tag:blogger.com,1999:blog-56547572409792340182024-03-13T15:44:27.635+00:00Circumcision NewsJakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.comBlogger34125tag:blogger.com,1999:blog-5654757240979234018.post-85424028118057874302012-03-13T12:35:00.002+00:002012-03-13T12:54:18.175+00:00Circumcision and prostate cancerThe journal <i>Cancer</i> has published a new study by Wright et al., entitled "<a href="http://onlinelibrary.wiley.com/doi/10.1002/cncr.26653/abstract">Circumcision and the risk of prostate cancer</a>".<br /><br />It's an interesting read. It's a case-control study, with 1754 cases and 1645 age-matched controls, making it by far the largest study of prostate cancer and circumcision to date. 68.8% of cases were circumcised, compared with 71.5% of controls. The risk of prostate cancer was about 13% lower among circumcised men.<br /><br />Complicating the issue somewhat was the timing of circumcision, as not all men had been circumcised at birth. The fact that some circumcised men had spent some of their lives with a foreskin obviously has an impact. Indeed, in the case of penile cancer the risk is actually greater in men circumcised after childhood, likely because such circumcisions tend to be associated with conditions such as phimosis and balanitis that themselves predispose towards penile cancer.<br /><br />Wisely, the researchers performed sub-analyses taking into account the timing of circumcision. They found that men circumcised before first sexual intercourse had 15% lower risk of prostate cancer. Interestingly, there was a small difference in the type of cancer: the risk reduction was 12% for less aggressive forms and 18% for more aggressive types.<br /><br />While not conclusive, this study is consistent with <a href="http://www.circs.org/index.php/Library/Ewings">earlier</a> <a href="http://www.circs.org/index.php/Library/Ross">studies</a> that also found a protective effect against circumcision. My colleagues and I previously published cost <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2007.06875.x/full">analyses</a> on circumcision vs prostate cancer.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com0tag:blogger.com,1999:blog-5654757240979234018.post-74794477334651867502011-09-25T19:07:00.002+01:002011-09-25T19:31:26.395+01:00Rebuttal to part 4...Darcia Narvaez has posted part 4 of Cannon's series of articles about circumcision. Let's dive in.<br /><br /><blockquote>No medical association in the world recommends routine infant circumcision. None.</blockquote><br /><br />Technically true, but <em>routine</em> infant circumcision means, literally, circumcision of all newborn boys. Consider what would justify such a recommendation: there would have to be an enormous net benefit to warrant taking such a decision out of the hands of parents.<br /><br />In practice, most medical associations agree that the matter is suitable for parental choice.<br /><br /><blockquote>Medicaid spends $198 million each year on routine infant circumcision in the 33 states that still pay for it, a procedure its own guidelines consider to be medically unnecessary. Private insurance programs are reimbursing an additional $677 million, raising prices for us all (Craig 2006.)</blockquote><br /><br />Actually, a CDC <a href="http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0008723">study</a> was published in 2010 that found that "Newborn circumcision was a cost-saving HIV prevention intervention for all, black and Hispanic males". And that study considered only one benefit. If other benefits were to be considered as well, it would obviously be more cost-saving still.<br /><br /><blockquote>Doctors have an ethical duty to treat the patient by the most conservative means possible, but removing healthy tissue in the absence of any medical need absolutely harms the patient.</blockquote><br /><br />By what logic? Cannon seems to think that asserting this claim is enough, but it isn't. Removal of tissue isn't inherently harmful; nor is it inherently beneficial. It <em>can</em> be either; to determine which the only rational approach is to look at the consequences.<br /><br /><blockquote>Everyone has a right to bodily autonomy and self-determination. This is a fundamental tenet of international human rights law (UNESCO 2005).</blockquote><br /><br />Then it needs to be determined whether circumcision represents a significant violation. Human rights are not absolute, and are not intended to be read as such. Free expression, for example, does not give a person the right to libel another. Applying common sense, could it apply to something as trivial as a foreskin? It deems doubtful.<br /><br /><blockquote>Parents' aesthetic preferences are not valid reasons for circumcision.</blockquote><br /><br />This statement makes sense only if one considers circumcision to be a bad thing that requires a lot of justification. But, since it is widely accepted that circumcision is harmless at worst and beneficial at best, that position seems unsupportable. Would it make sense to demand a valid reason for feeding a child a healthy diet?<br /><br /><blockquote>If you have never had a foreskin, you cannot possibly know what having one would feel like. You only know what it feels like to not have a foreskin. You cannot know now how your son will feel in 20 or 30 years. If you have your son circumcised, he may grow up to regret the decision you made for him, but circumcision is irreversible. (Yes, men can partially restore their foreskins, but it is difficult and the sensitive nerve endings are gone forever.)</blockquote><br /><br />Conversely, if you <em>don't</em> have him circumcised, he might regret that, too. And adult circumcision is much riskier, requires a long period of abstinence, and results in inferior cosmetic results. There's no way to guarantee that he won't resent the decision, unfortunately.<br /><br />Parents have a duty to educate themselves on circumcision rather than do it just because it was done to them.<br /><br /><blockquote>For clear, easy and plain-language help making the circumcision decision, try the Circumcision Decision Maker at http://circumcisiondecisionmaker.com/.</blockquote><br /><br />That website recommends non-circumcision in virtually every case (the exception, as I recall, being for Orthodox Jews). If you've already decided not to circumcise and want an excuse, use it. Otherwise, it's not recommended.<br /><br /><blockquote>Slavery and child labor were traditions sanctioned by religions and other authorities. But we abandoned those practices because they were unjust and harmful. Infant circumcision, similarly supported by authorities, should be abandoned by the people who care for children because it is unjust and harmful.</blockquote><br /><br />Except, of course, that it is neither unjust nor harmful. Asserting otherwise doesn't change the facts.<br /><br /><blockquote>You were circumcised because your dad was circumcised because everyone else was circumcised because 140 years ago, some perverted doctors wanted to stop boys from masturbating.</blockquote><br /><br />Probably not, but I'm sure this is impressive propaganda.<br /><br /><blockquote>Being circumcised isn't better, and it isn't popular anymore. The 70% of the world's men who have foreskins almost never choose to have them cut off and consider them to be the best part of the penis.</blockquote><br /><br />According to what research?<br /><br /><blockquote>Circumcision is ending with the generation being born now - only 32% of babies born in 2009 in the USA were circumcised.</blockquote><br /><br />Actually, CDC <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6034a4.htm?s_cid=mm6034a4_w">data</a> suggest that the figure is about 55%, and they caution that this is an underestimate. And, of course, rates vary greatly across the country.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com22tag:blogger.com,1999:blog-5654757240979234018.post-11676462196320419422011-09-18T16:33:00.002+01:002011-09-18T17:05:18.193+01:00Debunking myths, part 3Cannon and Bollinger have released <a href="http://www.psychologytoday.com/blog/moral-landscapes/201109/circumcision-social-sexual-psychological-realities">part 3</a> of their series of "myths" articles. As with previous parts, I'm analysing them here.<br /><br />We'll skip the first three ("You have to circumcise the baby so that he will match his dad" and "My first son is circumcised, so I have to circumcise my second son" and "My husband is the one with the penis, so it is his choice"), since as presented they are close to myths.<br /><br /><blockquote><i>Myth: Everyone is circumcised.</i> Reality check: Actually, world-wide, only 30% of men are circumcised, and most of these men are Muslim (WHO 2007). Most modern, Westernized countries have rates well below 20%. In the United States about 25 years ago, around 85% of babies were circumcised. The rates have dropped substantially to 32% in 2009, according to a report by the Centers for Disease Control (El Becheraoui 2010).</blockquote><br /><br />Here the authors cite a 2010 conference presentation regarding data gathered in a survey that wasn't designed to measure circumcision rates. The New York Times <a href="http://www.nytimes.com/2010/08/17/health/research/17circ.html?scp=1&sq=Bcheraoui&st=cse">quoted</a> a CDC spokesperson as saying "we cannot comment on the accuracy of this particular estimate of infant male circumcision." Figures that the CDC have actually <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6034a4.htm?s_cid=mm6034a4_w">released</a> are about 55%, but they caution that these underestimate the true rate.<br /><br /><blockquote><i>Myth: Circumcision is an important tradition that has been going on forever.</i> Reality check: In the United States, circumcision wasn't popularized until Victorian times, when a few doctors began to recommend it to prevent children from masturbating. Dr. Kellogg (of Corn Flakes fame) advocated circumcision for pubescent boys and girls to stop masturbation...</blockquote><br /><br />Ah, this old myth (and the obligatory Kellogg quote, too). No matter how striking it is, it's an error to conclude that circumcision arose because of Kellogg's recommendation. People advocate all kinds of things for all kinds of reasons. People in the late 19th century advocated circumcision for a variety of reasons, too. Gollaher, in his "Circumcision: a history of the world's most controversial surgery" devotes only a handful of pages to masturbation; he traces the history to a Lewis Sayre, who (oddly) believed circumcision could cure certain types of paralysis.<br /><br /><blockquote><i>Myth: Circumcision makes sex better for the woman.</i> and <i>Myth: Women don't want to have sex with uncircumcised men.</i> Reality check: In a landmark study of US women, 85% who had experienced both circumcised and intact men preferred sex with intact men.</blockquote><br /><br />Here the authors cite a study by O'Hara, which recruited most of the participants from an anti-circumcision mailing list, thus severely biasing the results. Credible studies, without such biases, find the opposite. See, for example, <a href="http://www.ncbi.nlm.nih.gov/pubmed/19522862">here</a>.<br /><br /><blockquote><i>Myth: "Being circumcised doesn't affect my sex life."</i> Reality check: Men who are circumcised are 60% more likely to have difficulty identifying and expressing their feelings, which can cause marital difficulties (Bollinger 2010).</blockquote><br /><br />Here the authors cite an unpublished study by the second author.<br /><br /><blockquote>Circumcised men are 4.5 times more likely to be diagnosed with erectile dysfunction, use drugs like Viagra, and to suffer from premature ejaculation (Bollinger 2010, Tang 2011).</blockquote><br /><br />Here the authors engage in cherry-picking. From memory, 3 studies have found increased risk of ED, 3 have found decreased risk, and six have found no statistically significant difference.<br /><br /><blockquote>Men who were circumcised as adults experienced decreased sensation and decreased quality of erection, and both they and their partners experienced generally less satisfaction with sex (Kim 2007, Solinis 2007).