Wednesday, November 2, 2011

The Kindest Cut, Part 2

Looks like I chose a touchy subject for my last blog post; there appear to be quite a few men mourning the loss of their infantile foreskin.  Let me summarize some of the arguments made against my opinion on male circumcision, with my responses:


1.  You cherry-picked studies showing a benefit for male circumcision.  It's true that while numerous observational studies have shown a benefit in terms of UTIs and STDs, there are some studies finding no effect, or even an opposite effect.  Non-experimental, observational studies are fundamentally flawed for this reason.  That's why it's so important to look at randomized, controlled trials whenever possible.


2.  The risk of UTIs in male infants is low and does not justify circumcision.  I totally agree.  The reduction in UTIs alone is not large or clinically important enough to advocate for this procedure.


3.  The trials in Africa are flawed because they weren't double-blinded, and they were stopped early.  OK, YOU design a study that does sham circumcision in the control group, and try to get that past an ethics committee.  Stopping a trial early because of a significant benefit in the treatment group (and offering it to the control group) is the most ethical thing to do in this situation, since HIV is a life-threatening disease.  It is true that stopping a study early for this reason tends to overestimate the benefit, and I might be suspicious of the results if they were seen in only one trial, but in fact, the benefits were seen in all three studies, in different parts of Africa.  The Cochrane Group, which is extremely conservative in its recommendations, concluded, "Research on the effectiveness of male circumcision for preventing HIV acquisition in heterosexual men is complete.  No further trials are required to establish this fact."

4.  The trials in adult heterosexual African men don't apply to infants in the developed world.  The majority of HIV infections in the U.S. and worldwide are due to unprotected sex.  Sure, the absolute reduction in HIV infection with circumcision will be lower in the U.S. than in some parts of Africa, but relative risk reductions tend to remain constant over various patient populations.  I do agree that if you're in a part of the world with extremely low rates of HIV infection (such as Australia -- which has a 0.004% annual risk of infection), routine circumcision may not make economic sense.


5.  Why not promote safe sex instead?  I'm not saying circumcision should be done instead of teaching safe sex.  HIV prevention needs to be multi-pronged, and must also include education, free condom distribution, low-cost antiviral treatment (which reduces transmission rates) and needle exchanges.


6.  Infants die from circumcision, and parents shouldn't be making this decision for them.  Yes, babies will rarely die from circumcision, just as people will rarely die from having IVs inserted into their hands or having a severe allergic reaction to antibiotics (both of which I have seen).  But AIDS is still a huge killer, even in developed countries.  As for parents who want to let their sons make the decision about circumcision once they come of age, I think that's fine.  Just realize that adult male circumcision is a bigger procedure, often involving general anesthesia, and may not be covered by insurance plans when done for purely preventive reasons.


7.  Your story about Dr. Nick operating on your kid sounds fishy.  Nope, absolutely true.  I got a list of low-cost providers because I gave birth at my own, public county hospital.

8.  You're a terrible mom.  OK, I will concede that in the moment that I let Dr. Nick circumcise my son, I was a terrible mom.  I'm an imperfect parent, which is why I think a lot of people read my blog.  If I had to do it all over again, I would still have my son circumcised, but I'd go with this guy instead:
Extra credit if you can name this Simpsons character*

9.  The foreskin is a part of normal male anatomy, and removing it is mutilation.  It occurred to me that this argument probably should have been #1, as many of you have a philosophical objection to circumcision.  You think it's wrong to remove normal foreskin for any reason, and I don't.  There's nothing we can say that will change each other's minds on this point. 

And so we have a parting of the ways.

 *It's Krusty the clown's dad, Rabbi Hyman Krustofski.



37 comments:

  1. Ok, so you've proven that both sides can pull facts and argue all day long about which facts fit whose agenda. Can I pull a billion more articles/studies that prove my point that infant circumcision is not beneficial and is, in fact, harmful? Yes. Can you do the same with your facts? Yes.

    In the end all we are left with is basic human rights: Are you correct in your opinion that your son does not have a right to his whole penis?

    Anna

    ReplyDelete
  2. Nope glibly glosses over the science, equating both sides by claiming billions of studies support either view. That's silly, and specious. The point of these articles (and this blog) is to summarize objective, good data. The state of the science is not in equipose on this issue.

    Nonetheless, it may be reasonable to say, "damn the science, I'm still correct!" on ethical grounds-- an area that's not testable or falsifiable through scientific methods. That would seem to be the point of Nope's second paragraph, claiming that circumcision is in fact a human rights issue.

    But parents have to make risk: benefit decisions for their children all of the time. There are some risks of vaccinations-- so it is right that parents expose their child to this risk without their consent? Leaving aside the anti-vaccine wingnuts (see paragraph above about science), most would argue that the demonstrable good of vaccines outweighs the risk, and that therefore good parents choose the vaccines to protect their child. Is that what a three year old would decide? No. That's why three year olds don't make these decisions.

    There are many other examples of "rights" of children that parents trample upon: many kids would choose to not attend school, or eat vegetables, or kiss Aunt Martha. More seriously, children may not consent to painful or even dangerous medical procedures that are objectively necessary. Parents are the decision makers, and ought to make their decisions based on solid evidence rather than hyperbole and slogans.

