Tuesday, November 1, 2011

The Kindest Cut?

When J.J. was born, our hospital gave us a list of outside physicians who performed circumcisions.  My husband called every provider on the list and made an appointment with the second cheapest one -- the same process by which he selects a bottle from a restaurant wine list.  I knew we were in trouble when we were greeted by none other than....
"Hi everybody!"

Actually, Springfield's Dr. Nick was way more professional than this joker, who was dressed in a hospital gown and dirty sneakers.  Without introducing himself or asking if we had any questions, he whipped out his instruments and started operating.  Rick fled, leaving me to comfort J.J. with a bottle.  In the middle of the procedure, the doctor (at least, I hope it was a doctor) said, "Here, hold this," and he handed me the thingy clamped to my son's penis, as he snipped away.  (I'm not a pediatrician or a surgeon, but I assure you that "thingy" is a formal medical term used by internists.)  And no, I wasn't wearing gloves, nor had I told this guy that I was a doctor. I fretted for days that J.J. would develop Fournier's gangrene, and that I would be to blame for his future as a eunuch.  

Fortunately, the risks of circumcision in a developed country are rare (0.2-0.6%) and minor -- typically bleeding, which usually stops on its own.  (We doctors have a saying: "All bleeding stops....eventually."  Think about it.)  But some would argue that there's no reason to put a baby under the knife when it isn't necessary.  And then there are those whack jobs (no pun intended) who blame their unhappy sex life on the loss of their infantile foreskin, not realizing that they can't get a date because they are whack jobs who blame their unhappy sex life on the loss of their infantile foreskin.  In fact, observational studies have been all over the map in terms of whether circumcision is linked to sexual dysfunction.


There are no randomized, controlled trials of circumcision in infants, and there probably never will be.  Since there aren't any studies employing sham mohels, we must rely on the results of observational studies to guide us on the risks and benefits of neonatal circumcision, with their imperfect corrections for baseline differences.  The procedure is linked not only with certain religions, but also with socioeconomic status, with babies born at higher income levels being more likely to be circumcised -- although Dr. Nick and his like-minded colleagues remain a low-cost option for the uninsured.


Circumcision does seem to reduce the risk of urinary tract infections in the first year of life - from 1% to 0.1%.  Not a huge absolute benefit for a surgical procedure, though infant UTIs do present a significant healthcare cost burden.  My pediatrician friends tell me that kidney ultrasounds are routinely performed in male infants with UTIs, to screen for anatomic abnormalities.  They often have to perform suprapubic aspirations (sticking a needle through the skin into the bladder) to obtain a clean sample of urine, which is a low-risk procedure, but not a particularly fun one for baby or parent.


Observational studies have also shown that circumcision is associated with a lower risk of sexually transmitted diseases, including HIV and human papillomavirus, the cause of most cervical, anal and now, oropharyngeal cancers.  But here the data get particularly sticky, since uncircumcised males are more likely to come from a lower socioeconomic status, which in turn, is associated with a higher rate of STDs.


Although there aren't any experimental studies of infant circumcision, there have now been three large randomized, controlled trials of circumcision in over 10,000 adult men.  All of these studies were performed in Africa, with the primary outcome being the subsequent rate of HIV infection.  It turns out that the foreskin is replete with special cells that are prone to invasion by the AIDS virus, so removing the foreskin should reduce the rate of HIV infection.  And indeed it did, by an impressive 50% over a 2-year period.  In fact, all three trials were stopped early, and circumcision was offered to the men in the control groups.  The studies also found reduced rates of HPV infection in both the circumcised men and their female partners.  


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.  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%.  Some of those are acquired from injection drug use or maternal-child transmission, but the vast majority of infections are due to unprotected sex.  Circumcision should decrease a child's risk of HIV infection, though the magnitude of benefit in the U.S. and other developed countries is unclear, not to mention the risk reduction in the future partners of these boys.

As for the drawbacks of circumcision in the African trials, there were but a few.  Some of the more pleasant "side effects" of the procedure were enhanced sensitivity and sexual satisfaction -- finally, a randomized (if not blinded) trial putting to rest the question of sexual dysfunction.  In fact, some of these trials found increased rates of unprotected sex and number of sexual contacts in the circumcised groups.  The increases were marginal, but remember that they were observed in an experimental setting.  Now that the benefits have been well-established, what if men got the mistaken notion that circumcision was completely protective against HIV, blunting the potential benefits?    I doubt this will be much of an issue in pediatrics, as I can't imagine any parents encouraging their son to sow his wild oats simply because he had been circumcised.