</blockquote><br /><br />Again, the authors are engaging in cherry-picking. More studies report increased sensation than report decreased sensation, we've dealt with ED and partner satisfaction above. There is a reasonable summary of the research at <a href="http://en.wikipedia.org/wiki/Sexual_effects_of_circumcision">Wikipedia</a>.<br /><br /><blockquote><i>Myth: "If I were any more sensitive, it would be a problem."</i> Reality check: The foreskin contains several special structures that increase sexual pleasure, including the frenulum and ridged band (the end of the foreskin where it becomes internal), both of which are removed in circumcision. The LEAST sensitive parts of the foreskin are more sensitive than the MOST sensitive parts of the circumcised penis (Sorrells 2007).</blockquote><br /><br />Here the authors cite a flawed study by Sorrells et al. The authors arrived at this conclusion by testing their results for statistical significance and ignoring the result (see <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2007.06970_6.x/full">here</a>). Interestingly, the authors only assessed the ability to sense the lightest touch; they did not test sensitivity to sexual stimulation. <a href="http://www.circs.org/index.php/Library/Schober">Schober</a> et al did (admittedly with a small sample of uncircumcised men), and found that the foreskin is actually the least sexually sensitive part of the penis.<br /><br /><blockquote>It may feel like the penis is overly sensitive to a circumcised man because there is little sensation left to indicate excitement, leading to unexpected premature ejaculation (a common problem with circumcised young men).</blockquote><br /><br />Actually more common among uncircumcised young men.<br /><br /><blockquote>However, as circumcised penises age they become calloused and much less sensitive. (See the interview listed below for more details.)</blockquote><br /><br />Better still, see the peer-reviewed research which shows that the level of "callousing" (keratinisation) is the same in circumcised and uncircumcised men (see <a href="http://www.circs.org/index.php/Library/Szabo">here</a>), and that the glans penis is equally sensitive (see <a href="http://www.circs.org/index.php/Library/Bleustein">here</a>, <a href="http://www.circs.org/index.php/Library/Masters">here</a>, <a href="http://www.circs.org/index.php/Library/Payne">here</a> and <a href="http://www.circs.org/index.php/Library/Bleustein2">here</a>).Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com1tag:blogger.com,1999:blog-5654757240979234018.post-89287491504828382952011-09-13T18:32:00.003+01:002011-09-13T20:29:53.782+01:00Debunking more "myths"Earlier today I posted a <a href="http://circumcisionnews.blogspot.com/2011/09/debunking-another-myths-article.html">rebuttal</a> to the first part of a "myths" article. The second part has <a href="http://www.psychologytoday.com/blog/moral-landscapes/201109/more-circumcision-myths-you-may-believe-hygiene-and-stds">also</a> been posted, and is just as bad. Let's dissect it:<br /><br />I'm going to skip the first two items ("You have to get the baby circumcised because it is really hard to keep a baby's penis clean" and "Little boys won't clean under their foreskins and will get infections"), because as presented they're so extreme that they almost are myths. That said, it <i>is</i> easier to keep a circumcised penis clean (except for the brief healing period, of course), and uncircumcised penises <i>are</i> more prone to infections.<br /><br /><blockquote><i>Myth: Uncircumcised penises get smelly smegma.</i> Reality check: Actually, smegma is produced by the genitals of both women and men during the reproductive years. Smegma is made of sebum and skin cells and lubricates the foreskin and glans in men, and the clitoral hood and inner labia in women. It is rinsed off during normal bathing and does not cause cancer or any other health problems.</blockquote><br /><br />Actually, these are rather dubious statements. A few hypotheses have been proposed, but to date no evidence supports the notion that smegma has any biological function. What little evidence there is suggests that it is associated with penile inflammation, HIV, and with penile cancer. (I should note that this evidence isn't particularly strong.) In the case of penile cancer, for example, all three of the human studies to investigate found an association between smegma and penile cancer; see <a href="http://www.hindawi.com/journals/au/2011/812368/tab3/">here</a>.<br /><br /><blockquote><i>Myth: "My uncle wasn't circumcised and he kept getting infections and had to be circumcised as an adult."</i> Reality check: Medical advice may have promoted infection in uncircumcised males. A shocking number of doctors are uneducated about the normal development of the foreskin, and they (incorrectly) tell parents that they have to retract the baby's foreskin and wash inside it at every diaper change. [...]</blockquote><br /><br />The author elaborates further on this interesting hypothesis, but utterly fails to provide any evidence whatsoever. But there's a really simple way to test it. If the difference is due to lack of knowledge about the foreskin in countries with high prevalence of circumcision, then we'd expect that studies conducted in countries with low circumcision rates wouldn't see any difference. In fact, though, the difference is observed both in the US and Canada (both of which have relatively high percentages of circumcised men) and in the UK and New Zealand (both of which have relatively low percentages of circumcised men).<br /><br /><blockquote><i>Myth: My son was diagnosed with phimosis and so had to be circumcised.</i> Reality check: Phimosis means that the foreskin will not retract. Since children's foreskins are naturally not retractable, it is impossible to diagnose phimosis in a child. Any such diagnoses in infants are based on misinformation, and are often made in order to secure insurance coverage of circumcision in states in which routine infant circumcision is no longer covered.</blockquote><br /><br />While an interesting conspiracy theory, there's no evidence for this. Phimosis can be diagnosed at any age, partly because acquired phimosis tends to be characterised by the presence of whitish, hard scar tissue at the tip of the foreskin. It may be <i>over</i>diagnosed in children, but to claim that it cannot be diagnosed is <i>dangerously</i> misinformed.<br /><br /><blockquote><i>Myth: Uncircumcised boys get more urinary tract infections (UTIs.)</i> Reality check: This claim is based on one study that looked at charts of babies born in one hospital (Wiswell 1985).</blockquote><br /><br />Wrong. There have been about 25 studies to date. See <a href="http://www.circs.org/index.php/Library/Topic/Urinary_tract_infection">here</a> for a partial list.<br /><br /><blockquote><i>Myth: Circumcision prevents HIV/AIDS.</i> Reality check: Three studies in Africa several years ago that claimed that circumcision prevented AIDS and that circumcision was as effective as a 60% effective vaccine (Auvert 2005, 2006). These studies had many flaws, including that they were stopped before all the results came in. There have also been several studies that show that circumcision does not prevent HIV (Connolly 2008).</blockquote><br /><br />Here the author is mistakenly treating all studies as equal. They aren't. The most rigorous studies are of a type called <i>randomised controlled trials</i>. The most important characteristic of these studies is that circumcision is performed as part of the study, and men are selected to be circumcised <i>at random</i>. A less rigorous (but much cheaper) study design is to look at men who've been circumcised previously, and see whether they're HIV positive or not. This design is called an observational study, and the main problem with it is that circumcision is often associated with something else (say, religion) that's also associated with behavioural differences. So it's difficult to tell whether circumcision, or these behavioural differences, are responsible.<br /><br />Of about 50 or so observational studies to date, probably 40 have found a protective effect. All three randomised controlled trials did likewise.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com0tag:blogger.com,1999:blog-5654757240979234018.post-57797654220238219112011-09-12T12:32:00.002+01:002011-09-12T13:14:36.200+01:00Debunking another "myths" articleAnti-circumcision authors seem to have a curious knack for writing articles that purportedly expose myths about circumcision while actually containing a number of incorrect statements. <a href="http://www.psychologytoday.com/blog/moral-landscapes/201109/myths-about-circumcision-you-likely-believe">This</a> is no exception. Let's dive in. (Note: I'm reformatting some of what follows for convenience.)<br /><br /><blockquote><i>Myth 1: They just cut off a flap of skin.</i> Reality check: Not true. The foreskin is half of the penis's skin, not just a flap. In an adult man, the foreskin is 15 square inches of skin. In babies and children, the foreskin is adhered to the head of the penis with the same type of tissue that adheres fingernails to their nail beds. Removing it requires shoving a blunt probe between the foreskin and the head of the penis and then cutting down and around the whole penis.</blockquote><br /><br />First, the average surface area of the foreskin is <a href="http://www.ncbi.nlm.nih.gov/pubmed/19770623">36.8 square centimetres</a>, which is 5.7 square inches not 15. Second, it's a gross exaggeration to liken the adhesions between the glans and foreskin to the nail bed. The foreskin and glans are primed to separate, and have often begun (though rarely completed) this process at birth. Separating the two is relatively trivial, requiring little force.<br /><br /><blockquote><i>Myth 2: It doesn't hurt the baby.</i> Reality check: Wrong. In 1997, doctors in Canada did a study to see what type of anesthesia was most effective in relieving the pain of circumcision. As with any study, they needed a control group that received no anesthesia. The doctors quickly realized that the babies who were not anesthetized were in so much pain that it would be unethical to continue with the study. Even the best commonly available method of pain relief studied, the dorsal penile nerve block, did not block all the babies' pain. Some of the babies in the study were in such pain that they began choking and one even had a seizure (Lander 1997).</blockquote><br /><br />Yes, circumcision without anaesthesia hurts. But the very study cited acknowledged that ring block was effective: "Of the 3 anesthetics considered in this investigation, ring block is clearly superior. It provides satisfactory anesthesia for all stages of the circumcision. While newborns fussed periodically over the restraints or being handled, they typically did not react to the most nociceptive elements of the circumcision (such as foreskin separation and incision)."<br /><br /><blockquote><i>Myth 3: My doctor uses anesthesia.</i> Reality check: Not necessarily. Most newborns do not receive adequate anesthesia. Only 45% of doctors who do circumcisions use any anesthesia at all. Obstetricians perform 70% of circumcisions and are least likely to use anesthesia - only 25% do. The most common reasons why they don't? They didn't think the procedure warranted it, and it takes too long (Stang 1998). A circumcision with adequate anesthesia takes a half-hour - if they brought your baby back sooner, he was in severe pain during the surgery.</blockquote><br /><br />The cited source (Stang and Snellman) is thirteen years old, and probably doesn't represent current practice very well. A more recent <a href="http://www.ncbi.nlm.nih.gov/pubmed/16843252">study</a> found considerable differences in use of anaesthesia in only five years: 71% in 1998 and 97% in 2003.<br /><br /><blockquote><i>Myth 4: Even if it is painful, the baby won't remember it.</i> Reality check: The body is a historical repository and remembers everything. The pain of circumcision causes a rewiring of the baby's brain so that he is more sensitive to pain later (Taddio 1997, Anand 2000). Circumcision also can cause post-traumatic stress disorder (PTSD), depression, anger, low self-esteem and problems with intimacy (Boyle 2002, Hammond 1999, Goldman 1999). Even with a lack of explicit memory and the inability to protest - does that make it right to inflict pain? Law requires anesthesia for animal experimentation - do babies deserve any less?