    ReplyDelete
  3. I'm with Nope on this one. The mind is so powerful. And many-a-mind has been engrained to believe that circumcision is a normal, okay thing. The ethical perspective should be obvious, but to those of us who know that, it's amazing how much support it can get and from what intelligent people the support can come from. We don't allow parents to remove the labia of their daughters, which could be easily compared to the removal of "some infantile foreskin". Labia are also folds of skin under which you will find smegma, you realize? However, would we be so lax in our approach towards women who suffered this decision made legally available to their parents? As a woman circumcised in such a manner, do you think you'd be okay without having "just those folds of skin"? A great point I see made time and again by others is would we remove our children's breasts to prevent breast cancer? Isn't it absurd to practice infant circumcision to prevent .01-1% chance of UTI, which is treatable and probably not even as dangerous as the practice of circumcision itself... or to argue that it decreases HIV rates? What do you believe the odds are that being circumcised is going to prevent the spread of HIV? As a circumcised man, would you feel so strongly that circumcision aids in prevention of HIV that you'd practice unsafe sex with an HIV-infected partner?... Then why is this even be discussed, yet alone, being supported? If this is about actually educating the public, shouldn't we be putting resources into doing that? And logic alone will tell you that if you take a group of people whom you are concerned about having unprotected sex, as a whole, and you circumcise them in the name of HIV-protection, what you are really doing is indirectly causing more of a problem... as the ignorance will continue ("circumcisd men have less of a chance of acquiring HIV") and the financing of an educational opportunity (i.e. what HIV does to the body, how to really prevent it) will have actually gone into promoting an extremely outdated, *truly* unethical procedure.

    ReplyDelete
  4. "1. You cherry-picked studies showing a benefit for male circumcision. It's true that while numerous observational studies have shown a benefit in terms of UTIs and STDs, there are some studies finding no effect, or even an opposite effect. Non-experimental, observational studies are fundamentally flawed for this reason. That's why it's so important to look at randomized, controlled trials whenever possible."

    Wait, non-experimental observational studies are "fundamentally flawed" because they don't find a desired effect? Am I reading this correctly?

    No, non-experimental observational studies are superior, because they are not looking for a desired effect; they are merely reporting the status quo.

    If there were any true "reduction" of HIV, then this would be observable at any given point, not just in your selected studies.

    Your argument is also based on a dubious premise; that the studies you quote were actually randomized and controlled. The studies looked at specific groups who were paid to participate, and there was NO CONTROL.

    Due to the very nature of circumcision, true randomized controlled trials would be unethical. How do you placebo a surgery? How do circumcise men without you or others finding out? How will you keep the men from talking to each other?

    ReplyDelete
  5. "2. The risk of UTIs in male infants is low and does not justify circumcision. I totally agree. The reduction in UTIs alone is not large or clinically important enough to advocate for this procedure."

    If the reduction exists at all. What studies are you citing for this claim? The AAP debunked and dismissed Wiswell in 1999. They conclude that circumcision is NOT effective against UTI, but people keep pushing this myth.

    ReplyDelete
  6. "3. The trials in Africa are flawed because they weren't double-blinded, and they were stopped early. OK, YOU design a study that does sham circumcision in the control group, and try to get that past an ethics committee."

    EXACTLY.

    But instead of circumcision, why aren't the "researchers" looking for better ways to prevent HIV? Why circumcision? Would you support equal "research" in female circumcision? Why? Why not?

    "Stopping a trial early because of a significant benefit in the treatment group (and offering it to the control group) is the most ethical thing to do in this situation, since HIV is a life-threatening disease."

    That sounds real noble of the so-called "researchers" to start thinking about "ethics," AFTER the fact that they started their so-called "experiments" in the first place. But in invoking "ethics," they put science in a bind; by circumcising the rest of their men and invoking "ethic," they have made it so that no other group of scientists can check their work, making their work the last say on the matter. "Ethical," or crafty?

    That's not the way science works. Science commands that results be replicated every single time. Making it so that other scientists cannot do this, and giving themselves ultimate authority on the matter in the name of "ethic" should call into question the true intention and "ethic" of the researchers.

    "It is true that stopping a study early for this reason tends to overestimate the benefit, and I might be suspicious of the results if they were seen in only one trial, but in fact, the benefits were seen in all three studies, in different parts of Africa."

    Suspiciously conducted by an interconnected group of people. Gray, Wawer, Bailey, Moses and Auvert weren't mere strangers passing in the night, and this wouldn't have been their first attempt; they had been trying to establish a non-existent link between circumcision to endorse "mass circumcision" campaigns for years. They weren't seeking to find a cure for HIV; they were seeking to perfect their numbers to finally push through with circumcision. This is called agenda-based, not "evidence based" medicine.

    "The Cochrane Group, which is extremely conservative in its recommendations, concluded, "Research on the effectiveness of male circumcision for preventing HIV acquisition in heterosexual men is complete. No further trials are required to establish this fact."

    And they would be wrong. If the results cannot be replicated in other trials, then no, the research is not "complete." Dare I say, the Cochrane Group is smoking crack, and so are you.

