Tuesday, 17 November 2009

Two new studies assessing the impact of circumcision against genital herpes

PubMed offers what they call an "alert" facility. It allows you to save a search, and then PubMed will automatically notify you once new entries match that search. It's wonderfully convenient, and ensures that you always have the latest information.

Anyway, today's alert included two new studies that investigated the effect of circumcision against genital herpes.

Jerath and Mahajan performed a fairly small study, but an interesting one. Their study population consisted of forty patients with recurrent genital herpes. Half were circumcised, half were not, and all (except 12 drop outs) were monitored afterwards. What they found was rather interesting. Prior to circumcision, 0.20 recurrences were noted per year, which is similar to the 0.17 that was recorded in the (uncircumcised) control group. But after circumcision, this fell to 0.0080 recurrences per year - a startling decrease to a mere 4% of the pre-circumcision figure. Now this is a small study, and as far as I can tell there was no randomisation process, but nevertheless the results are interesting.

Also of interest is a study by Van Wagoner et al. This was a fairly straightforward study of 460 African American heterosexual men. This study found an association between lack of circumcision and HSV-1 seroprevalence (OR: 1.85; CI: 1.15-2.96), but not HSV-2.

Monday, 2 November 2009

Intact America, part 4

Tony has responded to my most recent post in our ongoing discussion.

Let me address some of his points.
Rather, I believe that he is effectively a pro-circumcision advocate because he views his assessment of circumcision as containing some level of objectivity. It can't, just as my assessment can't. The difference between our views, I think, is that mine involves the child's opinion, placing it above that of his parents.
I may be mistaken, but I think Tony believes that I ignore the child's opinion altogether. That isn't quite so, but I see no reason not to incorporate it into my preferred framework for analysis. Expressed in my preferred framework (in which risks and benefits are expressed as the sum of probability x weight terms), Tony assigns a very large weight (possibly infinite) to the risk that a child may resent having been circumcised. I think it's reasonable to include it, as long as we also model the risk that a child may resent not having been circumcised too, but I don't think that such large weights are really justified.

Next, Tony responds to my comments regarding a hypothetical scenario. I originally wrote: "In this situation, it seems to me that this is a valid appeal to authority, in that the person is willing to adapt their position once the authority changes theirs." Tony replies:
I disagree, again because the focus of the appeal is infant circumcision, not circumcision. It's an abdication of judgment in favor of someone else's conclusion. If Person A is the individual being circumcised, I am indifferent to his acceptance of the authority's conclusion and judgment. That's not what's at stake.
I think that Tony and I may misunderstand each other somewhat. What I'm saying is that the appeal to authority is legitimate as long as the authority is taken as a true authority rather than a convenience. I'm not saying, however, that I necessarily agree with the appeal to authority, or that it is a strong argument. I'm simply saying that it is valid and self-consistent. Tony seems to be saying here that the appeal to authority is wrong because he disagrees with it.
It's possible to make this too broad. I am not suggesting that expert opinion is worthless or should be ignored. I am saying that, when the focus is on infant circumcision, and specifically the circumcision of healthy infants, citing the authority's subjective conclusion of a net benefit (or neutrality) is a diversion from the individual child's lack of need and possible preference for keeping his normal foreskin.
Put another way, it's emphasising one issue (risk:benefit balance) that you (Tony) consider relatively unimportant instead of other issues (necessity and risk of resentment) that you consider more important.

Next, re vaccination:
Yes, there is a difference. Surgery removes a healthy, functioning body part. Vaccination does not. I draw the line between them for that primary reason. So, yes, it makes sense to create multiple standards.
So if we consider surgical procedures that do not remove body parts, do they fall on the same side of the line as vaccinations?
I believe I've understood him correctly. He is wrong. If there is no medical reason (i.e. need)
(I'm not sure that the two terms are actually synonymous. One could have a medical reason without there being an actual need.)
for circumcision, it's unacceptable to permit it on children. Normal genitals are not a "problem," no matter how opposed the boy's parents are to his normal genitals. I repeat my earlier criticism: Jake is begging the question he wants to answer. Medical need is the standard for proxy consent to surgery. Without medical need, the process stops. No intervention is valid.
I understand that this is Tony's point of view, and it is completely consistent (as far as I can tell) with his system of ethics. But he seems to believe that his is the only system of ethics. It isn't: there are many systems. And many people - including myself - see no ethical problem with procedures that are, or are believed to be, in the best interests of the child, even in the absence of medical indication. I find it rather odd that Tony keeps repeating his principles as though they were universal truths.

