
Dr. Oliver: In my situation, there were three sisters in the family and the older sister had the feeling that this was the reason they were being taken back for the visit. She confided in me her fear of going back and that there were two younger children in the family. That gave me grounds to contact Children's Aid. They stepped in and prohibited the father from taking the daughters back to Somalia for a visit.
Ms Torsney: Wow. I know that we had a presentation with some of the cultural groups when the minister was still doing some research before this bill was introduced. In Toronto there's a pretty active working group, and I suffered through reading the brochures to doctors and teachers. Were you involved in the formation of those?
Dr. Oliver: Certainly not at the grassroots level, but I'm involved in helping on a medical level. It's very much a grassroots organization from the women of Somalia and Ethiopia to educate new immigrants about this practice, and particularly to help educate those women who are having female children, to prevent them from allowing their daughters to go back and have this done or have it done within the community. I think it's naive if we don't think it's still happening in the community. We just aren't seeing the complications yet.
Ms Torsney: To date you've never had someone come to you who had the operation performed in Canada, as far as you know.
Dr. Oliver: No.
Ms Torsney: Do you have the largest practice of this sort in Canada, or are there similar doctors in all of our major urban centres?
Dr. Oliver: I work in a group of five pediatric gynecologists at the Hospital for Sick Children. I would think we are the biggest in Canada, and we certainly have the highest Somalian and Ethiopian population to deal with.
Dr. Lalonde: Physicians are dealing more and more with this across Canada in terms of when you come to present. Some of them just find out when they come to present...have a baby.
Ms Torsney: Childbirth.
Dr. Lalonde: That's why we've had these guidelines written up and articles in the medical journals, so that they know what to do with this.
Ms Torsney: That brochure out of Ontario is about what to do when a women is delivering and how to make sure there's as little damage as possible.
I think that was the end of my questions.
The Chair: Mr. Rideout.
Mr. Rideout: I'm trying to get through this business of normal and the wording. Do you have any suggestions even in the general sense of wording, or about things we should be looking at in order that we don't tramp on your toes?
Dr. Oliver: I think I was just responding to interpretation of the word ``normal'', and I certainly don't feel comfortable commenting on the French interpretation. In medical literature normal is defined as what is the norm, not in our society but in our world. The idea of a normal anatomy is very clear. It is what it's supposed to look like, and whether you're Japanese, Ethiopian or North American, your genitals basically follow the same pattern. It's not a cultural definition. What I showed you was abnormal, accidents of nature and of life.
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So with ``normal'' as a medical term, I think it's very clear that if a physician carried out a circumcision, he would be violating normal.
Mr. Rideout: So you think the word ``normal'' is okay?
Dr. Oliver: From a medical perspective, I do.
Mr. Rideout: There is also talk about the benefit of physical health of the person. Is it too restrictive to limit it to just physical?
Dr. Lalonde: The reason I understood they limited it to physical is to prevent the cultural part, where somebody would say that psychologically they would feel better with this off of them because of their parentage or whatever. I think we agreed that it was okay to leave it like that.
Mr. Rideout: Fine. That's all the questions I have.
The Chair: Go ahead.
Ms Torsney: Someone suggested to us that there could be cases where the labia majora or minora were extra-large or something, and somebody wanted to have that changed. Does that occur? Is that something you would also need to allow room for within the legislation?
Dr. Oliver: Yes. Prominent labia minora are relatively common. There's definitely an individual tolerance, but some women find the extra-large labia difficult in that they will trap in underwear, making it very uncomfortable, and they find this difficult in their day-to-day lives. They may want them corrected for that reason. Other women find it very difficult during intercourse in that the labia minora get trapped and pulled and this causes prohibitive pain with intercourse. In those two circumstances you do need to correct them. Some of them actually become traumatized and ulcerated from this chronic irritation, so there is a need to allow us to operate on that.
Again, in the medical terminology a physician uses judgment as to what is too large, and it's really based on patient complaint. If it's not bothering the patient, it doesn't matter how large it is if they don't want the operation.
Ms Torsney: Again, that would mostly be in people who were over eighteen rather than children.
Dr. Oliver: No, not necessarily. It can present much earlier.
Dr. Lalonde: I think you're basically covered with that because as she just explained, the operation would usually be to correct it, not to do a total excision. If someone had to do a total excision, I'd think the way the hospital is made up now, you'd have to answer to a tissue committee. You'd be brought up to the board of the hospital and you wouldn't be able to defend that. I think you are covered with that under the current medical laws, but you cannot do an operation to do a complete excision unless you have pathological reports.
Ms Torsney: I think it was raised in the context of consent, and why certain adults would be having operations of any sort related to the labia minora and majora.
The Chair: I want to ask a couple of things myself, with the permission of my colleagues.
I don't want to ask you to comment on cultural issues - that's not the point - but I think it's important for people who are considering this, or who may be considering our process here, to understand why these types of operations might be performed in certain cultures. I'd like to know the answer to a couple of questions.
First of all, once a woman has been circumcised, does that then prevent her from having an orgasm or having any kind of sexual pleasure or physical excitement as a result of sexual intercourse?