</blockquote><br /><br />There's no credible evidence that circumcision has any such long-term psychological effects. Claims to the contrary are entirely speculative, as can be seen by reading the cited sources.<br /><br /><blockquote><i>Myth 5: My baby slept right through it.</i> Reality check: Not possible without total anesthesia, which is not available. Even the dorsal penile nerve block leaves the underside of the penis receptive to pain. Babies go into shock, which though it looks like a quiet state, is actually the body's reaction to profound pain and distress. Nurses often tell the parents "He slept right through it" so as not to upset them. Who would want to hear that his or her baby was screaming in agony?</blockquote><br /><br />This "explanation" is amusingly contrived, but of course Occam's Razor favours the alternative explanation: that the baby actually did sleep through the procedure. This is perfectly consistent with studies of adult circumcision under anaesthesia, in which pain is reported by only a few men. For example, pain was reported by 0.83% of men in <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020298"> one study</a>, and 0.2-0.3% in <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050116">another</a>.<br /><br /><blockquote><i>Myth 6: It doesn't cause the baby long-term harm.</i> Reality check: Incorrect. Removal of healthy tissue from a non-consenting patient is, in itself, harm (more on this point later). Circumcision has an array of risks and side effects. There is a 1-3% complication rate during the newborn period alone (Schwartz 1990). Here is a short list potential complications.</blockquote><br /><br />1-3% is a bit of an exaggeration. A recent systematic review found a median of 1.5%, but most are extremely minor.<br /><br />This section continues:<br /><br /><blockquote>Meatal Stenosis: Many circumcised boys and men suffer from meatal stenosis. This is a narrowing of the urethra which can interfere with urination and require surgery to fix.</blockquote><br /><br />While there's no proof, it seems likely that circumcision is a contributing factor to meatal stenosis. However, it's an exaggeration to say that "many" suffer. The largest <a href="http://www.cirp.org/library/procedure/cathcart1/">study</a> of circumcision and meatal stenosis found 7 cases in 66,519 circumcisions - 0.01%. The next two largest studies found risks of 0.9% (29 in 3,205) and 0.55% (11 in 2,000).<br /><br /><blockquote>Adhesions. Circumcised babies can suffer from adhesions, where the foreskin remnants try to heal to the head of the penis in an area they are not supposed to grow on. Doctors treat these by ripping them open with no anesthesia.</blockquote><br /><br />As with uncircumcised boys, adhesions can occur. And, as with uncircumcised boys, they usually resolve without treatment. See <a href="http://www.ncbi.nlm.nih.gov/pubmed/10893633">this study</a>.<br /><br />(I'm skipping discussion of buried penis and infection. Both can occur, though the risk of each is small.)<br /><br /><blockquote>Death. Babies can even die of circumcision. Over 100 newborns die each year in the USA, mostly from loss of blood and infection (Van Howe 1997 & 2004, Bollinger 2010).</blockquote><br /><br />This figure is wrong, as we've discussed <a href="http://circumcisionnews.blogspot.com/2010/05/fatally-flawed-bollingers-circumcision.html">previously</a>.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com18tag:blogger.com,1999:blog-5654757240979234018.post-57308374358972887492011-07-21T16:29:00.002+01:002011-07-21T16:44:36.572+01:00Sexual satisfaction & circumcision: latest from IAS 2011The International AIDS Society's 2011 meeting has now concluded, and — as is often the case these days — there some interesting presentations.<br /><br />Of particular interest are two abstracts: <a href="http://pag.ias2011.org/Abstracts.aspx?AID=1132">Breda</a> and <a href="http://pag.ias2011.org/Abstracts.aspx?AID=2349">Westercamp et al</a>.<br /><br />In Uganda, Breda reports on a study of 316 adult circumcision patients:<br /><blockquote>Compared to before circumcision, 87.7% (193/220) reported ease of reaching orgasm as “better”; 92.3% reported sexual satisfaction as “better”; 97.7% and 95.4% were satisfied with and thought their partners satisfied with their appearance, respectively.</blockquote><br />In Kenya, Westercamp et al reported on a study of 1016 adult circumcision patients:<br /><blockquote>Men reported a higher overall level of satisfaction with intercourse after circumcision (71% vs. 87%, p< 0.0001). 54% of men reported their penis being much more sensitive and 36% reported reaching orgasm much more easily 6 months after circumcision.</blockquote><br />Also, sexual dysfunctions (for two weeks or more) decreased:<br /><blockquote>inability to climax (20% vs. 16%, p=0.007), finding sex not pleasurable (31% vs. 24%, p=0.0005), and lack of interest in sex (45% vs. 39%, p=0.008).</blockquote><br />And fewer penile traumas were reported (consistent with <a href="http://www.ncbi.nlm.nih.gov/pubmed/20483156">Mehta et al</a>):<br /><blockquote>At 6 months, men reported experiencing fewer problems with reproductive health in the last 6 months compared to baseline: painful urination (10% before vs. 7%, p=0.008), difficulty passing urine (7% vs. 4%, p=0.01), and sores around genitals (7% vs. 4%, p=0.002). Similar reductions were found in measures of penile trauma in the preceding 6 months: pain during intercourse (15% vs. 8%, p< 0.0001); scratches, cuts, abrasions during sex (24% vs. 6%, p< 0.0001); and bleeding during or after intercourse (10% vs. 3%, p< 0.0001).</blockquote><br />These studies add to the growing body of evidence showing that circumcision does not harm, and may well improve men's sexual experience.<br /><br />As far as I can tell, neither study reports on RCT data; instead, both report on prospective study of patients circumcised as part of subsequent circumcision programmes in the same locations. Hopefully both studies will be published soon.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com0tag:blogger.com,1999:blog-5654757240979234018.post-23647326013446355622011-07-12T18:11:00.002+01:002011-07-12T19:57:04.538+01:00The so-called "lost list"Although less prominent these days, I still find that people occasionally cite the "lost list", seemingly unaware of its inaccuracies. For those unfamiliar with it, this is a list of structures or functions supposedly lost through circumcision.<br /><br />A number of different versions can be found on the Internet, but they're very similar. The text below is taken from <a href="http://www.norm-uk.org/circumcision_lost.html">NORM-UK</a>. My comments are in <i>italics</i>.<br /><br />The Foreskin which comprises up to 50% (sometimes more) of the mobile skin system of the penis. If unfolded and spread out flat the average adult foreskin would measure about 15 square inches( the size of a 3x5 inch index card).<br /><br /><i>This is a gross exaggeration. First, one <a href="http://www.ncbi.nlm.nih.gov/pubmed/19770623">study</a> has actually measured the surface area of the adult foreskin; it found an average surface area of 36.8 square centimetres (that's 5.7 square inches). (I previously stated that this was the only study. I was mistaken. A second <a href="http://journals.lww.com/plasreconsurg/Abstract/1998/09040/The_Prepuce_Free_Flap__Dissection_Feasibility.24.aspx">study</a>, with a small sample size, does exist. It reported an average surface area of 46.7 square centimetres, or 7.2 square inches.) Second, as I recently showed in my <a href="http://circumcisionnews.blogspot.com/2011/07/analysis-of-barefoot-intactivists.html">critique of Barefoot Intactivist's propaganda</a>, it is reasonable to estimate that the foreskin constitutes 14% of the penile skin system. Using the surface area figure from Werker et al., that's 18% — still less than half of the extraordinary 50% figure.</i><br /><br />This highly specialized tissue normally covers the glans and protects it from abrasion, drying, callusing (also called keratinization), and contaminants of all kinds.The effect of glans keratinisation has never been studied.<br /><br /><i>This sentence is dubious in many ways. The most obvious is the statement that the foreskin protects the glans from keratinisation — the only <a href="http://www.circs.org/index.php/Library/Szabo">study</a> in the literature to have examined keratinisation by circumcision status found no differences between the level of keratinisation of the circumcised and uncircumcised glans. Less obvious, but still troubling, is the implication that the circumcised glans is susceptible to abrasion or "contaminants". No evidence is cited in support.</i> <br /><br />[1. M. M. Lander, "The Human Prepuce," in G. C. Denniston and M. F. Milos, eds., Sexual Mutilations: A Human Tragedy (New York: Plenum Press, 1997), 79-81. 2. M. Davenport, "Problems with the Penis and Prepuce: Natural History of the Foreskin," British Medical Journal 312 (1996): 299-301.]<br /><br /><i>Note that only two sources are cited. One (Davenport) is peer-reviewed but does not support any of the claims attributed to it. The other (Lander) is a non-peer-reviewed paper presented at an anti-circumcision conference, which doesn't inspire confidence.</i><br /><br />The Frenar Ridged Band, the primary erogenous zone of the male body.<br /><br /><i>When I see a claim like this, I immediately wonder: who established this, and what was the study methodology? The cited source (Taylor, see below) established nothing of the sort. While a small number of studies have investigated sensitivity to non-sexual stimulus, only one study, to my knowledge, has investigated the relative degree of sexual pleasure produced by various parts of the anatomy. That <a href="http://www.circs.org/index.php/Library/Schober">study</a> (which was unfortunately limited by the small number of uncircumcised men) found that the foreskin actually produces the <b>least</b> sexual pleasure of any part of the penis.</i><br /><br />Loss of this delicate belt of densely innervated, sexually responsive tissue reduces the fullness and intensity of sexual response.<br />[Taylor, J. R. et al., "The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision," British Journal of Urology 77 (1996): 291-295.]<br /><br /><i>Note that the cited source says nothing of the sort! Its authors merely "postulate" that the "ridged band" is sensory tissue. They don't attempt to prove it, nor do they evaluate the effects of its removal on the "fullness and intensity" of sexual response.</i><br /><br />The Foreskin's 'Gliding Action' - the hallmark mechanical feature of the normal natural, intact penis. This non-abrasive gliding of the penis in and out of itself within the vagina facilitates smooth , comfortable, pleasurable intercourse for both partners. Without this gliding action, the corona of the circumcised penis can function as a oneway valve, scraping vaginal lubricants out into the drying air and making artificial lubricants essential for pleasurable intercourse.<br />[P. M. Fleiss, MD, MPH, "The Case Against Circumcision," Mothering: The Magazine of Natural Family Living (Winter 1997): 36-45.]<br /><br /><i>Note that the only source cited for this claim is an opinion piece published in a magazine. It's an interesting hypothesis, but little or no credible evidence supports it.</i><br /><br />[Indented box] Nerve Endings transmit Sensations to the Brain - Fewer Nerve Endings means Fewer Sensations<br /><br /><i>This simplistic model is faulty because the presence of nerve endings do not create sensations by themselves. Likely as not, your genitals are not buzzing with sensations as you read this, because they're not being stimulated. This means that the method and degree of stimulation is as important as the number of nerve endings. Put simply, a smaller number of nerve endings can produce just as much stimulation as a larger number, <b>if</b> stimulated more effectively. And this is effectively what circumcision achieves, by exposing the glans (especially the sensitive corona) to direct stimulation during intercourse, sensation is increased, compensating for the loss of sensation from the foreskin itself.