Whatever the studies show, most parents will probably still base their decisions on cultural and personal reasons.  Rick and I had no discussions at all about the benefits and risks of the procedure. I deferred to my husband's wishes, and when it comes to circumcision, that seems to be the rule among the couples we know.  In 1999, the American Academy of Pediatrics acknowledged the "potential medical benefits," but state that "these data are not sufficient to recommend routine neonatal circumcision."  Some have argued that the AAP needs to advocate more strongly for circumcision, now that we have proof that it saves lives.  

As for all you expecting, uncircumcised dads, maybe it's time to start a new family tradition.


*As a doctor, I know I should always use the correct anatomical term.  I fear, though, that too many mentions of the P-word will result in hordes of perverts stumbling on to my blog via their search engines.  (A lot of boys looking for "Girls Gone Wild" were no doubt disappointed to find themselves instead reading about cervical intraepithelial neoplasia.)

38 comments:

  1. The HIV article you cite cherry picks the trials- the full information concludes much difference.

    "There appears no clear pattern of association between male circumcision and HIV prevalence. In 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries HIV prevalence is higher among circumcised men." Source: USAID study http://www.measuredhs.com/pubs/pdf/CR22/CR22.pdf

    ...another

    "Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs."
    http://www.iasociety.org/Default.aspx?pageId=11&abstractId=2197431

    ...and on your HPV studies

    "The percentage of circumcised men reporting a diagnosis of genital warts was significantly higher than uncircumcised men, 4.5% (95% CI, 3.6%-5.6%) versus 2.4% (95% CI, 1.5%-4.0%)"
    http://journals.lww.com/stdjournal/Fulltext/2008/04000/Seroepidemiology_of_Human_Papillomavirus_Type_11.8.aspx

    CONCLUSIONS: The glans of the circumcised penis is less sensitive to fine touch than the glans of the uncircumcised penis.
    http://www.ncbi.nlm.nih.gov/pubmed/17378847

    Now, if that isn't enough 'evidence-based' information, here is some more:

    This study finds that approximately 117 neonatal circumcision-related deaths (9.01/100,000) occur annually in the United States, about 1.3% of male neonatal deaths from all causes. Because infant circumcision is elective, all of these deaths are avoidable.
    http://www.mensstudies.com/content/b64n267w47m333x0/?p=ec4ecb3ceb884756a452c5199dfb4cd8&pi=5

    If 108 wangs need to be whacked to save ONE child, and 117 boys (conservatively) die every year from wang whacking, which is the better outcome? If UTI's were such a danger, why do we not circumcise girls for the same reason? It's a silly reason. Infant circumcision does not advantage modern medicine.

    Why not teach children to use safe-sex practices? I realize that is a rhetorical question since I just obliterated your portion of research, but for fun- does your infant engage in promiscuity? I think not.

    Have a nice day and I hope you do a little better research next time you give birth.

    Anna

    ReplyDelete
  2. The risks of circumcision have not been properly measured, because a "risk" is defined as something brought to the attention of the medical profession within 3-6 months after the circumcision is performed. Many complications of circumcision are not apparent until after puberty, or after a man begins his sex life, or even after age 40 or 50.

    When a circumcised father desires to have his son circumcised, the father literally does not know what he is advocating, because he has no awareness of what it's like to have a natural penis.

    The following sentence is nonsense, junk science: "Some of the more pleasant "side effects" of the procedure were enhanced sensitivity and sexual satisfaction -- finally, a randomized (if not blinded) trial putting to rest the question of sexual dysfunction."

    Sexual dysfunction caused by circumcision often takes decades to manifest itself. No study has been designed to capture that. The best judges of the sexual consequences of circumcision are women with diverse sex lives. Quite a few women blog that they have been with both kinds of men, and prefer the kind with all the factory installed moving parts.

    The African clinical trials are a scientific scandal waiting to explode. A fundamental flaw is that they were cut short after only 6 months. There is no reason to believe that the alleged findings of these clinical trials carry over to North America. The Australian and Dutch medical societies have evaluated these studies, and concluded that circumcision is not relevant in their respective societies.

    The following quote from your post explains well the problem with studies claiming that the intact penis is unhealthy: "...since uncircumcised males are more likely to come from a lower socioeconomic status, which in turn, is associated with a higher rate of STDs."
    Studies of foreskin and STDs have to be conducted in Europe, where most circumcised men are from the Moslem underclass.