Dr. Oliver: It depends on the type of circumcision performed. A lot of women will have what we call a ceremonial circumcision, where a very small procedure is done and it really doesn't interfere with the clitoris or the vaginal function. Other women have more extensive surgery in which the clitoris is actually removed. So there is a spectrum of what the women will experience. In generalized terminology, most women will at least have some discomfort during intercourse, and that in itself may limit orgasm.
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The Chair: And the stitching together of the labia and the creation of this small channel, does that serve to increase pleasure to the male?
Dr. Oliver: No, my understanding is that there are two factors: it's to ensure that she remains virginal, and by removing the clitoris to ensure that she doesn't enjoy intercourse and that her function is only for male pleasure and for reproduction.
The Chair: That's what I was wanting to get to.
In the world of plastic surgery and the world of psychiatry there are occasions when a man or a woman may wish to change the outer manifestations of their sexuality. Have you turned your minds to that? Does this bill prevent a doctor from making a man a woman or making a woman a man? I'm concerned about the exception, because it talks about normal function. A person who starts life physiologically as a male has normal reproductive functions and normal health, but there is the phenomenon where he may believe that...or he may be a.... I don't know how to say that.
Dr. Lalonde: We looked at this at the board meeting and we've had the social sexual issues committee look at it too. The procedures for change of sex are complex and they usually require quite a work-up, including psychological, psychiatric assessment, etc. They are very rarely done by an individual physician in a small community hospital. It would have to go through a complete evaluation, so we felt there was no danger with that.
The Chair: So this bill doesn't, in your minds, prohibit that from occurring.
Dr. Lalonde: No.
The Chair: It wouldn't be something they'd be doing in a small town without some kind of guidance or some kind of -
Dr. Oliver: There are currently only three areas that I know of that are doing this: Montreal, Toronto and Vancouver. There are very clear guidelines, including that the individual must live in the cross-sex for at least two years as part of the work-up to ensure that this is what they want to go through. As the work-up goes through, they are then usually over eighteen as well. I don't think this would likely happen before age eighteen.
So the guidelines are there and they have to live as an adult in that sexual role. It's a period of at least two years completely in that role before any surgery is done. There are a lot of controls there.
The Chair: And you did turn your minds to it before you....
Dr. Oliver: Yes.
The Chair: Those are all the questions I had.
Are there any other questions, colleagues? Madame Gagnon.
[Translation]
Ms Gagnon: I am a little bit surprised to hear you talking about female circumcision rather than infibulation or excision. In Cairo, at the International Conference on Population and Development - I have attended a lot of conferences - a man talked about female circumcision. That caused an outcry. The women who were present and who were affected by this problem said that talking about feminine circumcision was a way of minimizing the act. I notice that you are using that word this morning. Do you usually use that expression? Do you define the practice of genital mutilation using the words "female circumcision"?
[English]
Dr. Oliver: Certainly not to undermine my abhorrence of the practice of female genital mutilation, I use the term ``circumcision'' because that's the more accepted medical terminology. It applies to the five different kinds of genital mutilation that can happen. Infibulation is one of the five. Circumcision is just a broader term; it's not in any way meant to undermine. I apologize if that's how you interpreted it.
[Translation]
Ms Gagnon: The purpose of male circumcision and female circumcision are not at all the same. Talking about female circumcision is very pejorative. That is what was stressed at the Cairo conference. I know that you are not minimizing the problem. However, defining female genital mutilation using the words "female circumcision" is offensive to some people in the field. I have attended a lot of conferences on the issue and I was anxious to tell you that that is not the expression used by the groups involved.
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[English]
Dr. Oliver: I'm here to speak on a medical term. I'm not here to become emotionally involved in this debate. I think ``circumcision'' is appropriate medical terminology.
[Translation]
Ms Gagnon: I would like some clarification on the proposed subclause 268(3). Would you like us to introduce amendments regarding the exception whereas the surgical procedure is performed by a person duly qualified by provincial law to practice medicine? Would you like us to amend that subclause or are you satisfied with it? It is not clear in my mind.
Dr. Lalonde: Are you talking about the proposed subclause 268(3)?
Ms Gagnon: Yes, sir. I know that you have made recommendations, but I would like that there be an amendment. I would like to know if you want an amendment.
Dr. Lalonde: For us, it is not really a question of naming the procedures. As my colleague indicated, it is very difficult, because we could never draw up an exhaustive list of all the procedures. Some would be left out. With a view to training and prevention, the society wanted to send out a national and international message.
The message should be very precise. While it is not stipulated in the Act, genital mutilation is never medically indicated. So the message is there, but sometimes we need a sentence that shock people. So they will say: "It is in the Act, for doctors, nurses and paramedical personnel." We must not forget that paramedical personnel are also involved in these situations. Doctors have been warned that the practice is unacceptable in Canada, but some other people could think that they are able to practice it. However, we do not see how we could draw up the list of all the procedures.
Ms Gagnon: But would you like there to be...
Dr. Lalonde: We are clearly stating that genital mutilation is not medically acceptable. In my view, that is stronger than saying certain things must not be done except to reestablish normal functions.
Ms Gagnon: Thank you.
[English]
The Chair: Thank you very much for your assistance. We appreciate having you make the effort to come and educate us. Thank you.
This meeting is adjourned.