</i><br /><br />Circumcision removes the most important sensory component of the foreskin - thousands of coiled fine-touch receptors called Meissner's corpuscles.<br /><br /><i>Most important? Who established this, and what was the study methodology?</i><br /><br />Also lost are branches of the dorsal nerve, and between 10,000 and 20,000 specialized erotogenic nerve endings of several types.<br /><br /><i>What is the source for this number? Neither of the two cited sources support it. In fact, having researched this in some depth, I feel quite confident in stating that <b>no</b> study has ever counted the number of nerve endings in the foreskin.</i><br /><br />Together these detect subtle changes in motion and temperature, as well as fine gradations in texture.<br />[1. R. K. Winkelmann, "The Erogenous Zones: Their Nerve Supply and Its Significance," Proceedings of the Staff Meetings of the Mayo Clinic 34 (1959): 39-47. 2. R. K. Winkelmann, "The Cutaneous Innervation of Human Newborn Prepuce," Journal of Investigative Dermatology 26 (1956): 53-67.]<br /><br /><i>Again, the sources fail to support the claims attributed to them.</i><br /><br />The Frenulum[.] The highly erogenous V-shaped web-like tethering structure on the underside of the glans; frequently amputated along with the foreskin, or severed, either of which destroys its function and potential for pleasure.<br />[1. Cold, C, Taylor, J, "The Prepuce," BJU International 83, Suppl. 1, (1999): 34-44. 2. Kaplan, G.W., "Complications of Circumcision," Urologic Clinics of North America 10, 1983.]<br /><br /><i>Neither of the cited sources actually supports these claims. This isn't terribly surprising because a) the frenulum's potential for pleasure is speculative, and b) the function of the frenulum, such as it is, is to hold the foreskin in place over the glans. Without a foreskin, then, it has no function.</i><br /><br />Muscle Sheath[.] Circumcision removes approximately half of the temperature-sensitive smooth muscle sheath which lies between the outer layer of skin and the corpus cavernosa. This is called the dartos fascia.<br />[Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): Plates 234, 329, 338, 354, 355.]<br /><br /><i>"Approximately half" is of course an exaggeration, but it is true that the foreskin does contain this layer.</i><br /><br />The Immunological Defense System of the soft mucosa. This produces both plasma cells that secrete immunoglobulin antibodies and antibacterial and antiviral proteins such as the pathogen-killing enzyme lysozyme.<br />[1. A. Ahmed and A. W. Jones, "Apocrine Cystadenoma: A Report of Two Cases Occurring on the Prepuce," British Journal of Dermatology 81 (1969): 899-901. 2. P. J. Flower et al., "An Immunopathologic Study of the Bovine Prepuce," Veterinary Pathology 20 (1983):189-202.]<br /><br /><i>The cited sources utterly fail to support these claims. The second is not even a study of the human prepuce, but rather that of the cow! While the foreskin doubtless contains the immunological functions of any skin, no special mechanisms are known.</i><br /><br />Lymphatic Vessels[.] the loss of which reduces the lymph flow within that part of the body's immune system.<br />[Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): plate 379.]<br /><br /><i>This is really scraping the bottom of the barrel, but yes, removing skin does remove the lymph vessels within it.</i><br /><br />Oestrogen Receptors The presence of estrogen receptors within the foreskin has only recently been discovered. Their purpose is not yet understood and needs further study.<br />[R. Hausmann et al., "The Forensic Value of the Immunohistochemical Detection of Oestrogen Receptors in Vaginal Epithelium," International Journal of Legal Medicine 109 (1996): 10-30.]<br /><br /><i>If confirmed, for that matter.</i><br /><br />[Indented box] The Body is Well Designed - Altering it Surgically can only Disrupt it's Natural Function<br /><br /><i>This is more a statement of faith than a serious claim, but we can transform it into a scientifically testable hypothesis: surgical alteration of the body cannot produce positive effects. It seems almost trivial to show that it is false.</i><br /><br />The Apocrine Glands of the inner foreskin, which produce pheremones -nature's powerful, silent, invisible behavioural signals to potential sexual partners. The effect of their absence on human sexuality has never been studied.<br />[A. Ahmed and A. W. Jones, "Apocrine Cystadenoma: A Report of Two Cases Occurring on the Prepuce," British Journal of Dermatology 81 (1969): 899-901.]<br /><br /><i>A serious problem with this claim is that apocrine glands are absent in the inner foreskin. Amusingly, one of the sources cited above (Taylor et al) <a href="http://www.cirp.org/library/anatomy/taylor/">says</a> this: "the mucosal surface of the prepuce is completely free of lanugo hair follicles, sweat and sebaceous glands". Similarly, Parkash et al <a href="http://www.cirp.org/library/anatomy/parkash/">report</a>: "Multiple small pieces were taken from the inner lining of the circumcised prepuce [...] A special search was made for glandular tissue. No such tissue was found in the material".</i><br /><br />Sebaceous Glands which lubricate and moisturise the foreskin and glans, normally a protected and internal organ-like the tongue or vagina. Not all men have sebaceous glands on their inner foreskin.<br />[A. B. Hyman and M. H. Brownstein, "Tyson's Glands: Ectopic Sebaceous Glands and Papillomatosis Penis," Archives of Dermatology 99 (1969): 31-37.]<br /><br /><i>In fact, according to the studies cited above, no men have sebaceous glands on their inner foreskin.</i><br /><br />Langerhans Cells Specialised epithelial Langerhans cells, a first line component of the body's immune system in a whole penis.<br />[G. N. Weiss et al., "The Distribution and Density of Langerhans Cells in the Human Prepuce: Site of a Diminished Immune Response?" Israel Journal of Medical Sciences 29 (1993): 42-43.]<br /><br /><i>The cited source actually states the opposite: that the foreskin is deficient in Langerhans cells.</i><br /><br />Colouration[.] The natural coloration of the glans and inner foreskin (usually hidden and only visible to others when sexually aroused) is considerably more intense than the permanently exposed and keratinized coloration of a circumcised penis. The socio-biological function of this visual stimulus has never been studied.<br /><br /><i>Ignoring the keratinisation error, this seems to be rather desperate. The appearance of the penis is changed, so this is a <b>loss</b>?</i><br /><br />Some of the penis length and circumference because its double-layered wrapping of loose and usually overhanging foreskin is now missing, making the circumcised penis truncated and thinner than it would have been if left intact.<br />An Australian survey in 1995 showed circumcised men to have erect penises an average of 8mm shorter than intact men.<br />[1. R. D. Talarico and J. E. Jasaitis, "Concealed Penis: A Complication of Neonatal Circumcision," Journal of Urology 110 (1973): 732-733. 2. Richters J, Gerofi J, Donovan B. Why do condoms break or slip off in use? An exploratory study. Int J STD AIDS. 1995; 6(1):11-8. ]<br /><br /><i>It should be noted that this Australian study is in fact the <i>only</i> study to report such a difference.</i><br /><br />Blood Vessels[.] Several feet of blood vessels, including the frenular artery and branches of the dorsal artery are removed in circumcision. This loss of the rich vascularity interrupts normal flow to the shaft and glans of the penis, damaging the the natural function of the penis and altering its development. [1. H. C. Bazett et al., "Depth, Distribution and Probable Identification in the Prepuce of Sensory End-Organs Concerned in Sensations of Temperature and Touch; Thermometric Conductivity," Archives of Neurology and Psychiatry 27 (1932): 489-517.� 2. Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): plates 238, 239.]<br /><br /><i>It is quite likely that several feet are lost, as the human body has an extraordinary number of blood vessels (a typical estimate is that the adult human body contains 100,000 miles of blood vessels). The claimed consequences, however, are unsupported by the references cited.</i><br /><br />Dorsal Nerves The terminal branch of the pudendal nerve connects to the skin of the penis, the prepuce, the corpora cavernosa, and the glans. Destruction of these nerves is a rare but devastating complication of circumcision. If cut during circumcision, the top two-thirds of the penis will be almost completely without sensation. [1. Agur, A.M.R. ed., "Grant's Atlas of Anatomy," Ninth Edition (Williams and Wilkins, 1991): 188-190. 2. Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): plate 380, 387.]<br /><br /><i>One wonders why such extremely rare, albeit possible complications are included, then. To pad out the list, perhaps?</i><br /><br />Complications Every year boys lose their entire penises from circumcision accidents and infection. They are then "sexually reassigned" by castration and "transgender surgery" and expected to live their lives as "females". [1. J. P. Gearhart and J. A. Rock, "Total Ablation of the Penis after Circumcision with Electrocautery: A Method of Management and Long-Term Followup," Journal of Urology 142 (1989):799-801. 2. M. Diamond and H. K. Sigmundson, "Sex Reassignment at Birth: Long-Term Review and Clinical Implications," Archives of Pediatrics and Adolescent Medicine 151 (1997): 298-304.]<br /><br /><i>It may be an exaggeration to claim that this happens "every year", but cases have been reported, unfortunately.</i><br /><br />Death Every year many boys lose their lives from the complications of circumcision, a fact the billion-dollar-a-year circumcision industry in the U.S. routinely obscures and ignores.<br />[1. G. W. Kaplan, "Complications of Circumcision," Urologic Clinics of North America 10 (1983): 543-549. 2. R. S. Thompson, "Routine Circumcision in the Newborn: An Opposing View," Journal of Family Practice 31 (1990): 189-196.]<br /><br /><i>Again, death does occur, albeit rarely. However, it would be foolish to consider such deaths in isolation. They should be weighed against deaths attributable to lack of circumcision. That is, if a million boys are circumcised, does this result in more or fewer deaths than if those boys are not circumcised. The evidence indicates that lives are saved.</i><br /><br />Emotional Bonding[.] Circumcision performed during infancy disrupts the bonding process between child and mother. There are indications that the innate sense of trust in intimate human contact is inhibited or lost.<br /><br /><i>Who established this, and what was the study methodology?</i><br /><br />It can also have significant adverse effects on neurological development. Additionally, an infant's self-confidence and hardiness is diminished by forcing the newborn victim into a defensive psychological state of "learned helplessness" or "acquired passivity" to cope with the excruciating pain which he can neither fight nor flee.<br /><br /><i>Who established this, and what was the study methodology? (How on Earth would one be able to prove such a thing? It looks suspiciously like an unfalsifiable statement: a product of pseudoscience, not science.</i><br /><br />The trauma of this early pain lowers a circumcised boy's pain threshold below that of intact boys and girls. [1. R. Goldman, Circumcision: The Hidden Trauma (Boston: Vanguard Publications, 1997), 139-175. 2. A. Taddio et al., "Effect of Neonatal Circumcision on Pain Responses during Vaccination in Boys," Lancet 345 (1995): 291-292.]<br /><br />Neurological Sexual Communication[.] Although never studied scientifically, contemporary evidence suggests that a penis without its foreskin lacks the capacity for the subtle neurological "cross-communication" that occurs only during contact between mucous membranes and which contributes to the experience of sexual pleasure.<br /><br /><i>What utter nonsense! How on earth would non-scientific evidence suggest such a thing? This appears to be nothing more than a wild theory, dishonestly presented as something suggested by evidence.</i><br /><br />Amputating an infant boy's multi-functional foreskin is a "low-grade neurological castration" [Immerman], which diminishes the intensity of the entire sexual experience for both the circumcised male and his partner.)