    ReplyDelete
  7. Despite circumcision being near-universal, it hasn't stopped HIV transmission in Israel.
    http://www.haaretz.com/print-edition/opinion/failing-the-aids-test-1.249088
    http://www.haaretz.com/print-edition/features/israeli-gays-shun-condoms-despite-worrying-rise-in-aids-1.249372
    http://www.haaretz.com/news/has-the-aids-cocktail-worked-too-well-in-israel-1.258520
    http://www.haaretz.com/print-edition/news/hiv-diagnoses-in-israel-climb-new-cases-among-gays-up-sharply-1.248651

    Circumcision hasn't stopped HIV in our own country.
    http://data.unaids.org/pub/Report/1998/19981125_global_epidemic_report_en.pdf

    And, it hasn't stopped other STDs either.
    http://www.reuters.com/article/2009/01/13/us-infections-usa-idUSTRE50C5XV20090113?pageNumber=1&virtualBrandChannel=0

    In America, the majority of the male population is circumcised, approximately 80%, while in most countries in Europe, circumcision is uncommon. Despite these facts, our country does poorly.
    http://www.advocatesforyouth.org/index.php?option=com_content&task=view&id=419&Itemid=177

    In fact, AIDS rates in some US Cities rival hotspots in Africa. In some parts of the U.S., they're actually higher than those in sub-Saharan Africa. According to a 2010 study published in the New England Journal of Medicine, rates of HIV among adults in Washington, D.C. exceed 1 in 30; rates higher than those reported in Ethiopia, Nigeria or Rwanda.
    http://www.nejm.org/doi/full/10.1056/NEJMp1000069

    The Washington D.C. district report on HIV and AIDS reported an increase of 22% from 2006 in 2009. According to Shannon L. Hader, HIV/AIDS Administration, Washington D.C., March 15, 2009: "[Washington D.C.'s] rates are higher than West Africa... they're on par with Uganda and some parts of Kenya." Hader once led the Federal Centers for Disease Control and Prevention's work in Zimbabwe.
    http://www.washingtonpost.com/wp-dyn/content/article/2009/03/14/AR2009031402176.html

    One would expect for there to be a lower transmission rates in the United States, and for HIV to be rampant in Europe; HIV transmission rates are in fact higher in the United States, where most men are circumcised, than in various countries in Europe, where most men are intact. It is telling that the HIV epidemic struck in our country in the 1980s, 90% of the male population was already circumcised. Somehow, we're supposed to believe that what didn't worked in our own country, or anywhere else, is going to start working miracles in Africa.

    "I do agree that if you're in a part of the world with extremely low rates of HIV infection (such as Australia -- which has a 0.004% annual risk of infection), routine circumcision may not make economic sense."

    SO WHY ARE YOU CITING THIS WORK HERE???

    "There is also experimental data from Africa, performed in men who have sex with men, showing a reduction in HIV acquisition in those who practice insertive anal sex. You should be able to extrapolate this data to gays and bisexuals in America."

    No, no, no. Even according to circumcision "researchers," circumcision has little to no effect in these groups. You ma'am, are pulling stuff from your behind.

    ReplyDelete
  8. "5. Why not promote safe sex instead? I'm not saying circumcision should be done instead of teaching safe sex. HIV prevention needs to be multi-pronged, and must also include education, free condom distribution, low-cost antiviral treatment (which reduces transmission rates) and needle exchanges."

    It is unethical to promote surgery when there are better, more effective, less invasive ways to prevent disease.

    ReplyDelete
  9. "6. Infants die from circumcision, and parents shouldn't be making this decision for them. Yes, babies will rarely die from circumcision, just as people will rarely die from having IVs inserted into their hands or having a severe allergic reaction to antibiotics (both of which I have seen)."

    The difference is that while IVs and antibiotics may actually be medically indicated, in a healthy, non-consenting child it is usually NOT. Because there is no medical or clinical indication for this in infants, your cost-benefit analysis goes out the window.

    The bottom line is always this:
    Unless there is actually medical or clinical indication for surgery, doctors have absolutely no business performing it on healthy, non-consenting individuals, much less stoking a parent's sense of entitlement.

    "But AIDS is still a huge killer, even in developed countries."

    Yes, even developed countries where circumcision is already near-universal, such as the United States. Compare with Australia, Japan, Denmark, Germany, the UK, etc., where circumcision is rare.

    "As for parents who want to let their sons make the decision about circumcision once they come of age, I think that's fine. Just realize that adult male circumcision is a bigger procedure, often involving general anesthesia, and may not be covered by insurance plans when done for purely preventive reasons."

    And just realize that most adult males would not want this for themselves, opting for safer sex and condoms instead. You would not forcibly circumcise an adult male; how the ethics changes for healthy, non-consenting, sexually inactive children is beyond me.

    ReplyDelete
  10. "7. Your story about Dr. Nick operating on your kid sounds specious. Nope, absolutely true. I got a list of low-cost providers because I gave birth at my own, public county hospital."

    You say that you are a doctor, which should earn you a very good salary. Yet you had to hunt around for a bargain? Seriously? And, as a doctor, you let someone hand you, the patient's parent, medical equipment wearing no gloves? If this story is true, then it sounds like you're not a very good doctor.

    ReplyDelete
  11. "8. You're a terrible mom. OK, I will concede that in the moment that I let Dr. Nick circumcise my son, I was a terrible mom."

    Not to mention a terrible doctor!!!

    "I'm an imperfect parent, which is why I think a lot of people read my blog."

    Nobody is judging you if you truly wanted the best for your son. No parent should ever be judged because they chose circumcision, because their doctor told them that not doing this to their boys will give them AIDS, cancer and their foreskin is going to overgrow and eat them up.

    But you know what, your blog is supposed to be INFORMING parents, and you yourself, if you say you want the best for your children, should be informing yourself better on basic human anatomy, and on better ways to prevent disease. I'm not sure about you, but the less surgery for my children, the better.

    I think the bigger concern is that, you say you're a doctor, and yet you allowed such un-doctorly conduct to happen. You, as a doctor who knows the dangers of surgery and infection allowed this to happen to one of your very own! Really? At the very least, doctor, momma, you would have ensured that this procedure on your son was performed in the most pristine way possible, with a professional that would not put your son in any danger (as if circumcision weren't already putting your son in danger enough...) instead of going to a budget mohel. More so than a "bad parent," you sound like an extremely incompetent doctor.

