Tuesday, 20 October 2009

Analysis of Intact America propaganda

I recently became aware of this. An obviously well-funded group called "Intact America" have placed what appears to be a full-page advertisement in the Washington Post. They must be terrified that the AAP will decide to recommend circumcision - the advert must have cost a fortune! Anyway, I thought it would be instructive and educational to analyse their advertisement, to see what propaganda techniques they're using. So let's dissect An Open Letter to the American Academy of Pediatrics:

American parents trust their pediatricians and rely on them for the best advice in caring for their children. As a matter of ethics, that advice cannot include neonatal male circumcision - a medically unnecessary, potentially risky surgery that no major medical authority in the world recommends.

Let's start with the last point: what Intact America are arguing, in effect, is that the AAP (a major medical authority) should not recommend circumcision because no major medical authorities have done so to date. Now, that's an ... interesting ... argument. It's a good thing that these people weren't around when people invented fire!

(As a point of fact, I'd question whether their assertion is even true. Many African countries are embarking on large-scale circumcision programmes in the fight against HIV, and it seems likely that they're doing so with the assistance and approval of their national medical bodies.)

So what do we have left? A "potentially risky surgery". Well, yes, it is. There are risks, of course, albeit small. But these need to be weighed against the benefits: a reduction in the risk of certain conditions.

Finally, "medically unnecessary". Again, yes, it is. But that's not an argument against it: something can be beneficial, even advisable, without being necessary. Take vaccinations, for example: they're not strictly necessary, but they're certainly advisable.

Their claim that circumcision is unethical seems to be on shaky ground.

That is why Intact America is asking the task force charged with reviewing the American Academy of Pediatrics' current neutral position on infant circumcision NOT to revise that position in favour of the surgery. Further, we ask you to take an ethical stand against the removal of a healthy, functioning body part - the prepuce, or foreskin - from non-consenting newborn babies.

Well, I guess they're entitled to ask, however bizarre the request may be.

The United States is the only western nation today where doctors routinely circumcise infant boys in medical settings. Although the rate has fallen from above 90 percent 30 years ago to below 60 percent today,

This is false. The recorded infant circumcision rate 30 years ago (ie., in 1979) was 64.3%. Figures for today are unavailable, but from the same source, the most recent data (for 1999) indicate a rate of 65.3%.

still, more than one million American babies undergo the surgery every year driving one billion dollars in health-care spending.

And, no doubt, saving comparable figures in disease prevention.

Now, based on studies conducted among adults in sub-Saharan Africa that found reduced transmission of HIV from women to men (though not from men to women, nor men to men), some are suggesting that the AAP - meeting this week in Washington - should recommend circumcision for all newborn boys in the United States.

"Some" is rather vague, but this seems basically correct. News reports over the past year or so have contained similar suggestions.

Doctors have a responsibility to tell parents the truth: circumcision does not prevent disease.

Which? Should doctors tell parents the truth, or should they tell parents that circumcision does not prevent the disease?

Most European nations, with circumcision rates near zero, have lower HIV/AIDS rates than the United States.

Are Intact America really so naive about epidemiology that they think that between-country comparisons constitute a decisive answer to such a question? Evidence-based medicine requires use of the best available evidence (usually randomised controlled trials), not the least (ecological analyses such as this are considered one of the weakest methodologies, and for good reason).

Circumcision rates in America do not correlate with HIV rates in any ethnic population or geographical region.

Yes, they do. The CDC cited several American studies in which such correlations were observed in their factsheet (see the section entitled "HIV Infection and Male Circumcision in the United States"). Are Intact America unaware of this, or are they intentionally making false claims?

Furthermore, circumcision has significant risks, including infection, bleeding, impairment of sexual function, and even death. Earlier this year, an Atlanta family was awarded $2.3 million because a physician accidentally amputated much of their infant son's penis during a "routine" hospital circumcision. A Canadian baby bled to death in 2004, after being circumcised in a British Columbia hospital. In 2008, a baby from South Dakota bled to death, and his parents have filed suit against the hospital where he was circumcised, as well as the doctor who performed the surgery.