    "There are no randomized, controlled trials of circumcision in infants, and there probably never will be." I agree with your assessment, but assert that the ethical conclusion is to not circumcise.

    If circumcised was healthier, we would know it by comparing data from Japan and continental Europe, where circumcision is rare, with the USA and Korea, the western societies with the highest circ rate. I have been waiting 30 years for such a comparison, and stopped holding my breath long ago.

    "As for all you expecting, uncircumcised dads, it's time to start a new family tradition."
    NO THANKS AND NO WAY. Because circumcision destroys the most sexual part of the entire male body. Sorry, but that's simply the truth, no matter how hard middle class America tries to evade it.

    ReplyDelete
  3. This is quite possibly the most ignorant post regarding circumcision I have ever seen (complete with degrading comments!)

    "There are no randomized, controlled trials of circumcision in infants, and there probably never will be."

    Probably because it's thoroughly unethical to perform unnecessary surgery on a non-consenting patient for the sole purpose of justifying said unnecessary procedure.

    I notice that in your babbling about UTIs, that you don't mention that even intact boys have a much lower rate of UTIs than girls do. Is that because you have some urgent need to promote genital cutting to justify your "choice", or do you just not realize that UTIs are treated with antibiotics, not amputations?

    "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."

    Ignoring the fact those studies only relate to female-to-male transmission, which is not how most men in the U.S. acquire HIV, how is 1 in 108 a "good number"?

    And your comment about circumcision enhancing sexual feeling and satisfaction is ludicrous. Yes, chopping off 20,000 or so fine touch nerve endings is a great way to increase sensitivity. Removing the protective shield from an internal organ is a great way to make it more sensitive, too. That is, until it becomes desensitized by not being protected anymore. Try checking back with the members of that study in 10-15 years when the true damage of circumcision has reared its head. Remember, we're talking about neonatal circumcision here, not adult circumcision in Africa. By the time most boys ho were circumcised reach sexual maturity, they've already been desensitized to a level these men won't experience for years.

    BTW, I'm cut and I have no problem with my sex life. And I'm the father of two children, a boy and a girl. And BOTH of them are intact because it is NOT my right nor anyone else's to remove part of their body for any imagined reason you can think of. If it's a serious medical problem, then yes, do it. But that's such an infinitely small occurrence, that I can't believe someone claiming to base their opinions on evidence would even spend half a second deciding whether it was right or not, let alone encouraging everyone else to do it. BTW, you do realize 80% of the men in the world are intact and have no problem with it, right?

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  4. Oh, I forgot to include this link you obviously haven't seen. Thanks to RD for reminding me:

    http://intactnews.org/node/138/1319461990/acquisition-erectile-dysfunction-circumcision?mid=50

    ReplyDelete
  5. "My husband called every provider on the list and made an appointment with the second cheapest one."

    Wow. This is "well-researched?"

    "Actually, Springfield's Dr. Nick was way more professional than this joker, who was dressed in a hospital gown and dirty sneakers."

    But you still let him do it?

    "Without introducing himself or asking if we had any questions, he whipped out his instruments and started operating."

    Wow. You let him proceed.

    "Rick fled, leaving me to comfort J.J. with a bottle."

    So you let the doctor do something to your KID that your HUSBAND couldn't handle... :-/

    "In the middle of the procedure, the doctor (at least, I hope it was a doctor)..."

    Should I continue reading this "informed" mommy blog?

    ...said, "Here, hold this," and he handed me the thingy clamped to my son's penis, as he snipped away."

    Now I'm even having credibility this story is even true.

    "(I'm not a pediatrician or a surgeon, but I assure you that "thingy" is a formal medical term used by internists.)"

    I want to faint.

    "And no, I wasn't wearing gloves, nor had I told this guy that I was a doctor."

    You. Are a doctor. Really.

    "I fretted for days that J.J. would develop Fournier's gangrene, and that I would be to blame for his future as a eunuch."

    You seriously cannot be a doctor.

    "Fortunately, the risks of circumcision in a developed country are rare (0.2-0.6%) and minor -- typically bleeding, which usually stops on its own. (We doctors have a saying: "All bleeding stops....eventually." Think about it.)"

    You are quoting the CDC. Have you heard of these guys lately? You DO know that there are doctors that specialize in circumcision botches? That there are enough botches for doctors to make a living off of should be enough to scare you.