    "Next time, I'm definitely going with this guy:
    Extra credit if you can name this Simpsons character*"

    Doctor. Seriously?

    I hate to say this, but you are seriously out of line.

    Are you aware of the recent string of lawsuits against mohels because they severed the heads of the penises of many babies? In NY a while back, a mohel gave herpes to 3 children, one of whom died.

    "That said, for those of you who chose circumcision, do you really know who circumcised your baby when they whisked him away from your bedside? I did a few as a medical student, and I doubt the parents were aware of it. (The standard consent form states that, "Dr. X and/or his/her subordinates" will be performing the procedure.)"

    And that speaks to the ignorance of the parents, and to the opportunistic hospitals that predicate no them. It makes me glad that parents are being fully informed as to what is happening to their children. NOT!!!

    "I even knew a high school volunteer who was allowed to insert breathing tubes into patients getting general anesthesia, which actually made the med students squirm, both in discomfort and envy."

    Well, thank you for informing me how things go down in American medicine. This anecdote will serve as grounds for a campaign to have American medical institutions audited. This is seriously horrifying to know. Forget circumcision; what ELSE are doctors getting away with...

    "Hmmmm, now that I think about it, I guess that last one is a point for the anti-circumcision crowd."

    THIS ISN'T A CONTEST! You're supposed to be fully informing your audience, not to mention be fully informed yourself.

    Seriously! Are you even a real doctor? What was your degree in? The Simpsons? Remember Dr. Laura? You're not one of THOSE "doctors" are you? Geez...

    ReplyDelete
  12. The bottom line is this:
    The foreskin is not a birth defect. Neither is it a congenital deformity or genital anomaly akin to a 6th finger or a cleft. Neither is it a medical condition like a ruptured appendix or diseased gall bladder. Neither is it a dead part of the body, like the umbilical cord, hair, or fingernails. The foreskin is normal, natural, healthy tissue with which all boys are born.

    Unless there is a medical or clinical indication, the circumcision of healthy, non-consenting individuals is a deliberate wound; it is the destruction of normal, healthy tissue, the permanent disfigurement of normal, healthy organs, and by very definition, infant genital mutilation, and a violation of the most basic of human rights.

    Doctors have absolutely no business performing surgery on healthy, non-consenting individuals, much less stoking a parent's sense of entitlement.

    ReplyDelete
  13. Joseph has become truly overwrought.

    ReplyDelete
  14. Hello Hydro, the 'billions of studies' is obviously not meant in exact numbers, although you seem to enjoy calling me out on that. I am trying to keep a level of mutual respect here; this issue gets fairly nasty and I aim to avoid putting down people who truly want to learn. I couldn't tell you exactly how many studies I can pull, but I can pull a lot. I'll bet you can as well. Was 'billions' the correct word choice? Maybe not, but come on.

    In the previous blog entry I gave equally damning evidence against every pro-circ study that was brought up, and I can keep going if needed. I am not equating sides, but again- this is the internet, all of us can pull things sided one way or the other. IF I agree that the studies are equal, (which I do not, I only agree that both sides of the argument can pull their information)- then all that is left is human rights. Why is that not important? To Hydro, do males not deserve equal protection as females enjoy in the US? In other countries?

    The vaccine comment is laughable, and I'm not even going to rally a decent argument against it. Not even CLOSE to the same thing.

    Anna

    ReplyDelete
  15. A number of these posts are quite hostile. This is simply a mom facing the kind of decisions we as parents face with doubts about dr competence and the entire procedure.

    We all have times where on hindsight we may have chosen to walk out but didn't. She is not advocating this as a model of care she is simply stating life as it unfolded.

    As for the cherry picking champion, wow give me a break if you are going to make virtual research misconduct charges then be very specific about the cherry picking.

    I understand that of course you have written to the journals involved citing the cherry picking offences rather than splitting hairs with a mommy blogger like a bully so why not cite your professional efforts there and show us your appropriate meta analysis and correspondence with authors to check with what studies they eliminated and why.

    ReplyDelete
  16. Hydro, you'll find plenty of overwroughtness, with good reason, coming from those of us concerned about exposing infant circumcision for the atrocity that it is.

    ReplyDelete
  17. @Dr. Price, if you will check the other (part 1) of this series you will find all the links you need in the comments.

    Anna

    ReplyDelete
  18. It's unreal that you claim to promote 'evidence-based medicine', then praise infant circumcision, an archaic ritual with its modern American roots in last-century thinking on sex and morality. It is a practice that most of the world never took up or has long-since abandoned - in fact, there's been a general shift away from amputative medicine - we don't routinely remove appendices, and even inflamed tonsils are more often than not left alone these days.

    That you can claim to support 'evidence-based medicine' yet condone RIC shows how culturally blinkered you are. You'd be well advised to move on and accept that we don't get it right all of the time - and I'm sure your sons would forgive you, if you gave them a heartfelt explanation to that end. Religion, tradition and cultural habit are not good reasons for continuing to vivisect infant genitalia whist propping it up with flimsy medical arguments. Have you read ANYTHING that doesn't have a USA pro-circ spin on it? These position papers, for example? http://www.nocirc.org/position

    ReplyDelete
  19. EBM your evidence and analysis is flawed. Your statement in the original post:

    “Now, a 50% relative reduction is a big deal in parts of the world with high baseline rates of HIV infection. In these African studies, only 56 members had to be trimmed to prevent one infection at 2 years. Currently, about 50,000 people in the U.S. are newly infected with HIV each year, and about 3 out of 4 are male. If you crunch the numbers, the annual risk in men is about 0.02%, so with a 50% relative reduction, 5,000 weenies* would need to be skinned in order to prevent one infection in one year. Of course, if you circumcise a baby, the point it to try to reduce his lifetime risk of infection. The 2004-2005 U.S. data show that the lifetime risk of HIV infection in men is 1.87%. That means that only 108 wangs would have to be winged in order to prevent one infection in that child's lifetime -- an awfully good number, by any preventative standard.** And that number doesn't even include the risk reduction in the future partners of these boys.”