<br /><br /><i>So prove it. Should be trivial. Except, of course, that scientific studies of satisfaction, etc., don't support this claim.</i>Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com0tag:blogger.com,1999:blog-5654757240979234018.post-74151423924129345832011-07-05T16:04:00.005+01:002011-07-05T18:51:51.436+01:00Analysis of the Barefoot Intactivist's claimsA man calling himself the "Barefoot Intactivist" (BI from here onwards) has posted a <a href="http://www.barefootintactivist.com/2011/07/my-response-to-gordon-habers-defense-of.html">"Response To Gordon Haber's Justification Of Child Genital Cutting"</a>.<br /><br />It's predictably awful. I thought I'd share my thoughts about it.<br /><br />BI begins (after a brief introduction) by complaining that:<br /><blockquote>Here we go. First Haber says I’m assuming he’s biased because he disagrees with me -- in reality, my response called him out on his bias exactly one time, in response to a specific, incredibly biased remark: Haber called the foreskin a “bit of skin.”</blockquote><br /><br />This is utterly irrational: the foreskin <b>is</b> a bit of skin, so why on earth shouldn't it be described as such? To claim that somebody is biased because they made an accurate statement is absurd.<br /><br /><blockquote>Actually, what we call the foreskin is easily 12-15 square inches of skin (depending on where the cut is made - think the size of an index card), and it’s loaded with erogenous nerve endings.</blockquote><br /><br />Two claims here, so lets address each in turn. First, only one <a href="http://www.ncbi.nlm.nih.gov/pubmed/19770623">study</a> in the literature has actually measured the surface area of the adult foreskin; it found an average surface area of 36.8 square centimetres (that's 5.7 square inches). Second, while it's true that nerve endings are present in the foreskin, it's disingenuous at best to claim that it is "loaded" with "erogenous" nerve endings: the actual number is unknown. Furthermore, no study has shown that those present are particularly erogenous in nature; in fact the only <a href="http://www.circs.org/index.php/Library/Schober">study</a> to pose a remotely comparable research question found that the foreskin actually produced the <b>least</b> sexual pleasure of any part of the penis.<br /><br /><blockquote>Before Haber even gets into my arguments he starts with ad hominem attacks, saying that I either lack “reading comprehension” or I’m “batshit crazy.” You’ll notice this tactic throughout Haber’s response, as opposed to the calm, rational tone of both his original article and my response to it.</blockquote><br /><br />As we shall see, the pot is calling the kettle black.<br /><br /><blockquote>Remember, Haber allowed part of his own son’s genitals to be amputated based on the flaws in his reasoning that I exposed. So it’s perfectly normal that he would get upset when confronted with facts about the harm of genital cutting.</blockquote><br /><br />The mistake that BI is making here is to assume that what he has to say is "factual", and that what Haber has to say is "flawed reasoning". He is apparently unwilling to consider the notion that others might legitimately have alternative viewpoints, and for that matter that he might actually - gasp - be wrong.<br /><br /><blockquote>Circumcision is the amputation of the foreskin of the penis. Contrary to popular belief, the foreskin is not a discrete entity, but rather a part of the contiguous penile skin system. The amount of skin cut off is entirely up to the person doing the cutting. Based on my own unscientific observation of YouTube videos online, it appears that easily around 50% of the penile skin is typically cut off in infant circumcisions (more on this later) -- sometimes significantly more, sometimes significantly less.</blockquote><br /><br />(At this point BI includes a still frame from a circumcision video, which he has annotated to indicate that half of the skin is being removed. Two problems here. First, the line at which he has decided the foreskin begins is his own arbitrary choice, so drawing a conclusion based upon its placement tells us more about his opinion about circumcision than about circumcision itself. Second, and more importantly, he's failed to take into account the fact that the penile skin system is <b>extremely</b> elastic, and the foreskin is under tension, as it is being stretched. So it should stand to reason that this will exaggerate the apparent length of the foreskin.)<br /><br />Assume that the average penis is 5.9 inches long and has a circumference of 5 inches (these figures are taken from http://www.free-condom-stuff.com/education/research.htm). Further assume (for the sake of argument) that the average glans is 1 inch in length, and that the foreskin can (with assistance if necessary) fully cover the glans when erect.<br /><br />Since the foreskin is a double fold, we'll count it twice. The penile skin of the penis is therefore a cylinder 5.9 + 1 + 1 = 7.9 inches long and 5 inches in circumference. This means that the surface area is 39.5 square inches.<br /><br />As noted above, the adult foreskin is, on average, 5.7 square inches. 5.7 is 14% of 39.5.<br /><br />(At this point BI includes a pair of videos. It's unclear what his point actually <b>is</b>, so I won't even try to address it.)<br /><br />Regarding a study by Sorrells et al:<br /><br /><blockquote>Haber first admits that the study, which shows that the five most “fine-touch” sensitive parts of the penis are amputated during circumcision, is “interesting,” but then he completely discards it because it was funded by NOCIRC. [para break] Nevermind that the design of the study was sound. Nevermind that it was published in the British Journal of Urology.</blockquote><br /><br />While the study was, unquestionably, published in BJU International, this is an extraordinarily weak argument. Weaker still is BI's claim that the design of the study was sound, for which he provides no evidence whatsoever.<br /><br /><blockquote>In fact, despite Sorrells’ study on penile sensitivity being widely cited by critics of circumcision, there has never been a legitimate published critique of the study made by circumcision advocates. The closest was a letter written by Waskett and Morris, two notorious circumcision fetishists, neither of which have any medical credentials. (Morris is known for calling on the state to institute compulsory male infant circumcision.)</blockquote><br /><br />Here BI engages in ad hominem attacks against the authors of the <a href="http://www3.interscience.wiley.com/cgi-bin/fulltext/118508593/HTMLSTART">critique</a> (which he apparently feels either isn't legitimate or isn't published; it's unclear which). Note that, even if his claims about Prof Morris and myself were true, they still wouldn't constitute an argument against <b>what we actually said</b>. BI hasn't even <b>attempted</b> to address the substance of our critique, perhaps because we actually made some rather solid points.<br /><br /><blockquote>But no, we should disregard Sorrells’ study because it was funded by NOCIRC. My question for Haber -- who the hell do you think is going to fund a study about the negative effects of circumcision in the U.S., the epicenter for foreskin cluelessness in the world? Who do you think NOCIRC is made up of? Does NOCIRC stand to earn profits by discouraging circumcision?</blockquote><br /><br />Surely it should be obvious that NOCIRC is made up of people who are opposed to circumcision, and who are extremely passionate about that? He seems to imply that because there is no financial gain to be made then NOCIRC have no reason to be biased, but that is rather short-sighted. People are willing to fly planes into skyscrapers for their beliefs, after all.<br /><br />Personally, I doubt that NOCIRC would deliberately falsify their results, but I suspect that the strength of their beliefs may have blinded them to the flaws in their study, and may have influenced their dodgy interpretation.<br /><br /><blockquote>How is this any more noteworthy a conflict then the Circumcision/HIV studies conducted by a woman (Dr. Wawer) who has built her entire reputation and career on “researching” the benefits of circumcision?</blockquote><br /><br />This bizarre attack against Dr Wawer is utterly unprovoked and false. Searching PubMed for articles by MJ Wawer <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=wawer%20mj[au]">reveals 136 results</a>. Adding the term "circumcision" returns only <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=wawer%20mj[au]%20circumcision">35</a> results; about a quarter of the total. Why make such a claim without checking the facts? It doesn't make sense.<br /><br /><blockquote>Sorrells is a medical doctor. His study was conducted in a research university setting and published in a well known peer-reviewed medical journal. We are now four years removed from its publication, and the veracity of the study’s results have never been seriously challenged.</blockquote><br /><br />Actually, the results have been seriously challenged. Flatly claiming otherwise in the face of evidence to the contrary is unconvincing at best. Furthermore, the arguments in favour of the study are almost pathetically weak.<br /><br /><blockquote>Okay, here’s another study for you. This one’s from South Korea, where circumcision has apparently taken hold after being exported by American military doctors 60 years ago. Based on a survey of 373 sexually active men, all of whom had been circumcised after the age of 20 years old [...]</blockquote><br /><br />Ah yes, Kim and Pang's 2006 study. Interestingly, the authors of this study attended a NOCIRC symposium in 2000, where they received a "human rights award" for their work to stamp out circumcision (see <a href="http://www.nocirc.org/symposia/sixth/symposium.pdf">here</a>).<br /><br />It's a very poorly described study, and BI clearly hasn't read it. (Compare, for example, his above claim with the following: "The study included 373 sexually active men [...] of whom 255 were circumcised [...] and 118 were not [...]".) The study does state that "To focus on the effects of circumcision on their sexual lives, only those 138 men who could compare the quality of their sex lives including masturbation before and after circumcision were asked to complete questions 7–11, which compare the quality of sex life before and after circumcision"; however it is far from clear which results stem from which comparisons. Also unclear (in fact, completely undocumented) is the selection process, making it impossible to evaluate the study for possible biases.<br /><br />More reliable results are found in RCT-based studies (one of which BI attacks below; another which can be found <a href="http://www.circs.org/index.php/Library/Krieger">here</a>.<br /><br />(At this point BI announces his intention to "quickly pick apart" an RCT-based <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2007.07369.x/pdf">study</a>, apparently having forgotten that it was a) it's conducted by a medical doctor, b) in a research setting, and c) published in a peer-reviewed journal.)<br /><br /><blockquote>Unlike the Korea study, the circumcised men in this study were never asked to compare sexual pleasure before and after circumcision. In fact, the men were not asked about pleasure at all, only about desire and satisfaction.</blockquote><br /><br />Apparently BI has created a distinction between satisfaction and pleasure. I'm not altogether sure what that distinction is: the two seem closely related to me.<br /><br /><blockquote>The men were only given two levels of possible satisfaction as options: “Satisfied” and “Very satisfied.”</blockquote><br /><br />Once again, BI appears to be attempting to criticise a study without the benefit of having read it. It is quite clear from the appendix that the possible responses were: Very satisfied, Satisfied, Dissatisfied, Very dissatisfied, No response, and Other (specify). Again, why make a claim like that without bothering to check?