    "But some would argue that there's no reason to put a baby under the knife when it isn't necessary."

    "Doctor," this usually goes for any other surgery you name.

    "And then there are those whack jobs (no pun intended) who blame their unhappy sex life on the loss of their infantile foreskin, not realizing that they can't get a date because they are whack jobs who blame their unhappy sex life on the loss of their infantile foreskin."

    Really? It can't be at all because they've lost all sensation? "Well-researched" indeed.

    ReplyDelete
  6. Cont...
    "In fact, observational studies have been all over the map in terms of whether circumcision is linked to sexual dysfunction."

    This much is true.

    "There are no randomized, controlled trials of circumcision in infants, and there probably never will be."

    Interesting point. This will be relevant later.

    "Since there aren't any studies employing sham mohels, we must rely on the results of observational studies to guide us on the risks and benefits of neonatal circumcision, with their imperfect corrections for baseline differences."

    Hopefully you will have actually checked what said "studies" entail.

    "The procedure is linked not only with certain religions, but also with socioeconomic status, with babies born at higher income levels being more likely to be circumcised."

    Nothing new here...

    "-- although Dr. Nick and his like-minded colleagues remain a low-cost option for the uninsured."

    You are a doctor, but you are uninsured... mm-hmm...

    "Circumcision does seem to reduce the risk of urinary tract infections in the first year of life - from 1% to 0.1%."

    If the studies you are looking at are actually valid. What is it. Wiswell?

    "Not a huge absolute benefit for a surgical procedure, though infant UTIs do present a significant healthcare cost burden."

    Actually, no, UTIs are rare. They are the rarest in boys, whether they have been circumcised or not, occurring more often in baby GIRLS, and being as easily as curable.

    "My pediatrician friends tell me that kidney ultrasounds are routinely performed in male infants with UTIs, to screen for anatomic abnormalities. They often have to perform suprapubic aspirations (sticking a needle through the skin into the bladder) to obtain a clean sample of urine, which is a low-risk procedure, but not a particularly fun one for baby or parent."

    Anecdotal accounts from your friends really don't account for UTI, incidence and treatment. This very irrelevant.

    ReplyDelete
  7. Cont...
    "Observational studies have also shown that circumcision is associated with a lower risk of sexually transmitted diseases, including HIV and human papillomavirus, the cause of most cervical, anal and now, oropharyngeal cancers."

    Observational studies in ADULTS, in high-risk communities in heterosexual men in AFRICA. Remember what you state above.

    "But here the data get particularly sticky, since uncircumcised males are more likely to come from a lower socioeconomic status, which in turn, is associated with a higher rate of STDs."

    Not to mention that this "reduction" is not observable in 10 out of 18 countries, according to USAID.

    "Although there aren't any experimental studies of infant circumcision, there have now been three large randomized, controlled trials of circumcision in over 10,000 adult men."

    Only 201 of which actually acquired HIV.

    "All of these studies were performed in Africa, with the primary outcome being the subsequent rate of HIV infection."

    In 137 intact men got HIV as opposed to 64 circumcised men. We must remember that 10,908 men were involved in the study. That "reduction" is not significant at all.

    "It turns out that the foreskin is replete with special cells that are prone to invasion by the AIDS virus, so removing the foreskin should reduce the rate of HIV infection."

    This is a hypothesis that has long been debunked. The "special cells," the Langerhans cells to be exact, actually secrete Langerhin, which destroys HIV. These cells are actually quite efficient at thwarting HIV. Check your studies; scientists cannot demonstrably prove that removing the foreskin prevents anything.

    "And indeed it did, by an impressive 50% over a 2-year period."

    50% of 201, not 10,908 men.

    "In fact, all three trials were stopped early, and circumcision was offered to the men in the control groups."

    The trials were stopped early, and then the researchers deemed it "unethical" to conduct any further studies (so why did they even begin?), making it impossible for other scientists to reproduce their results.

    ReplyDelete
  8. "Now that the benefits have been well-established..."

    You WISH.

    "...what if men got the mistaken notion that circumcision was completely protective against HIV, blunting the potential benefits? I doubt this will be much of an issue in pediatrics, as I can't imagine any parents encouraging their son to sow his wild oats simply because he had been circumcised."

    But you can imagine them to sow his wild oats if they were not??? HONESTLY.

    "Whatever the studies show, most parents will probably still base their decisions on cultural and personal reasons."