Yes, accidents happen, and of course they're tragic. But let's be sensible. If we're going to consider the risks associated with circumcision, we also have to consider the risks associated with non-circumcision. Babies die of urinary tract infections - and circumcision reduces the risk. Adults die of penile cancer (again, the risk is reduced) and of HIV (and again).

Infrequent though complications may be, because the surgery is performed on healthy babies who have no need for it, each injury and death is utterly indefensible.

This is illogical. If you choose to avoid the risks associated with circumcision, you choose the risks associated with non-circumcision. It's impossible to avoid risk altogether.

Growing numbers of medical professionals and expectant parents are saying "No" to infant circumcision.

There's no convincing evidence that this is the case.

We urge members of the AAP's circumcision task force, and all pediatricians, to make the same decision on behalf of the babies who are their patients.

They're entitled to urge, but how convincing do they imagine they are? It's easy to put together a bunch of illogical arguments and false claims, but a persuasive argument requires factual accuracy and logical reasoning.


hoodycub said...

There will always be arguments for and against circumcision. And every man should be able to decide for himself. Why is that so hard to comprehend?

ght said...

I am absolutely disgusted that there is a blog about the "merits" of circumcision. America's baby girls are protected from genital mutilation, why aren't our boys? And for those who say they aren't comparable, please educate yourself before you do, because FGM is done for the same reasons as MGM and while there are several different kinds of FGM, most are much less severe than male circumcision.

Momo said...

I am with both hoodycub and ght. You're a sick fool if you support circumcision. I don't know how you can consider yourself sane supporting the mutilation of a birth-given body part.

usha said...

It's interesting that you say the numbers of circumcisions are not falling. I have seen a number of reputable sources stating they are. This includes many pro-circ groups such as those concerned about the drops in low-income populations now that many state medic-caid programs won't pay for the procedure. Many of the recent news programs on the subject focus on the reduced numbers of circumcisions. Many pro-circ doctors are concerned about this. For good or bad the numbers ARE dropping.

How can you say that a study of African men has relevance to American infants where European men do not? I understand that the African studies were controlled studies as opposed to simple observation. However the populations are very different.
I plan to teach my sons safe sex to protect THEMSELVES from HIV rather than amputate healthy tissue to protect a future female partner from a disease they have yet to contract.
It's not my body, it's not my choice. If my sons wish to remove part of their penis as adults they may do so, but I won't make that decision for them.

cthulhi said...

If a man wants to be circumcised for what ever reason then fine, the that man decide to do so when he has the faculties available to do so, not when he is an infant and cannot make an informed decision.

Faux Hammer said...

The "analysis" in this blog needs to be deconstructed--it is full of opinions unbacked by evidence.
Show ME the "no doubt comparable savings in prevention" of future healthcare costs due to circumcision. And even if it is a financial wash (or savings), that does not give anyone the right to remove functional skin from a non-consenting newborn just because it's the current status quo.

And circumcision DOES NOT prevent HIV--abstinence, monogomy and condom use REDUCE HIV RISK with exponentially more reliability (by the way, I AM an epidemiologist). Surprise surprise, it doesn't prevent epilepsy or masturbation either--just a couple of the "maladies" that were purported to be prevented by circumcision historically in this country.

I wonder also about a blog dedicated to circumcision. WHY?? Self-therapy for dealing with the fact that the author was circumcised without haven given consent himself? If this is the case I'm very sorry for him.

Yes, I AM terrified AAP will begin to recommend routine infant circumcision because only a minority of parents will even think to question their doctors' recommendation, and the currently hopeful trend in decreasing rates of circumcision will likely go in the other direction.

Eoin said...
This comment has been removed by the author.
Reginald said...