    As you noted there are about 50K people who are infected annually in the US with HIV. However, of those, only about 3.5K were thought to be infected by heterosexual transmission F->M and this works out to an annualized risk of 0.003% and a lifetime risk of less than 2 tenths of a percent. Your primary mistakes appears to be that you combined heterosexual male transmission and MSM which is a significant error since the risk profiles are substantially different between the two groups. Of all the studies that have been performed to date on MSM acquired HIV, none have shown any meaningful risk reduction connected with circumcision. Yes, if you data mine and contort the figures you can produce a result that may show a small risk reduction when the MSM is primarily insertive. But it is unreasonable to believe that gay men will necessarily be primarily insertive their whole lives. Most of this data, incidentally, has been gathered in first world western countries. I doubt you have any MSM data on men in Africa since even admitting such activity in most countries on that continent has some pretty unpleasant consequences.

    Your statement regarding HPV is also illogical. Considering the fact that there has been a very efficient vaccine available for more than 7 years, and it's just now finally been approved for boys in the US, it is difficult to understand how any rational individual would believe that circumcision could be justified as an HPV prophylaxis. Indeed if there even was any relationship between circumcision and HIV, its use is clearly deprecated.

    Your estimation of the potential complications is off by at least a factor of 2. The Royal Australasian College of Physicians estimate a rate of complication of at least 1.5% and that only covers the immediate ones. Who knows how many boys may later go on to develop meatal stenosis or problems related to the circumcision causing more damage than intended. About the only part of your post you got right is that the potential reduction in UTIs are trivial and irrelevant. Finally, I find your condescending attitude toward men who resent that they were circumcised disgusting. They have every right to feel violated for have a non-therapeutic medical procedure performed on them for no rational reason.

    ** This is a second repost because I think my first post got lost. If it simply went into an approval bin then pick which ever you like best and delete the other.

    ReplyDelete
  20. I should add that your point that an adult circumcision might require general anesthesia is also incorrect. There is no reason it can't be done with a local. It's an irrelevant point though since that, and any other obstacle real or perceived, is part of the decision making process. A decision that, absent therapeutic need, only the individual man should make for himself.

    ReplyDelete
  21. Putting aside the EBM, and concentrating on looking at circumcision as a "human rights issue," there's an angle here that I don't believe has been brought up, and one that makes me very uncomfortable. Look at the language here in these comments, and those of the prior post. Circumcision is an "atrocity"; it's "barbaric"; people who contemplate it are "horrible mothers."

    There are some who sincerely believe circumcision is a commandment from God. It's right there, in Genesis: a direct command for the Sons of Israel (the Jewish people) to circumcise their sons, starting right there with Abraham and Isaac. Now, you may be quite dismissive of the Old Testament, and religion, and the very idea that this old book has any relevance or moral authority-- but what about the millions of Jews who sincerely believe otherwise? (Most Muslims also circumcise their boys, though whether it is a religious imperative, I don't honestly know.)

    The Jews may be misguided in following what they understand as the commandments of God, but are they committing an atrocity? Are you saying they're horrible barbaric parents? Should they be locked up, their children taken from them? Or should we just round 'em up on trains and gas them?

    I you are concerned about human rights, you might ought to think about what your language is saying, and what that means to people of faith. You are denigrating-- no, vilifying-- a people. Disagree, sure. Try to convince, sure. But once you call a people these sorts of names, you dehumanize them and legitimize their persecution. I don't think you really mean to do that. Do you?

    ReplyDelete
  22. @ Hydro- Your religious freedom ends where someone elses body begins. End of story.

    ReplyDelete
  23. So, lock 'em up? OK. At least you're honest about your intentions. Human rights doesn't have to extend to Jews. Got it.

    ReplyDelete
  24. I think Joseph has said all there needed to be said about HIV prevention. In the last decade or so, it was about UTI prevention and that's what doctors were touting and now that's all been disproven.

    So, now they are rigging studies to "prove" that circumcision prevents HIV transmission. And in 10-20 years when THAT is disproven, they'll move onto something else?

    Why?

    Money....OB's can make hundreds of bucks for 15 minutes of a little boys pain and hospitals sell the foreskin to cosmetic and biopharmaceutical companies.

    The rigged the UTI study by including "females" in the "uncircumcised" group and we all know that females are more likely to get UTI's than either circ'ed or Intact males.

    And for these studies in Africa, they are using very specific populations of men that are NOT REPRESENTATIVE of a normal Westernized male's sexual experience....for example, one study used Intact Ugandian truck drivers who frequently engage in sex with prostitutes and who engage in Dry Sex....a method of "practice of drying and/or tightening the vagina by various methods of douching and/or application of leaves and powders to absorb the vaginal lubrication. This practice is purported to increase sexual pleasure.

    Reports indicate that dry sex dramatically increases HIV infection risk. Several reports document that dry sex causes various problems with condom usage. Dry sex is associated with an increased report of STDs in men. Several studies report increased HIV incidence among women. Vaginal dryness is associated with increased lesions, lacerations, peeling of the vagina, chlamydial infection, and epithelial trauma in both male and female, thus creating a portal of entry for HIV.