    And your reason for attempting to decipher them here is...?

    "Rick and I had no discussions at all about the benefits and risks of the procedure. I deferred to my husband's wishes completely, and when it comes to circumcision, that seems to be the rule among the couples we know."

    Researched. Very well researched.

    "In 1999, the American Academy of Pediatrics acknowledged the "potential medical benefits," but state that "these data are not sufficient to recommend routine neonatal circumcision.""

    Pay attention. Not enough for the AAP, or any other medical organization in the US to recommend (in fact, no medical organization in the world recommends it), but enough for parents, who have never picked up a book on basic human anatomy, who base most of their decisions on culture anyway, to weigh and decide for themselves. You got that?

    "Some have argued that the AAP needs to advocate more strongly for circumcision, now that we have proof that it saves lives."

    Who is "some?"

    "As for all you expecting, uncircumcised dads, it's time to start a new family tradition."

    But then their sons won't look like them.

    Remember that?

    This blog post is self-serving trash. I doubt the author is in any way related to the medical profession, given her own anecdote. It sounds like all other parents who have circumcised their sons, she's simply searching for a reason, where there is none.

    BOTTOM LINE:
    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
  9. How far are we interested in so-called "medical benefits?"

    Would there be a number of "benefits" that would make you consider circumcising your daughter?

    Is there a number of "studies" that would convince you to go get done yourself?

    What if there were "studies" that showed that a labiaplasty could reduce the risk of HIV by "50%?" Would you do it then?

    What would you think if someone proposed these same "trials" in women? What if someone proposed we circumcise 1,000 women and follow them around to see how many STDs they got? Would that be acceptable to you?

    Would you support more "studies" and "research" into the matter?

    But more so than this, would you advocate for research finding a better solution than circumcision?

    If the doctor had told you that there were better ways to prevent disease, would you be interested?

    If the doctor told you "Look! We have found the cure for HIV. Now we don't have to circumcise your son!" Would you be jumping for joy? Or would you try finding a doctor who would do it?

    The answers to these questions would tell us how much we are really interested in actual "medical benefits," and not just some scientific-sounding alibi that would satisfy our already made-up minds.

    There are better ways to prevent disease. This "reduction" in HIV is not observable in the real world. Circumcision fails. Every researcher you name must acknowledge this and stress the use of condoms.

    Circumcision is tradition masquerading as "medicine."

    It is child abuse and it has to stop.

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  10. Pathetic-they let anyone into medical school nowadays.

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  11. No medical organization in the entire world recommends infant circumcision. Including the American Academy of Pediatrics.

    None.

    Nada.

    Zip.

    http://www.cirp.org/library/statements/

    Those "studies" conducted over in Africa are put on by pro-circ companies with an agenda and are often conducted on populations of men that lead lifestyles much unlike most men in the Westernized world....for example, in one they used Ugandian truck drivers who frequently engage in sex with prostitutes and use a method called "dry sex" which increase STD's a SIGNIFICANT amount.

    I guess you'll be raising your son to choose than kind of lifestyle then???

    It's kind of like those old UTI studies in which they divided people into circumcised and uncircumcised but what they DID NOT tell people is that included in the "uncircumcised" group were WOMEN, who are more likely to get UTI's than circ'ed or Intact men.

    How about the fact that circumcision is unheard of in Europe and they have much lower rate of STD's of all sorts than the good ole' US of A???


    Mean anything to you now??

    http://www.cirp.org/library/disease/HIV/

    Every generation tries to keep circumcision going with bogus studies that are debunked, so in another decade, we will move past the STD thing onto something else?

    Why?

    Because circumcision is a billion dollar a year business for doctors and hospitals. The docs get paid big bucks for your son's 15 minutes of pain and then the hospital sells the circumcision to cosmetic and biopharmaceutical companies.

    Not to mention that it is complete violation of human rights to remove a part of a child's body without their consent for no medical reason whatsoever! Let alone without sufficient anesthesia.

    I wish you nothing but girls in the future! I would much rather girls be born to people who will welcome to their son's to the world with a slice to their penis.

    ReplyDelete
  12. Even if the STD studies you cite were not so thoroughly flawed, they still would not be relevant to INFANT circumcision. They would be relevant to men reaching sexual maturity who wanted to weigh them in their decision to either use condoms and practice monogamy OR cut off the most sensitive part of their penis and use condoms and practice monogamy.

    http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102282676.html

    http://www.youtube.com/watch?v=Ceht-3xu84I

    P.S. "uncircumcised" is a ridiculous term to refer to the normal, natural state of the human body. I am normal, intact woman, not "unclitoridectomized."