<br /><br /><blockquote>Selection bias -- they are taking men who volunteered to be circumcised as adults, circumcising them, and asking them about sex afterwards. This, after telling the men that circumcision is healthy and prevents disease. Are we supposed to believe that neither the fact that the men selected themselves to be circumcised nor the fact that they were told it was a healthy, disease-preventing measure had an impact on their survey answers?</blockquote><br /><br />But "healthy" does not imply "better sex".<br /><br /><blockquote>The survey was conducted two years after circumcision. What about negative sexual impacts 5, 10, 25 years later, as what’s left of the penis is left to become keratinized (calloused) through exposure to air and rubbing on clothing?</blockquote><br /><br />That myth has been well and truly disproven. The only <a href="http://www.circs.org/index.php/Library/Szabo">study</a> in the literature found no difference in keratinisation levels between circumcised and uncircumcised penes, and <a href="http://www.circs.org/index.php/Library/Bleustein">multiple</a> <a href="http://www.circs.org/index.php/Library/Masters">studies</a> <a href="http://www.circs.org/index.php/Library/Bleustein2">have</a> <a href="http://www.circs.org/index.php/Library/Payne">shown</a> that the two are equally sensitive, even in adults circumcised as neonates.<br /><br /><blockquote>Conflict of interest: This survey was conducted by the same team (headed by Dr. Wawer) trying to prove that circumcision prevents HIV. Establishing that the foreskin does not benefit sexual pleasure was required in order to promote the results of their HIV study.</blockquote><br /><br />BI is being disingenuous by implying that the researchers were seeking a predetermined outcome. In fact they were trying to determine whether circumcision protects against HIV. Science is about gathering data.<br /><br /><blockquote>Haber completely ignores my argument (maybe it just went over his head?), which is that any negative sexual impact of circumcision is unlikely to be noticed for many years: possibly when a boy reaches puberty and starts masturbating, when he becomes sexually active, or maybe not even until many years later after the penis is fully calloused and/or damaged from excessive friction.</blockquote><br /><br />As noted above, this myth has been disproven.<br /><br /><blockquote>How is a study of circumcision complications in babies addressing any of the sexual complications a circumcised man could have? Here are just a few of the possible complications that the studies Haber is referring to would never catch, because they would have to follow up 5, 10, 15, 25 years later: [...]Here is a gallery of botched circumcisions if you think I am inventing all of these</blockquote><br /><br />BI displays a worrying lack of logic here. Firstly, three of the speculative complications that he lists ("Tight, painful erections", "Numbness", and "Pain") couldn't be determined from a photograph. Secondly, the remaining items <b>would</b> be apparent in babies ("Skin bridges", "Curvature", "Twisting", and "Excessive scarring"). Thirdly, the existence of a photograph establishes that something has happened once; it doesn't provide any indication of frequency.<br /><br /><blockquote>Answer the fucking question, Haber -- who is checking up on kids 15 years later and asking them how their dick works when they start masturbating? How many of these kids are having tight, painful erections from so much skin getting cut off? Who is checking up on 40-year old men asking them if they have any feeling left in their penises after decades of keratin build-up to the exposed glans and remnant inner foreskin?</blockquote><br /><br />First of all, the keratinisation claim is, as we've seen, a myth. Second, it's very unlikely that a circumcision should cause pain on erection. In fact most evidence seems to indicate that the opposite is true.<br /><br />(At this point BI includes a video of a guy singing about his circumcision. Strange.)<br /><br /><blockquote>Haber again completely avoids my point: that the foreskin isn’t just “a bit of skin” but 12-15 square inches of skin. He makes an irrelevant comparison to the total amount of skin surface area on the human body.</blockquote><br /><br />I'm utterly perplexed here. Even if the foreskin were that large (and it appears exaggerated by about three-fold), would that mean it wasn't a "bit"? Is there an upper size limit on "bittiness"?<br /><br /><blockquote>The important point is that 50% (HALF) of the penile skin is being cut off. </blockquote><br /><br />Addressed above.<br /><br /><blockquote>There’s actually an even more important element here. Not only is a massive amount of penile skin being removed in circumcision, but a large percentage of the most sensitive tissue, which is everything on the inside of the fold, or the “inner skin,” including specialized penile structures like the “Ridged Band” of nerve endings and the frenulum. (See Sorrells’ study above.)</blockquote><br /><br />The evidence does not support this claim. When properly analyses, Sorrells' study shows no differences between the foreskin and other parts of the penis. But that is sensitivity to light touch (Sorrells did not measure any of the other kinds of sensitivity), which is arguably least important to sexual pleasure, and which the foreskin (due to its innervation) would be expected to be most sensitive.<br /><br /><blockquote>It turns out the most sensitive sexual tissue on the penis is on the inside of the foreskin</blockquote><br /><br />Interesting approach. Make a completely unsupported (and unsupportable) claim and prefix it with "it turns out that".<br /><br /><blockquote>I should have been more clear here. My point was that circumcision does not work in the real world to prevent HIV. It only works in a fabricated clinical setting due to a number of flaws that call into question the validity of the results of the studies.</blockquote><br /><br />But they were performed by medical doctors, weren't they? In a research setting? And published in peer-reviewed journals? Gosh, is BI applying a different standard to studies depending upon whether he likes the results of a study?<br /><br /><blockquote>I’m not going to spend a ton of time on this, because others have already done a much better job than I could hope to do.</blockquote><br /><br />If BI changes his mind, we can certainly analyse his arguments.<br /><br /><blockquote>A couple of quick things to consider from these clinical trials: [...] The men who were circumcised also received counseling on condom use.</blockquote><br /><br />BI is being very disingenuous here. While what he says is technically correct, he's omitting the important point that <b>both</b> groups of men, circumcised and uncircumcised, received counselling.<br /><br /><blockquote>The same studies also found that men who were HIV-positive were actually more likely to pass on HIV to their wives if they had been circumcised.</blockquote><br /><br />Wawer's study actually found no statistically significant difference.<br /><br /><blockquote>More importantly, babies are not even sexually active.</blockquote><br /><br />But they do become sexually active, when they grow.<br /><br /><blockquote>Forcing this on a non-consenting child on the other hand -- based on clinical studies that are questionable at best and contradict all available real-world data (see below)</blockquote><br /><br />Here BI completely misrepresents the facts. The three clinical trials were not conducted in a vacuum. They were conducted because of a series of 40 or more observational studies, from the late 1980s onwards, the majority of which showed that the risk was considerably lower among circumcised men.<br /><br /><blockquote>The USAID data shows quite clearly that there is no real-world evidence of circumcision having any benefit whatsoever for HIV prevention on entire populations that practice it.</blockquote><br /><br />That's one observational study among many. Most find results consistent with the RCTs. BI has merely shown his ability to cherry-pick studies with conclusions that he likes.<br /><br /><blockquote>Circumcision as HIV prevention just does not work in the real world. Ask the families of all the American men who died of AIDS in the 1980’s.</blockquote><br /><br />Here BI attacks a strawman. Nobody has claimed that circumcision completely prevents HIV; it reduces the risk. So it should be expected that a non-zero number of circumcised men will become HIV positive.<br /><br /><blockquote>You are correct, men have penises and women have vaginas/vulvas (congratulations on recognizing this). That doesn’t mean male and female genital cutting aren’t analogous (more on this below),</blockquote><br /><br />One could construct an analogy with mowing the lawn (which does, after all, usually involve the use of a blade), but that doesn't mean that the analogy is particularly meaningful.<br /><br /><blockquote>You want to know what sexism in genital cutting is? It’s when you call it “circumcision” on boys, but “mutilation” on girls, in the very same sentence.</blockquote><br /><br />No, that's not sexism, it's realism. FGM/C is a net harm. Circumcision isn't.<br /><br /><blockquote>As of 1996, all forms of female genital cutting have been outlawed by federal law, down to the slightest pinprick. That means boys have no legal protection from having half or more of their penile skin removed*, despite all of the significant sexual impact and risk of further complications (see above), </blockquote><br /><br />But, as we've seen, BI's claims about those issues were nonsensical.<br /><br />(Hilariously, BI inserts a note claiming that "Circumcision of boys is quite clearly illegal". Not according to any court decision that I've heard of.)<br /><br /><blockquote>So congratulations, you got something right: Intactivists think people should be just as outraged by the forced genital cutting of little boys as they are with the forced genital cutting of little girls. That sounds perfectly logical to me.</blockquote><br /><br />I suppose it might seem logical, if one were either ignorant of the differences between the two or unwilling to learn.<br /><br />(At this point BI gives a lengthy discussion of what FGC and circumcision are "all about". He offers nothing more than his opinion, so in the hope of finishing this analysis at some point I'll skip it.)<br /><br /><blockquote>This is where even the most basic history lesson on circumcision could have saved Haber. Let’s start with religious circumcision -- nobody knows exactly how it started, but it’s very much about controlling and reducing a man’s sexuality. Famous Jewish scholar Maimonides had this to say[...]Even to Maimonides the function of the foreskin and the purpose of circumcision were obvious.</blockquote><br /><br />I'm skipping what Maimonides had to say, because it's <b>completely irrelevant</b>. Maimonides lived in the 12th century, thousands of years after circumcision began, and thus would have no way of knowing why it began. All he could do is to <b>speculate</b>. Similarly, scientific understanding was poorly developed in the 12th century, and Maimonides' views about the function of the foreskin are hardly authoritative.<br /><br /><blockquote>But how did circumcision get started among non-religious people in the U.S.? Believe it or not -- it was introduced by medical doctors in the 1800’s to “cure” or reduce masturbation and excessive sex, which were believed to cause a number of diseases. This is all over the medical literature from the mid-to-late 1800’s through the mid 1900’s. Here is one particularly damning quote from a medical journal:</blockquote><br /><br />I wonder if BI has ever heard of the "fallacy of the striking instance"... That something is striking does not imply that it was representative or even influential. In fact, Gollaher, in his exhaustive "Circumcision: A history of the world's most controversial surgery", states that circumcision began for a quite different reason, and devotes only a handful of pages to masturbation.<br /><br />(At this point, BI engages in a long and frankly bizarre digression, including an Eminem video of all things.)<br /><br /><blockquote>So you see, YES male circumcision is performed to reduce/control male sexuality.</blockquote><br /><br />This is illogical. Sure, Maimonides and a handful of 19th century doctors believed that circumcision might reduce or control male sexuality, but in what way does that establish that parents <b>today</b> are choosing circumcision for that reason?