    Because of this increased risk, dry sex is an obvious confounding factor in any study of HIV seroconversion vs. circumcision in sub-Saharan Africa. However, all of the approximately forty existing studies have ignored this potential confounding factor." (definition of dry sex taken from CIRP)



    Why they hell do you think they keep these studies relegated to Africa?!?! They have to because of this stuff or their pro-circ agenda will not be proven. It wouldn't be proven anywhere else in the entire world!

    ReplyDelete
  25. Electing to have your son circumcised using the HIV "studies" as your reasoning to hide behind is ridiculous. As parents, we want our children to be protected throughout their life, but we're not electing to have the appendix taken out at birth, or their tonsils, or their gallbladders. The difference is that if at some point in our children's lives they develop an illness, one of those three things might HAVE to be removed (due to a true medical issue!), whereas the foreskin is a part of the body that does serve an actual purpose (read all the purposes HERE: http://www.drmomma.org/2009/09/functions-of-foreskin-purposes-of.html). I sincerely hope that any parents-to-be that stumble across your articles here do some true research before attempting to locate a doctor who will make the cut.

    ReplyDelete
  26. I also wanted to add that I didn't know until recently that you are a doctor. I'm not sure what kind of doctor you are but I wanted to tell you that it's doctors like you that make me scared to take my Intact son to a doctor. Doctors who have had NO training about the natural development of the foreskin and doctors who do not know what to do with foreskin unless they are cutting it off.

    My son's own pediatrician thinks that she boys need to be forcibly retracted by age 5 if they haven't already. When I whipped out the AAP's stance on foreskin care that says that the average age of retraction is 10.5 and that you should NEVER EVER forcibly retract an Intact boy, she was stunned.

    This is scary.

    And if I were you, I would be damn careful about what you post on the internet and what you tell your patients as a doctor.

    You weren't trained right. Accept that and educate yourself. It's not your fault.

    The arrogance of U.S. doctors never ceases to amaze me.....do you REALLY think the rest of the world is wrong and we are right in this practice?

    Do you seriously believe that the rest of the 90% of the Intact males that make up the rest of the world's male population are disease-infested people?

    How can you overlook the fact that NOT ONE medical organization in the entire world recommends infant circumcision?

    I just don't get it...just please do NOT hurt an Intact boy because of your ignorance, it's not their fault that you have your own biases about the foreskin and they don't deserve to be hurt because of it.

    ReplyDelete
  27. Hydro, if we were to strap you down, as a grown man who can speak for himself and remove skin from your genitals without your consent, you wouldn't consider that cruel? This is what I mean by "atrocity".

    Whether the people performing it are jewish, christian, atheist, white, black, green, is unimportant. It is the practice which many would like to see end, not the people performing it.

    You say, "The Jews may be misguided in following what they understand as the commandments of God, but are they committing an atrocity? Are you saying they're horrible barbaric parents? Should they be locked up, their children taken from them? Or should we just round 'em up on trains and gas them?"

    These are your words, but not mine. My word was "atrocity". I used it to explain why it is that people become so overly-heated and anxious when arguing for the rights of babies... all babies, that is... jewish, muslim, christian and atheist ones.

    ReplyDelete
  28. @Hydro

    Are you prepared to use the same defense for those whose religious or cultural traditions require some kind of female circumcision?

    ReplyDelete
  29. My objection is based on a combination of evidential issues and philosophical stance, and unlike your position (according to you), it is amenable to change if appropriate evidence were to come to light.

    Here's where I am: removing a healthy body part (especially one involved in sexual satisfaction) is a huge, irrevocable decision, and if you're going to do it to someone without their consent, you'd better have an avalanche of evidence that it is urgently important to that person's health.

    Using evidence of UTIs and such to justify it is like saying we should cut off kids earlobes because they might someday develop skin cancer there. Also, any body part you retain may develop a problem, so you can't argue that possible future maladies of the foreskin are a reason to routinely remove it without the owner's consent.

    As for HIV, even if you take those studies as gospel, the risk of infection is small and there are very good ways of achieving the same result *without cutting off anyone's body parts without their consent.* Also, one should note that the African studies looked at adult circumcision - can it necessarily be extrapolated to routine infant circumcision? I of course support the right of adults to obtain circumcisions to reduce their risk of HIV. (I have a feeling the vast majority will opt for condoms.)

    I really like your blog, but I think on this issue you're too invested in protecting your self-image as a good mother to look at the evidence impartially. No one wants to believe that they amputated a healthy organ from their infant for no good reason.

    ReplyDelete
  30. If the discussion here illustrates nothing else, it's that the decision whether or not to circumcise is not primarily a rational, evidence-based one. The evidence shows potential benefits and potential harms for specific populations, but it is by no means sufficiently definitive that one can recommend for or against the procedure on a purely rational basis, as one might recommend measles vaccination, for example.

    Evidence informs our decisions, but let's not make the mistake of thinking it can always reduce our options to only one that is rational or appropriate in any circumstance. EBMed involves, in one common definition, ""The integration of the best research evidence with our clinical expertise and our patient's unique values and circumstances." If we ignore evidence, we are practice opinion-based or faith-based medicine. But if we ignore "the patient's values and circumstance," we aren't going to be able to achieve good compliance or help our patients achieve the best possible quality of life, and we will likely merely drive them into the arms of providers of non-evidence-based alternatives.