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  13. Wow. Just wow. You let a man that you didn't even trust or respect CUT your child? Poor baby. I just wish he could have been born to a family that loves and respects him.

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  14. I am horrified.....for your son.

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  15. Check out www.drmomma.org that is how you use ACTUAL evidence to HELP people make educated decisions.

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  16. I wonder why the US, with so many cut adult men has such a high rate of STIs? My son can cut off part of his penis when he is old enough to give informed consent. It really is that simple.

    I'm just having a hard time becoming concerned about his risk of HIV while he still thinks he's Batman.

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  17. I second Megadoula, if you want to find out how much damage is being dome to countless boys across America, completely unnecessarily have a browse around www.drmomma.org.

    Here are a few to get you started

    http://www.drmomma.org/2011/04/is-pain-of-circumcision-truly-brief.html

    http://www.drmomma.org/2011/03/he-didnt-cry-babies-in-shock.html

    http://www.drmomma.org/2009/04/cut-slicing-through-myths-of.html

    I am truly shocked and horrified to see an "educated" women writing such utter garbage.

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  18. "As for all you expecting, uncircumcised dads, it's time to start a new family tradition"

    It would be one thing if you were just discussing your decision to have your son circumcised, but to suggest that it is a superior decision that everyone make? Horrifying.
    We are doing the opposite.

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  19. As a Primary Health Care provider (Podiatric Medicine) it is a very strange and sad state when a doctor will treat a new born's penis with less respect than is afforded to his tonsils, appendix and even lowly truly vestigial toenails. We have determined that the tonsils have an important function in immune system development, and appendix is actually to maintain gut flora and has a function. Toe nails get dirty, become ingrown, need to be trimmed regularly etc yet we respect that child's right to decide whether he would prefer to trim them and deal with any future problems as they arise rather than remove them at birth.

    Seriously. More respect for toenails than healthy sexually responsive erogenous penile skin.

    His body, his choice. Do you agree with female genital mutilation too? Those labia harbor all manor of bacteria, and cultures invested in FGM practice have performed studies proving benefit.

    Sarah

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  20. You've just lost yourself another reader.

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  21. Oh & this may be helpful if you want to educate yourself:
    http://www.drmomma.org/2009/09/functions-of-foreskin-purposes-of.html

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  22. The amount of misinformation in this is really saddening. I can't believe some people have no regard for the bodily integrity of boys. Just cut if off you say but would you cut a girl's genitals? No way. Circumcision takes the lives of healthy baby boys and you are advocating for it? Condoms save lives, not cutting the most sensitive part of your baby's penis off. I seriously hope you reconsider your beliefs because they are far from being truths.

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  23. Wow...it seems silly to cite a reduction in STD transmittal when discussing a procedure being performed on a baby, that is NOT recommended by any medical organization and is purely cosmetic. I really wish I had known better with my two older boys, but I am quite thankful that I did ACTUAL research prior to my 3rd boy being born and he is WHOLE. There really is no advantage to cutting a baby who has no say in the matter. If my son decides when he's an adult that he wants to be cut, then that will be his choice to make. It's unfortunate that you weren't given the correct information to make a more informed decision prior to your son being cut.

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  24. I am so sorry for your readers that are actually looking for TRUE fact based evidence re: circumcision because they won't find it written in this awful blog post! Thankfully you seem to have some very educated commenters here to help you out. I won't bother with your ridiculous studies and misinformation, and degrading opinion of others, but for those people truly looking for truth and real information, pls google: NOCIRC, Intact America, Dr. Momma/peaceful parenting, The Whole Network, Saving Our Sons for real, up to date, true (and accurate) information. In our house, my circumcised partner and I, chose to end the cycle of violence!! Raising 4 happy, healthy intact boys.

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  25. Wow, this has generated a lot of interest.
    As a pediatrician and mom, I've enjoyed reading your blog, and appreciate your evidence-based approach. I do have to quibble a little bit though with a couple things in this post. The first point is, as a pediatrician in practice for almost 5 years I have treated many, many UTI's in infants and have never ordered or performed a supra-pubic aspiration. I would guess that most pediatricians would tell you the same. Catheterization is widely accepted as the standard of care for obtaining clean urine specimens in infants, and although uncomfortable, is very safe and much less scary for parents than SPA's. See the AAP's new UTI Guidelines released this year (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/4/843). Also, I'd just like to make the point that many insurance companies no longer cover circumcision, many hospitals don't routinely perform it during the newborn admission, and the roughly $300 that families pay out of pocket is cost-prohibitive for some families. After 2 weeks of age, it is almost impossible to get a child circumcised, because they would require OR time, which almost no family can afford to pay for out of pocket.