If an adult wishes to be circumcised, that is his choice--he can look at the studies, weigh his options. To slice off part of a baby's penis is entirely another matter.

Steve said...

Tips from an unbiased observer:

Your circumcision rate statistics come from the CDC; interestingly, these data disagree with data from all other sources, including a UCLA study and many other studies. You may want to research those statistics rather than assume they're correct. They conflict with all other statistical reports.

And please use legitimate argumentation rather than a string of ad hominem attacks and such :\

Emad said...

According to the CDC statistics that you provided a link for it
percentage of people infected by HIV in USA is analyzed like that

48% due to male to male sex (circumcision can't protect them)

4% due to either male to male sex or drug injection (also circumcision here can't help)

32% high risk takers (circumcision can't help them too because if circumcision provide 50% protection then that means the person will get infected if he is high risk taker after twice number of times practicing sex than if he is not circumcised)

Total now is 84% circumcision can't help them

Add to that females percentage (not mentioned in the report)

Add to that infections due to pure drug injection (not drug injection with male to male sex)

The remaining percentage is very very very little
actually I doubt if any thing left
because I think the remaining is unprevented

Kileah said...

I am of the opinion men should have the right to choose to mutilate themselves-otherwise, we shouldn't be making that decision for those who can't/aren't capable of making that decision for themselves. You don't see us trying to mutilate our little baby girls-why the boys? it's sick. Anybody in their right mind would know that mutilating a boy's genitals based on historical misinformation is just sad, gross, wrong, ignorant and blatantly uneducated.

rich said...


Jake said...

To respond to usha and Steve:

Steve, you've referred to other sources that conflict with data from other sources. Unfortunately you haven't actually cited these other sources, which presents certain difficulties.

The CDC data that I cited is derived from the National Hospital Discharge Survey (NHDS). This is one of two main data sources giving nationally-representative neonatal circumcision rates. The other is the Nationwide Inpatient Sample (NIS). The two do not provide identical data for the same years, presumably due to differences in sampling methodologies. Neither seem to support the claim of a massive decline in circumcision rates.

By the "UCLA" study, I'd guess that you mean Leibowitz et al. (Determinants and policy implications of male circumcision in the United States. Am J Public Health. 2009 Jan;99(1):138-45); that study used 2004 data from the NIS, reporting a rate of 55.9%. An earlier study using the same data source - Nelson et al. (The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol. 2005 Mar;173(3):978-81) - reported an increase in circumcision rates from 1988 to 2000. So this wouldn't seem to support the claim that there is a decline.

Usha, you state that you've seen a number of reputable sources stating that circumcision rates are falling. So have I, but that doesn't mean that it is the case. I have yet to see convincing evidence that it is. It's possible that there may have been a small decrease over time, but nothing like the fall claimed by Intact America.

The basic problem with tracing circumcision rates over time is that reliable data are limited. Put simply, there are no nationally representative data for neonatal circumcision rates prior to 1979. What I've seen people do is to compare samples of the current circumcision status of adult men who were born in, say, the 1970s with samples of babies who were born in, say, the 1990s. But of course that's not valid: it's a comparison between apples and oranges.

Blake said...

I'm a normal, well adjusted guy that wishes
I was not circumcised. Why were my rights ignored? I know there are at least a few million guys asking this question. What is your answer for us? We don't know what we want??? We do. Leave our dicks alone. Thank you

Cindy said...

"still, more than one million American babies undergo the surgery every year driving one billion dollars in health-care spending.

'And, no doubt, saving comparable figures in disease prevention.
If we're going to consider the risks associated with circumcision, we also have to consider the risks associated with non-circumcision. Babies die of urinary tract infections - and circumcision reduces the risk. Adults die of penile cancer (again, the risk is reduced) and of HIV (and again).'
'If you choose to avoid the risks associated with circumcision, you choose the risks associated with non-circumcision. It's impossible to avoid risk altogether.'"

To circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. The “risks associated with non-circumcision” do not justify routine circumcision:

Ganiats et al., Routine neonatal circumcision: a cost-utility analysis. Medical Decision Making. 1991. Oct-Dec;11(4):282-93. (Department of Community of Family Medicine, University of California, San Diego School of Medicine, La Jolla 92093-0807.)
A cost-utility analysis was performed to evaluate the relative importance of each of the various elements in the current circumcision debate. Elements used in the analysis included the cost of the procedure, the pain associated with the procedure, the risk of urinary tract infections, and the risk of penile cancer. The net, discounted lifetime dollar cost of routine circumcision is $102 per person, while the net, discounted lifetime health cost is 14 hours of healthy life. ***These results suggest that the financial and medical advantages and disadvantages of routine neonatal circumcision cancel each other and that factors other than cost or health outcomes must be used in decision making.*** (PMID: 1766331 [PubMed - indexed for MEDLINE])
Van Howe RS. A cost-utility analysis of neonatal circumcision. Medical Decision Making. 2004. Nov-Dec;24(6):584-601. (Department of Pediatrics, Michigan State University College of Human Medicine, Marquette, Michigan, USA.)
A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. ***Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective.*** Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically. (PMID: 15534340 [PubMed - indexed for MEDLINE])

Cindy said...
This comment has been removed by a blog administrator.
Jake said...

To reply to Cindy:

To circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate.

Maybe so, but I don't think we were discussing circumcision for therapeutic reasons.

The “risks associated with non-circumcision” do not justify routine circumcision:

I didn't say that they did. My concern is that Intact America are considering only the risks associated with circumcision, while ignoring the risks associated with non-circumcision. That's invalid: any rational analysis needs to weigh both sets of risks.

The two papers that you cite, incidentally, both have some fairly serious faults. Ganiats only considered two of the known benefits: UTI and penile cancer, ignoring many others. Van Howe's analysis suffered from numerous problems, including inclusion of elective foreskin restoration as a cost of circumcision, but failing to include elective circumcision as a cost of non-circumcision. In addition, there were many dubious assumptions, as can be seen in his Table 1. For example, he estimated that UTIs would occur in 1.01% of circumcised boys, and 1.52% of uncircumcised boys (studies invariably show, in fact that the risk in uncircumcised boys is approx 7x that in circumcised boys). For another example, he estimated that more circumcised boys than uncircumcised boys would suffer from balanitis (10% vs 8%); with the exception of his own study published elsewhere, every single study has shown the opposite.

Jake said...

The following was posted by Cindy, in a comment dated 21 October 2009 18:28:

Letter to the Sydney Morning Herald


Cindy, you've quoted an entire article from the source. Unfortunately this violates copyright law, so I'm going to delete your post. I'm reposting the above so that the purpose of your post is served; I've made the URL a link so that readers can easily access the content.

Sigismond said...


jwb3 said...

I just don't get it. How can you think that mutilating the male sex organ is going to some how prevent a deadly disease? Advocating circumcision in Sub-Saharan Africa will only add to the myriad of tribal customs and practices that have taken them where they are today. In a region where unprotected sex is a cultural norm, circumcision will only serve to exacerbate the problem. Cut men will feel invincible because they will think they can't contract the disease. Let me see the study that explains in medical terms why Sweden, where infant genital mutilation is almost unheard of, has the lowest rates of HIV infection. Or Japan where HIV infection is a tiny fraction of .1 percent. It is a cultural phenomenon that can be altered with education, not surgery.

Anonymous said...

If you (or anyone) thinks that circumcision prevents ANY disease, then go have unprotected sex with a prostitute or two.

I got STD's from a circumcised man, AND 2 UTI's from circumcised men as well. Circumcision prevents no disease.

Terrible that this sort of lie is pushed by pro circumcision people. It's the baby's penis, let HIM decide if he wants to use a condom or be irresponsible sexually.