    So while everyone would like to claim that the research evidence supports their favored position on this issue, it seems pretty obvious that the driving factor is values and moral beliefs, with the documented risks and benfits elucidated by the scientific literature coming in second not only because that's how people really make their decisions most of the time anyway, but because the particular risks and benefits for the infant in the developed world just aren't great enough to dictated the decision even for the most rationally inclined among us.

    ReplyDelete
  31. @skeptvet

    Indeed, evidence is what informs our decisions but ethics must play at least an equal roll. Where it comes to proxy consent, the ethics are pretty clear. The AAP committee on bio-ethics noted that, "Such [medical] providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. [...] the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent."

    As you noted in your final paragraph, "[T]he particular risks and benefits for the infant in the developed world just aren't great enough to dictated the decision even for the most rationally inclined among us." Which essentially means that the standard required to accept a proxy consent on this matter is not met.

    ReplyDelete
  32. Great post - Christie Aschwanden explains with wit and insight why it generated the responses it got:

    http://www.lastwordonnothing.com/2011/10/26/you%E2%80%99ve-got-mail-you-idiot/

    ReplyDelete
  33. twaza - Christie Aschwanden couldn't have said it better... "Showing readers they’re wrong is like punching them in the face."...

    And I deal with this response frequently when I share with others why infant circumcision should not be performed.

    There is plenty of hate-filled commentary from both sides of this debate, but I have read numerous articles and responses of those against infant circumcision that were purely factual.

    For those in favor of circumcision to acknowledge the facts which pro-intact experts promote, it would mean acknowledging they were not right when circumcising their own son... or their own parents did not do what was right... or both. It's a truly emotional process, no matter how some in favor of circumcision want to deny that. It's the perfect storm for others to cling to denial and simply see what they wish to see, which actually just perpetuates the problem.

    I am 99.99% certain that circumcision is unnecessary as a routine procedure on infants, carries serious risks and complications, painful when done without proper anesthetic, cannot be guaranteed to be pain free during, painful for an infant upon recovering, done without an infant's consent and much more influenced by culture and social acceptance, rather than medical benefit.

    ReplyDelete
  34. 1. The gold standard is double-blinded, placebo-controlled randomised control studies.

    Not only were the African studies not blinded or placebo-controlled, opening the way to experimenter and experimentee effects - everybody involved had an investment in circumcision being effective - and the Hawthorne effect (just being in a study has an effect) - they were randomised only in the allocation of subjects to experimental or control groups, not in the selection of people from the population. All the men were paid volunteers for circumcision, influencing the demographics. Poorer men would be more likely to join, and men who didn't enjoy their foreskins would be more likely to join.

    2. "Circumcision does seem to reduce the risk of urinary tract infections in the first year of life - from 1% to 0.1%." With those figures, 991/1000 circumcisions would not prevent a UTI - 990 boys would never have got one, and 1 would get one anyway. So why did you even mention UTIs? It's like sweeping up biscuit crumbs off the bakery floor and selling them as biscuits. Circumcision advocates do this all the time.

    3. Maybe no ethical study can ever be designed to prove that circumcision prevents HIV. Humans are not lab rats. We can't cage HIV- men and HIV+ women together, circumcise half, and see what happens. We have to live with that lack - not pretend that inadequate studies are good ones.

    The latest of several reviews damning the Africa RCTs is in the (Australian) Journal of Law and Medicine this month.

    The ENTIRE basis of the claim is 73 out of 5,400 circumcised men who didn't get HIV in less than two years, who MIGHT have if they hadn't been circumcised, while 64 circumcised men DID get it.

    In their review G. Boyle and G. Hill unravel some of the many reasons that may not be cause and effect:
    researcher expectation bias;
    participant expectation bias;
    inadequate double blinding;
    lead-time bias;
    selection and sampling bias;
    attrition bias; and
    early termination.
    Contacts were not traced so we don't even know which if any of the men got HIV from women or even by sex.

    Women are at several times greater risk than men, and circumcision does NOTHING to protect them. It may even INcrease the risk to women, according to a Ugandan study (Wawer, et al., Lancet 374:9685, 229-37) it was cut short for no good reason (nothing they could then do or not do would prevent any new infections) before that could be confirmed.

    Non-sexual and male-male transmission are large and unaddressed issues in Africa (expecially not gay sex in countries like Uganda, where to even admit to being gay is dangerous). Circumcision does nothing to prevent either.

    The Cochrane review also says "At a local level, further research will be needed to assess
    whether implementing the intervention is feasible, appropriate, and cost-effective in different settings". Just because something works doesn't mean we ought to do it. Penectomy would be 100% at preventing (female to male) HIV transmission...

    4. You're ignoring different modes of transmission. HIV in the developed world is primarily transmitted from men to men and by contaminated needles - neither of which circumcision will prevent. In Africa, heterosexual tranmission is believed to be much more significant (but there's a lot of denial about male-male sex and reuse of sharps). The blood supply is also badly monitored. I have even seen a proposal that circumcised men be encouraged to give blood because they're less likely to be HIV+ - another recipe for disaster.

    ReplyDelete
  35. 6. It's scandalous that we don't even have good figures for the death rate from circumcision. Parents, doctors and ritual circumcisors all benefit from denial, blaming the death on anything else. A baby who died in London within an hour of his ritual circumcision was ruled to have died of SIDS - "cot death". (The Initiation Society was represented at the inquest, and the pathologist who performed the post-mortem was not called.)

    A baby's body can afford to lose only two tablespoonsful of blood before he is in danger, and there is a tiny artery that is easily cut. Disposable diapers can easily conceal that much blood.