    So, although I appreciate your analysis and agree that there are some good arguments for circumcision, I still encourage my patients' families that not circumcising their son, either for preference/cultural/financial reasons, is still a perfectly acceptable option and that they are not putting their son at medical disadvantage. I think this is an issue for each individual family to decide.

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  26. "It turns out that the foreskin is replete with special cells that are prone to invasion by the AIDS virus, so removing the foreskin should reduce the rate of HIV infection." This is shear conjecture and has never been proven scientifically. You really should stop posting on this issue. It is clear you know nothing about it. Your flippant attitude is insulting. May I ask do you come from a culture that typically condones genital cutting? It would seem so by many of the bold, incorrect and outrageous statements you make! Shame on you! Even more so since you are an Medical Doctor. Please consider surrendering your license for the safety of society in general.

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  27. Typical jabber from a narcissistic female who's been offered federal protection for her genitalia. I'm ashamed to say she and I share a gender. Men, like women, should have a 'choice' concerning their bodies.

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  28. This is the most comical doctor I have ever read an article by. Truly laughable as well as the low class jargon.... I would never listen to a doctor that makes such lewd references about babies or sexual anatomy. I will not bother to list any links whatsoever because what would be the point? The whole article is completely ridiculous and laughable. Maybe this so called doctor should really try to break into the comedy business!!!!!!

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  29. I can't believe you made a joke about, "All bleeding stops... eventually."

    I'm surprised that as a doctor you are unaware of the process of bleeding to death. A few years ago a baby in Canada died from bleeding that began after he was circumcised. An uneducated person might assume that all the blood just leaked out of the wound on his penis until he was dead- but that's not how it works. When the body loses such a great amount of blood- a cascade of things begin to go wrong internally. The blood loses it's ability to clot- and the internal organs begin to bleed as well. A post mortem examination of Ryleigh's body revealed "hemorrhagic damage of his brain, heart, liver, intestines, kidneys, and lungs, confirming the clinical diagnosis of severe multi-organ injury from hypovolemic (abnormally decreased plasma volume) shock."

    A very detailed report of his death was issued and I hope you read through it with humility and never ever joke about a baby bleeding to death again.

    http://www.circumstitions.com/death-exsang.html

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  30. "And then there are those whack jobs...who blame their unhappy sex life on the loss of their infantile foreskin..."

    Stephanie, I wonder if you would be equally callous towards a woman who resents that she had the most sensitive parts of her vulva amputated against her will. Or is it only men who have no right to express negative emotions over having had a normal, healthy part of their bodies amputated sans necessity or their consent? I suppose that for you to acknowledge that some men feel deeply harmed (physically, sexually, and psychologically) over their circumcision, you would then have to deal with the painful realization that your sons could some day feel the same way as a result of your failure to protect them from harm.

    As for myself, I will continue to empathize with those who are brave enough to speak openly about the harm they have endured as a result of such a grotesque form of child abuse.

    Jonathon Conte
    San Francisco

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  32. To quote a pathologist I once worked with: "There's no reason to do it and babies have died."

    He's a doctor too, and one who is informed about disease. No, he's not an epidemiologist, but he said he knows enough to know all the studies coming out of Africa promoting Circ to halt the spread of AIDS are bullshit.

    I prefer the advice of someone who doesn't promote the cutting of babies' genitals.

    Do you mind sharing with us where you graduated from medical school? Or did you get your license off e-bay?

    Yeesh. Keep your medieval ideas and misinformed brain away from my kids. I can't believe you let that guy 'work' on yours...

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  33. Your PROFESSION is writing about evidence-based medicine and you could write the above steaming heap of ...?

    "Rick and I had no discussions at all about the benefits and risks of the procedure. I deferred to my husband's wishes"

    And let me guess; Rick can't remember what it's like to have a complete penis, right? Yeah, evidence-based.

    "finally, a randomized (if not blinded) trial putting to rest the question of sexual dysfunction."