<br /><br />(At this point BI presents a list of similarities between FGC and circumcision. As I've noted above, one can easily find similarities between dissimilar things, and such a list proves little except its authors determination to write it. So I'll omit it.)<br /><br /><blockquote>You may have different values. But to say that it is okay for one sex to be genitally cut but not the other? Pure sexism and an incredible double standard.</blockquote><br /><br />If it is "okay" or "not okay" <b>because</b> of gender, yes, that's sexism. If it's "okay" or "not okay" <b>because</b> of consequences, that's not inherently sexist.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com0tag:blogger.com,1999:blog-5654757240979234018.post-43779581115521577552011-02-27T22:33:00.002+00:002011-02-27T22:38:16.384+00:00Phimosis, redundant prepuce, and mental healthJust a short post.<br /><br />An interesting new <a href="http://www.ncbi.nlm.nih.gov/pubmed/21348200">study</a> by Yang et al. reveals news that shouldn't be terribly surprising: "Patients with redundant prepuce or phimosis have poor mental health, and there is an interaction between PE [premature ejaculation] and the mental state of the patient."<br /><br />As I said, this shouldn't be terribly surprising. But it does make one wonder about the degree to which prophylactic circumcision might prevent this suffering, especially as phimosis is not uncommon. I'm not saying that widespread circumcision would be justified on this basis alone, but clearly it should be incorporated into cost-benefit models.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com4tag:blogger.com,1999:blog-5654757240979234018.post-5313370483592460902011-01-13T11:06:00.002+00:002011-01-13T11:34:51.457+00:00The penis and sexual pleasureNow this is an interesting study: <a href="http://www.ncbi.nlm.nih.gov/pubmed/19245445">"Self-ratings of genital anatomy, sexual sensitivity and function in men using the 'Self-Assessment of Genital Anatomy and Sexual Function, Male' questionnaire"</a> (<a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2008.08166.x/pdf">PDF</a>).<br /><br />It's a study of self-assessed ratings of sexual pleasure, orgasm intensity, and similar items by area. The study included 81 healthy men. One weakness of the study was that only eleven men were uncircumcised; this shouldn't bias the results, but it does mean that the foreskin's scores are known with less precision than those for other areas.<br /><br />The key results were as follows:<br /><br /><blockquote>Overall discrimination between genital areas was highly significant (mixed-model anova, P = 0.001) for ratings of 'sexual pleasure', 'orgasm intensity' and 'orgasm effort', but was not significant for 'discomfort/pain'. Ranked by degree of 'sexual pleasure', the area 'underside of the glans' was highest, followed by 'underside of the penile shaft', 'upper side of the glans', 'left and right sides of the glans', 'one or both sides of the penis', 'upper side of the penile shaft', 'foreskin' (11 subjects), 'skin between the scrotum and anus', 'back side of the scrotum', 'front side of the scrotum', and 'around anus', but not all pair differences were significant. The rank order was similar for 'orgasm intensity', but less similar and with fewer significant pair differences for 'orgasm effort'.</blockquote><br />What this means, effectively, is that the foreskin is the <i>least</i> sensitive of all areas of the penis, when "sensitive" is defined as "capable of producing sexual pleasure or orgasm".<br /><br />This is no great surprise to me. It's entirely consistent with the bulk of evidence indicating that the foreskin can be removed without adverse effects on sexual satisfaction, which would seem inconsistent with the foreskin playing a major role in sexual pleasure. But it may come as a surprise to those who were mislead by studies such as <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2006.06685.x/pdf">Sorrells et al.</a>, which (erroneously) presented the foreskin as the <i>most</i> sensitive part of the penis. Why?<br /><br />Well, as Prof. Morris and I noted (among other points) in our <a href="http://www3.interscience.wiley.com/cgi-bin/fulltext/118508593/HTMLSTART">critique</a> of Sorrells' paper:<br /><br /><blockquote>The authors conclude that ‘circumcision ablates the most sensitive parts of the penis’, although they only tested the ability of subjects to detect the lightest touch. Meissner’s corpuscles, being light-touch receptors, would be expected to cause such a measurement to exaggerate the sensitivity of the prepuce. However, sensitivity, particularly when discussing erogenous sensation, depends on several different modes of stimulation and their interaction. In addition, sexual sensation depends upon the types of mechanical stimulation generated during intercourse, which might in turn be influenced by circumcision status. Thus circumcision has the potential to either increase or decrease sexual sensation.</blockquote><br />Put bluntly, the two studies measured completely different things. Sorrells et al tested response to having a nylon filament pressed against the skin; Schober assessed response to sexual stimulation. And the two are not the same at all.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com2tag:blogger.com,1999:blog-5654757240979234018.post-50900408239146983782011-01-12T12:55:00.002+00:002011-01-12T13:18:53.005+00:00Circumcision, HPV, and HIVAfter a period of relative quiet, I found two interesting new studies in my PubMed alert this morning.<br /><br />First, Wawer et al. published <a href="http://www.ncbi.nlm.nih.gov/pubmed/21216000">Effect of circumcision of HIV-negative men on transmission of human papillomavirus to HIV-negative women: a randomised trial in Rakai, Uganda</a>. This is a fascinating study, not least because it is yet another study cleverly piggy-backed on one of the randomised controlled trials that effectively proved that circumcision reduces the risk of HIV. Results have been published <a href="http://www.ncbi.nlm.nih.gov/pubmed/20370483">previously</a> showing that circumcision reduced the risk of (and increased clearance of) HPV infection in <i>men</i>; what's unusual about this study is that it directly measured the effect on infection in women (to be precise, the female partners of the men in the trial). And as previous observational studies indicated, the risk was reduced, from 38.7% to 27.8%.<br /><br />The significance of this, of course, is that HPV is the virus responsible for cervical cancer in women (and about half of penile cancers in men). According to the <a href="http://www.who.int/vaccine_research/diseases/hpv/en/">World Health Organisation</a>, cervical cancer is the second biggest cause of cancer deaths worldwide, resulting in 288,000 deaths annually. Could circumcision programmes reduce those deaths by a third, as a happy side-effect of HIV prevention programmes?<br /><br />It does raise an interesting ethical question, though: when weighing costs and benefits of circumcision, how much weight should be given to something that does not affect the male directly, but rather a possible partner in the future? It's a difficult question, and I don't claim to have the answers.<br /><br />Moving on, Anderson et al. have published what looks to be an interesting review entitled <a href="http://www.ncbi.nlm.nih.gov/pubmed/21214659">HIV Infection and Immune Defense of the Penis</a>. Their subject matter, of course, is the mechanism by which circumcision protects against HIV. I haven't had the opportunity to read the full text, but from the abstract it appears that they reject the traditional view of the foreskin's mucosal layer as an HIV target, instead preferring a model in which the subpreputial cavity traps HIV and HIV-infected cells, bringing them into contact with the urethra. It's an interesting hypothesis, but I personally suspect that attempts to find a single explanation are doomed to failure; I believe that the protective effect seen is a result of multiple mechanisms acting together.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com0tag:blogger.com,1999:blog-5654757240979234018.post-88264141216841192112010-10-20T10:35:00.003+01:002010-10-20T10:45:56.753+01:00Attitudes re circumcision in AfricaThis newly-published <a href="http://www.gallup.com/poll/143768/Belief-Male-Circumcision-Varies-Sub-Saharan-Africa.aspx">page</a> shows the results of a set of Gallup surveys in a number of African countries.<br /><br />They found that attitudes varied by country. The percentage who agreed with "male circumcision reduces the risk of being infected with HIV/AIDS" varied from 26% to 80%. The percentage of respondents agreeing with the statement "all men should be circumcised" varied from 39% to 85%. <br /><br />Interestingly, both sets of responses were strongly related to education level: the more educated people were, their responses to the first question were more consistent with the scientific evidence, and their responses to the second were more "pro-circumcision".<br /><br />The question is, is it that more educated people are more aware of circumcision, and more receptive to scientific information about it? Or is it that less educated people are less resistant to anti-circumcision propaganda, perhaps lacking the critical thinking skills that allow us to see it for what it is?<br /><br />Some follow-up questions: how do we ensure that information about circumcision reaches the less educated members of society? Or, how can the less educated members of society be protected from anti-circumcision propaganda?Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com0tag:blogger.com,1999:blog-5654757240979234018.post-83504963000933702802010-05-23T16:59:00.002+01:002010-05-23T17:08:05.255+01:00Reduced risk of sexual injuries in circumcised malesYet another piggyback study using data from the HIV RCTs has been published. In this newly published study, using data gathered as part of the Kenyan trial, Mehta <i>et al.</i> report reduced risk of "penile coital injuries".<br /><br />The authors report:<br /><blockquote>At baseline 1,775 (64.4%) men reported any coital injury including 1,313 (47.6%) soreness, 1,328 (48.2%) scratches, abrasions or cuts and 461 (16.7%) bleeding. On multivariable analysis coital injury risk was lower for circumcised than for uncircumcised men with soreness (OR 0.71, 95% CI 0.64-0.80), scratches/abrasions/cuts (OR 0.52, 95% CI 0.46-0.59), bleeding (OR 0.62, 95% CI 0.51-0.75) and any coital injury (OR 0.61, 95% CI 0.54-0.68).</blockquote><br /><br />So, these injuries — while minor — are fairly common and disproportionately affect uncircumcised males.<br /><br />The authors suggest that this may affect the risk of HIV acquisition. This seems perfectly plausible, though it would be a mistake, I believe, to say that it is "the" mechanism by which circumcision protects against HIV. What's becoming clear, I think, is that circumcision protects against HIV through multiple mechansisms acting simultaneously.<br /><br />I wonder, though, whether these findings might partly explain the fact that several studies have found that dyspareunia (painful intercourse) is more common among uncircumcised males?Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com1tag:blogger.com,1999:blog-5654757240979234018.post-40771290078182170142010-05-08T16:31:00.003+01:002010-05-08T17:37:51.853+01:00Fatally flawed: Bollinger's circumcision death calculationsDan Bollinger (of the International Coalition for Genital Integrity) has published "LOST BOYS: AN ESTIMATE OF U.S. CIRCUMCISION-RELATED INFANT DEATHS". In it, he claims that circumcision causes 117 deaths per year in the United States. It's a lengthy paper, and is frankly rather tedious to wade through, but I thought it might be interesting to see how he derived his estimate:<br /><br /><blockquote>Though the data previously cited are insufficient to establish a definitive death rate on their own, there is enough available information to calculate an estimate. Not all of the reported 35.9 deaths out of 1,243,392 circumcisions can be attributed to related causes.