Many men are restoring their foreskin because it increases sensation. Circumcision destroys sensation.

Anonymous said...

What's really interesting is your lack of real facts or compassion or understanding of basic human rights in this article.

In what way is circumcision "advisable?" UTIs? STDs? Old hat. Provide some numbers that are not skewed. Why not chop off your hand instead of wearing a glove?

Neonatal or routine circumcision seems especially ill-advised, something that is done WITHOUT consent of the affected party.

Can you see that while you may find it "advisable" to permanently damage sexual function and anatomy, it should be up to the owner of the penis, not his parents?

John Flushing said...

I read this article and I am furious right now. As a man who had 100 percent of his foreskin stolen from him against his will when he was an infant, I am forced to be reminded of this blatant act of thievery every time I go to the bathroom-and my anger is uncontrollable.

Every physician promises to do no harm. If what they did to me is not harmful, then I do not know what is. Male Genital Mutilation, euphemistically referred to as circumcision, constitutes a very serious human rights violation that must come to an end immediately. And your organization urges physicians to perform this procedure, not because I had a disease, or because I was suffering from cancer, but because I am a male.

Federal laws prohibit discrimination based on gender, race, religion, creed, or sexual orientation. Furthermore, federal laws wholeheartedly condemn the genital mutilation of baby girls, dismissing it as a criminal act worthy of severe punishment to the fullest extent of the law. Yet to deny those same protections to baby boys, simply because of who they are, seems like a very clear-cut case of gender discrimination, plain and simple. As a male, I do not seek any special rights or privileges. I merely seek the same rights and privileges afforded to infant girls, and these rights were stolen from me against my will.

It is for this reason that I hope to personally track down the individual responsible for stealing my foreskin. If I am able to track him down, then I WILL file assault charges.

You will often hear the crusade against male genital mutilation dismissed as a radical, pseudoscientific, “anti-circumcision” agenda. Actually, it is a civil rights issue, plain and simple. Bodily integrity, which entails having the fully-functioning genital area that you were born with, is not merely a female desire. It is a basic human right not limited to women. If a physician were to cut off the clitoral hood and/or the labia minoria of a baby girl, then that physician would immediately have his license revoked and be put on trial for crimes against humanity. Yet the fact that your organization encourages the removal of a portion of my genitalia, simply because of who I am, is proof that your organization has no concept of who owns the body of the child and who has the right to decide what to do with it.

I am the one who lives in this body. Technically, this is my penis. The foreskin of my penis is not yours to slice off and throw into the biohazard container any more than the clitoral hood of a girl is yours to chop up and turn into skin grafts for burn victims. The excuse has been made that it is cleaner and healthier for a boy not to have a foreskin; however, it is also true that it is cleaner and healthier for a little girl not to have a clitoral hood and/or a labia minoria (it is important to note that your teeth will get infected if you don't brush them, and that your toes will get infected if you don't wash them). Therefore, the fact that the mean-spirited thieves at the hospital thought that I would be too stupid to keep my genitals cleaned is something that I view as deeply insulting to my intelligence, because a woman can clean her genital area just as easily as a man can clean his.

Nonetheless, your organization continues to think nothing of removing a perfectly healthy, functioning part of the male anatomy. This crime against humanity has been committed against me simply because of who I am, and I could not have been asked whether or not I wanted to be male any more than I could have been asked whether or not I wanted to exist.

Shame on you, Circumcision News. You need to stop encouraging this clandestine, reckless, and provocative violation of human rights, and you need to go out and respect me for the human being that I really am.

Mike said...

In about 15 days, on July 8th I will be circumcised at age 26 and I am looking forward to being circumcised and "ready" again on August 19th. I've developed a condition called phimosis, basically my foreskin is too tight and irritates and constricts my penis during sexual activity. I think what I find so daft about Intactivism is that circumcised men do not EVER suffer from such issues despite being "mutilated". Also American women prefer it. Sorry Haterz(lol).