    Morten Frisch, who co-authored the Danish study showing circumcision impairs sex (graphically summarised here), deals to those studies in a rebuttal to his critics:

    "The questionnaires used to assess potential sexual problems in the two cited randomized controlled trials in Kenya and Uganda were not presented in detail in the original publications. Rather than blindly accepting such findings as any more trustworthy than other findings in the literature, it should be recalled that a strong study design, such as a randomized controlled trial, does not offset the need for high-quality questionnaires. Having obtained the questionnaires from the authors ..., I am not surprised that these studies provided little evidence of a link between circumcision and various sexual difficulties. Several questions were too vague to capture possible differences between circumcised and not-yet circumcised participants (e.g. lack of a clear distinction between intercourse and masturbation-related sexual problems and no distinction between premature ejaculation and trouble or inability to reach orgasm). Thus, non-differential misclassification of sexual outcomes in these African trials probably favoured the null hypothesis of no difference, whether an association was truly present or not."

    "those whack jobs ... who blame their unhappy sex life on the loss of their infantile foreskin"

    Yeah, whack jobs like these men.

    Your article has a Coefficient of Objectivitity and Circumcision Knowledge of 8, the highest so far recorded. Here is how the coefficient is calculated, at the end of a useful guide for writing about circumcision, one you hardly needed.

    @Hisbodyhisrights: "Pathetic-they let anyone into medical school nowadays." - where they teach them nothing about the foreskin except how to cut if off, from textbooks that don't even show it.

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  34. I am horrified at the overwhelming ignorance and complete lack of rational thought throughout this post. The only possible *evidence based* conclusion is not to perform unnecessary amputations on non-consenting minors.

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  35. My husband, my father, and his father were all circumcised. They are quite happy with it. As far as babies dying... there are babies who have died from just being in a hospital. (So... does this mean I now need to avoid all medical personal? Sweet!) I know a baby girl who has come close to dying from a bacterial infection because someone didn't wash their hands properly in the nursery. She had to have major surgery to remove 30% of her intestines and now has digestive issues at the age of 5. Most babies who have died from circumcision was not because of the procedure itself... but from bacterial infections caused by the idiots who didn't take the time to sterilize the equipment properly or the parents who didn't pay attention to the warning signs. (the real culprits in the story) I personally use a Mohel (rabbi) because they are trained specifically for that. It is what they do exclusively, the babies are in pain for 60 secs tops (versus the 5-10 mins in the hospital) and they believe that it is a sacred duty (less likely to cut corners than some hack-n-slash for $199. There is something about divine retribution that is very motivating...) Obviously, I support it. The foreskin is notorious for being a nice haven for bacteria and culturing all sorts of fun life/vagina threatening nano-critters. (I am an engineer who started college at the age of 14 so I can call them critters) As far as waiting to let the kid decide if they want to nip the tip, ok... I can go with that. But now they risk bleeding to death. (as is the case with Fred who got gonorrhea so bad they had to cut it off. If you could ask him... he is a advocate of circumcision) I think you people's venom should pick a more important issue. How about you focus on saving the millions of lives ended by abortion (or are you more worried about a penis than a beating heart?), or giving child a family by adoption, or here is a radical thought... volunteer for one of the hours you spend on the internet and make the world a better place. Geez...

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  36. I can only hope your son grows up and reads your stupid blog so he can see how little his mother cares about him or his safety. There are things you just go with your husband on and there are things you buy like wine that you can get cheap...The removal of your sons body parts that make him a "son" should be discussed at length and the cheapest is NOT the best. The way you describe what took place when you arrived and the fact you went through with it shows you have little regard for the safety of your son and you should not be allowed to be a parent. Shame on you...For your sake I hope your son doesn't read this..As finding out his mother was willing to put him in harms way by a whack job Dr. might scar him worse than the side effects of the circ. SHAME ON YOU AND YOUR HUSBAND....Poor baby.

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  37. evidence based???? no
    have you ever seen this video? It's called Child Circumcision: An Elephant in the Hospital
    It clears up a lot of your so called facts
    http://www.youtube.com/watch?v=Ceht-3xu84I

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  38. I am always amazed at all of the comments stating the foreskin is the most sensitive part of the penis and that men who are circumcised have, and I quote, "lost all sensation". Funny how many women out there whine about men who can't last ten minutes making love and wish it took their men longer to achieve orgasm. Seems like a little less sensation would be a GOOD thing. Makes me glad my husband is circumcised and I am sure my sons wives will be some day too!

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