    Short of death, there are many complications of circumcision. A Richmond VA pediatrician had to repair 1600 botched circumcisions in three years, suggesting a rate of more than 13% Many do not come to light until adulthood, men thinking (with the help of the silence around all things sexual) what they have is what every man has. A full list on the consent form should include:

    1 Infection and sometimes death
    2 Haemorrhage and sometimes death
    3 Pain / shock, and sometimes death
    4 Methemoglobinemia, brain damage and possibly death, if EMLA cream is used to anaesthetise a newborn
    5 Necrotising fasciitis ("galloping gangrene")
    6 Damage (scarring, pitting) to the glans or shaft. In the case of Dustin Evans Jr, the scarring caused a urethral stricture (narrowing of the urinary tube), and it was during an operation to relieve this that he died.
    7 Urethral fissure/fistula
    8 Scaphoid megalourethra
    9 "Trapped/buried penis"
    10 Occlusion of penile venous system
    11 Urinary Tract Infection
    12 Meatitis
    13 Meatal ulcer (very common)
    14 Meatal stenosis
    15 Multiple pyogenic [caused by pus] granuloma - a series of papillomatous [brushlike] growths around the circumcision wound
    16 Eczema of the glans and meatus
    17 Oedema of local tissue
    18 Loss of *sensitivity / impotence
    19 Reduced volume of penis
    20 May shorten the penis:
    "Circumcised men had shorter erect penises than uncircumcised men (p<0.05)." - Richters J, Gerofi J, Donovan B. Are condoms the right size(s)? a method for self-measurement of the erect penis. Venereology 1995; 8(2): 77-81.
    21 Painful erections
    22 Wound re-opening (in adulthood)
    23 Chafing from underwear
    24 Production of ugly scar tissue, skin-bridges, skin-tags, malapposition (rejoining on the twist) and/or suture holes

    "adult male circumcision is a bigger procedure" And a more exact one, since the organ is now full sized. Any mistake on a baby is magnified when he grows up.

    8. Many men feel like this about their circumcisions.

    9. "Mutilation" is a loaded word, but how can you deny that the foreskin is a normal part of the anatomy? 2/3 of the men in the world still have ours, with no problems. Are there any other normal, healthy, integral, functional, non-renewable parts of your child's anatomy you claim the right to remove? There aren't even any other such parts it is legal to remove, and the most nearly corresponding part of a girl's anatomy has additional federal protection. At what age does this right of yours end? 18? So you could circumcise your son for failing his driving licence? Or older? "Congratulations, son, I hope you'll be very happy together. But come here, there's something we forgot to do earlier...."

    ReplyDelete
  36. @ Hydro: "many kids would choose to not attend school, or eat vegetables, or kiss Aunt Martha"

    I love it that circumcision advocates can make comparisons like this, but let us so much as mention cutting part of a boy baby's genitals off in the same breath as cutting part of a girl baby's genitals off (even with an instrument like this [NSFW], with its shield to spare the clitoris) and "Oh, no, they're completely different!"

    "children may not consent to painful or even dangerous medical procedures that are objectively necessary" Aye, there's the rub. Nobody in his right mind (I am not speaking of Professor Brian Morris) thinks non-therapeutic circumcision is objectively necessary. No national medical association in the world recommends it. The fact that we may perform a dangerous procedure on a non-consenting child whose life is at stake has no bearing on cutting a healthy body part off a healthy child who will (we hope) grow up to be a man with his own opinion on the matter.

    "Parents are the decision makers" This reflects a fundamental difference of philosophy. Parents are not owners but stewards of their children, making such decisions as they have to, progressively relinquishing them to their offspring as those offspring mature. Since circumcision is irrevocable, its main effects are sexual, it is seldom objectively necessary and most of the world does very well without it, this is not one of those decisions. (It's something they only even think about in the USA because it is pushed on them and it is already customary.)

    "Human rights doesn't have to extend to Jews. Got it. "

    On the contrary, we say that children of Muslim and Jewish parents have exactly the same human rights as other children, to decide for themselves, when they can, what (normal, healthy, integral, functional, non-renewing) parts of their own bodies they may keep, and whaat coventants with supernatural beings they want to enter into, and how. To make a religions exemption would be to discriminate against those children.

    But I agree with you that it would be a hardship to imprison people so desperately committed to their custom. The advancing moral zeitgeist works nearly as well:

    "Rabbi Binyomin Jacobs, president of the Dutch Association of Rabbis, said only about 50 male Jewish babies are circumcised in the Netherlands each year." (Ynet News, September 27, 2011) Today the Dutch Jewish population numbers about 30,000 so if the Jewish birth rate is the same as the national average of 10.23 births/1,000 population, about 307 Jewish children are born annually, about 157 of them boys, so their circumcision rate is less than 32% - lower than goyish circumcision in many states of the USA.

    Here are contact details for celebrants of Brit Shalom (Brit B'li Milah - Covenant Without Cutting).

    ReplyDelete
  37. @skpetvet:
    "If we ignore evidence, we are practice opinion-based or faith-based medicine. But if we ignore "the patient's values and circumstance," we aren't going to be able to achieve good compliance or help our patients achieve the best possible quality of life,"

    But prior to that we need to establish clearly, who is the patient? Not the parents, but the baby. What are his circumstances? Being male, having a penis with a foreskin. What are his symptoms? None. What then, is the best treatment? Why, none of course.

    Non-therapeutic infant circumcision is not just not evidence-based medicine. It is not medicine.

    ReplyDelete