Next, regarding "Setting the ability to chase potential benefits as the ethical standard opens the range of allegedly valid parental interventions to include any number of surgeries we recognize as offensive" Tony writes:
Immediately following my objection, I wrote that "I am attacking a way of thinking," which is to say that I reject the notion that because we can achieve a potential benefit, it is ethically valid to pursue it. At its core, prophylactic infant circumcision is about chasing potential benefits. I reject that for the multitude of reasons I've presented. Speculating that I did not cite any because none exist is a straw man.
Nevertheless, I think that it is an interesting point. If we assume, for the sake of argument, that the actual "number of surgeries that we recognize as offensive" is zero, then what is the objective difference between the two systems of ethics? It seems that, with the exception of circumcision, the two systems produce identical results. And so your argument then becomes "Setting the ability to chase potential benefits as the ethical standard opens the range of allegedly valid parental interventions to include circumcision" - an argument that might persuade an intactivist, but perhaps not anybody else. On the other hand, if there are many such surgeries, then we can see that the standard would lead to unacceptable consequences, and thus clearly needs to be revised.
Citing "surgeries we recognize as offensive" is a pointless diversion. However, I'll play along briefly. I nominate removing the breast buds from infant females to reduce their risk of breast cancer. I have no idea if this would work or it's been studied in any manner. It doesn't matter, because my point was to reject the thinking that believes a potential benefit may be chased. I suspect this would be offensive to most parents, as it almost always is when I raise it in debate. Non-essential, healthy, functioning breasts are different from non-essential, healthy, functioning foreskins, somehow. My guess is that Jake's approach to this would be his utilitarianism, which would assess whether removing breast buds has a potential benefit. (Unless he has some objection I haven't determined.) If it does in his evaluation, it is a valid choice for parents, even if only chosen by those few parents who don't find it offensive. I reject that because the healthy girl may not want the intervention.
Tony is essentially correct when he suggests that my approach would be utilitarian, but that wouldn't involve assessing only potential benefits. It is the net effect that matters, so it would also be necessary to weigh the potential benefits against risks (in which I include certain harms). I'm happy to assume, for the sake of argument, that there would be a potential benefit in terms of reduction of breast cancer risk. However, I think this would need to be weighed against the risks. These would include immediate risks (primarily bleeding and infection), which would probably be greater than those for circumcision due to the more invasive nature of the surgery. In addition, we would also need to consider loss of function - primarily ability to breastfeed, with consequent detrimental effects on any children, but also sexual functions such as a role in attracting partners. And finally, I would think the probability of resentment is fairly high. I think it would be difficult to find a balance that favours benefit.

Lastly, regarding Tony's incorrect statement that "Girls may not have their healthy genitals cut for any reason. Boys may have their healthy genitals cut for any reason", Tony writes:
I think it's obvious that my declarative statement about genital cutting implied "as it's commonly practiced in Western society," which would preclude intentional glansectomy, for example. Moving on.
Why should we consider only genital cutting that's commonly practiced in Western society? And if we're to do so, need we consider FGC, since that is only very rarely practiced in Western society?
What Jake omits here is telling. Circumcision is neutral or a net benefit, according to him. He's ruled out that prophylactic infant circumcision can be a net harm, the glaring mistake in his analysis. [...] A male who suffers a serious complication from circumcision would unquestionably qualify as experiencing a net harm.
Incorrect, because my analysis is fundamentally statistical, considering probabilities (or, if you prefer, large populations). The risk of serious complications is included in the analysis. So, for that matter, is the risk of serious illness that can be avoided. In both cases we can quantify the probability, and the severity, and that is the appropriate way to weigh them against each other.