</blockquote><br /><br />(Here Bollinger references a figure he has provided previously: "Hospital discharge records reveal that, during the 1991–2000 decade, on average 35.9 boys died from all causes each year during their stay (average 2.4 days) in the hospital in which both their birth and circumcision occurred (Thompson Reuters, 2004).")<br /><br /><blockquote>What portion, then, is circumcision-related and how may we extrapolate to the number of deaths after hospital release? What we can safely assume is that it is unlikely that any of these infants would have been subjected to the unnecessary trauma of circumcision if they had been in critical condition, or that they would have been circumcised after their death.</blockquote><br /><br />This is indeed a relatively safe assumption, though it is not one that actually gets us any closer to an answer.<br /><br /><blockquote>Gender-ratio data can help extrapolate a figure. Males have a 40.4% higher death rate than females from causes that are associated with male circumcision complications, such as infection and hemorrhage,4 during the period of one hour after birth to hospital release (day 2.4), the time frame in which circumcisions are typically performed (CDC, 2004). Assuming that the 59.6% portion is unrelated to gender, we can estimate that 40.4% of the 35.9 deaths were circumcision-related. This calculates to 14.5 deaths prior to hospital release.</blockquote><br /><br />This is extraordinary! Bollinger is, in effect, assuming that the difference between male and female death rates is due entirely to circumcision. But it is a well-established fact that male babies are more susceptible to deaths than females, and there is no evidence that this is due to circumcision. Indeed, if circumcision alone were responsible for the difference, then we might expect countries with low circumcision rates to have the same infant mortality rates among males and females. But in fact, that's not the case, as the following table shows:<br /><br /><table><br /><tr><th>Country</th><th>Est. neonatal circ. rate</th><th>IM (male)</th><th>IM (female)</th><th>IM m:f ratio</th></tr><br /><tr><td>Israel</td><td>> 90%</td><td>4.39</td><td>4.05</td><td>1.08</tr><br /><tr><td>Nigeria</td><td>80-90%</td><td>100.38</td><td>87.97</td><td>1.14</td></tr><br /><tr><td>United States</td><td>50-80%</td><td>6.90</td><td>5.51</td><td>1.25</td></tr><br /><tr><td>Australia</td><td>< 20%</td><td>5.08</td><td>4.40</td><td>1.15</td></tr><br /><tr><td>United Kingdom</td><td>< 5%</td><td>5.40</td><td>4.28</td><td>1.26</td></tr><br /><tr><td>France</td><td>< 5%</td><td>3.66</td><td>2.99</td><td>1.22</td></tr><br /><tr><td>Finland</td><td>< 1%</td><td>3.78</td><td>3.15</td><td>1.2</td></tr><br /></table><br /><br /><i>Table: Infant mortality (IM) rates for selected countries. Derived from <a href="http://www.photius.com/rankings/population/infant_mortality_rate_female_2010_0.html">female rate table</a> and <a href="http://www.photius.com/rankings/population/infant_mortality_rate_male_2010_0.html">male rate table</a>.</i><br /><br />Clearly, infant mortality rates are consistently higher among males regardless of circumcision rates. So Bollinger's approach is clearly flawed. <i>When he is trying to estimate the risk due to circumcision he is actually estimating the risk due to being male!</i><br /><br />But it gets even worse (this would be laughable if the subject weren't so serious). Even if we assume that Bollinger's method is sane and appropriate (in spite of evidence to the contrary), he manages to miscalculate those attributable to being male. If the rate is 40.4% higher among males then the observed rate (35.9) will be the rate in females <i>plus</i> 0.404 times that rate again (or 1.404 times the rate in females). So, to find the rate in females:<br /><br /><i>1.404f = 35.9</i><br /><br /><i>f = 35.9 / 1.404 = 25.57</i><br /><br />And so the rate attributable to being male will be 40.4% of that, which is 10.33.<br /><br />But, as noted, this is the rate attributable to being male, <i>not</i> to circumcision.<br /><br /><blockquote>But as is often the case with hemorrhage and infection, some circumcision-related deaths occur days, even weeks, after hospital release. The CDC’s online searchable database, Mortality: Underlying cause of death, 2004 (CDC), lists causes by various age ranges and reveals that the percentage of deaths after release, compared with deaths before, is 772% greater. This ratio is comparable to Patel’s (1966) 700% postrelease infection rate.</blockquote><br /><br />Bollinger expresses this with less than optimal clarity, but what he seems to be saying is that the ratio between deaths in the hospital stay (which Bollinger identifies as typically 2.4 days) and those after the hospital stay (but presumably within the first 28 days of life) is 7.72.<br /><br />Frankly, that shouldn't be surprising. There are 10.7 times as many days in the latter period than there are in the former, so one would ordinarily expect more deaths simply due to there being more time in which people can die.<br /><br /><blockquote>Multiplying the 772% adjustment factor for age-at-time-of-death by the 14.5 hospital-stay deaths calculated above, the result is approximately 112 circumcision-related deaths annually for the 1991–2000 decade, a 9.01/100,000 death-incidence ratio.</blockquote><br /><br />This multiplication is irrational. It stands to reason that there would be more deaths in the first 28 days than the first 2.4 days, simply because there is more time in which infants <i>can</i> die. If we look at the first 100 years of life, then the ratio will be even greater (in fact, the mortality rate over that period will be almost 100%), but would it make any sense to apply that ratio? Of course not — people die of other things than circumcision, and it wouldn't make any sense.<br /><br />It doesn't make sense to apply this multiplication, either. Yes, a certain number of circumcision-related deaths will likely occur some time after the event, but it doesn't make any sense to assume, in effect, that <i>any</i> deaths in the period must be due to circumcision.<br /><br /><blockquote>Applying this ratio to the 1,299,000 circumcisions performed in 2007, the most recent year for which data are available (HCUP, 2007), the number of deaths is about 117. This is equivalent to one death for every 11,105 cases, which is not in substantial conflict with Patel’s observation of zero deaths in 6,753 procedures. It is more than some<br />other estimates (Speert, 1953; Wiswell, 1989),</blockquote><br /><br />It is perhaps a little disingenuous to refer to these as "estimates". These are observations showing 1 death in 566,000 circumcisions (Speert), no deaths in 100,000 boys (Wiswell). Similarly, King reported no deaths in 500,000 circumcisions. So if we use 1 in 500,000 as a reasonable estimate, we would expect 2.6 deaths in 1.3 million circumcisions. Bollinger's errors have led him to a figure some 45 times greater than that which can be extrapolated from actual statistics!<br /><br /><blockquote>but less than the overstated 230 figure derived from Gairdner (1949). Breaking this statistic down further, about 40% of these deaths (47) would have been from hemorrhage, and the remainder (70) from sepsis, using a hemorrhage-to-sepsis ratio for infant mortality (NCHS, 2004).</blockquote><br /><br />Yes, I suppose the nice thing about imaginary numbers is that there is an inexhaustible supply of them.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com24tag:blogger.com,1999:blog-5654757240979234018.post-85182028238124863542010-04-20T16:36:00.002+01:002010-04-20T17:45:20.254+01:0020 reasons revisitedSagaciousMama has posted an article entitled <a href="http://sagaciousmama.wordpress.com/2010/04/20/20-reasons-i-did-not-circumcise-my-son/">20 Reasons I Did Not Circumcise My Son</a>.<br /><br />Now I'm supportive of parents who choose not to circumcise, as well as those who do, but this article is alarmingly misinformed. Here's my analysis.<br /><br /><blockquote>1) The Pain is Excruciating</blockquote><br /><br />Always? Even when local anaesthetic is used? If that were so, men circumcised as adults would report unbearable pain. But in fact, men circumcised under local anaesthetic generally report only mild pain, if any. (Eg., <a href="http://www.ncbi.nlm.nih.gov/pubmed/19889061">Long et al.</a> report "No patient experienced pain during circumcision.")<br /><br /><blockquote>The foreskin is attached like a fingernail (see #4).</blockquote><br /><br />This is a common anti-circ myth. In fact, the fingernail is fused to the nail bed; in contrast the foreskin's attachment to the glans is primed to detach anyway, and can easily be separated. (This is quite obvious from the many circumcision technique videos on the Internet, which show that the foreskin can be detached through moving a probe around, without excessive force.)<br /><br /><blockquote>2) The procedure and pain has long lasting consequences.</blockquote><br /><br />Here SagaciousMama cites only a number of weak sources. These sources speculate that neonatal circumcision causes numerous psychological problems, but they fall short of the most important quality of scientific work: testing one's hypothesis. In no cases do they provide any evidence showing that their theory is correct.<br /><br />Until they do their theories don't really seem worthy of a response.<br /><br /><blockquote>3) It is genital mutilation.</blockquote><br /><br />No, it isn't. "Mutilation" is <a href="http://www.thefreedictionary.com/mutilate">defined</a> as:<br /><br /><i>1. To deprive of a limb or an essential part; cripple.</i><br /><br />The foreskin isn't a limb, and it is clearly not essential, since if it were we would not be able to survive without it.<br /><br /><i>2. To disfigure by damaging irreparably: mutilate a statue.</i><br /><br />Circumcision neither damages nor disfigures. If it damaged the penis, then there would be clear evidence that the penis functioned better with a foreskin than without, but — if anything — the opposite seems to be true. "Disfigurement" is a little more subjective, but the fact that circumcision is widely perceived as a cosmetic improvement is incompatible with the notion that it is a disfigurement.<br /><br /><i>3. To make imperfect by excising or altering parts.</i><br /><br />Again, this is somewhat subjective. That circumcision excises the foreskin is clear, but does this make the penis imperfect? Or does it make it more perfect?<br /><br />Since SagaciousMama appears to indicate that her statement is a kind of timeless truth, frankly I think she needs something stronger than highly subjective assessments.<br /><br /><blockquote>4) In babies, the foreskin is attached like a fingernail.</blockquote><br /><br />This is a repeat. See no. 1.<br /><br /><blockquote>5) I wouldn’t alter a girl in this way, and boys count, too.</blockquote><br /><br />It would be impossible to alter a girl in this way: girls don't have penes. But, as a hypothetical, suppose that there was a form of minor surgery that could be performed on girls, that had multiple benefits, minimal risks, and no long-term harms. Would it be rational to oppose it?<br /><br />Here SagaciousMama quotes the ever nutty circumstitions.com:<br /><br /><blockquote>For over a hundred years, circumcision has been a solution looking for a problem, and the problem has typically been the most frightening disease of the day - ... “masturbation insanity” in the 19th century, ... then tuberculosis, ... Sexually Transmitted Diseases (then called Venereal Disease or VD) after World War I, ... penile cancer in the 1930s, and ... * cervical cancer in the 1950s, when cancers were terrifyingly untreatable, ... urinary tract infections from 1982 onward, ... * and now HIV.</blockquote><br /><br />Oh dear. It's troubling that anyone can find this line of argument convincing. The basic idea is this: construct a list of positive claims that have <i>ever</i> been made about a subject, <i>regardless of merit or basis in evidence</i>. Now present them side by side. For example, you can show that hand-washing used to be a religious ritual in ancient times, and more recently, as germs became known, it was promoted for that reason. It's true, but what does it prove? That we should abandon handwashing? Of course not — such a conclusion is ludicrous.<br /><br /><blockquote>6) It is pointless and absolutely unnecessary. ... There are no advantages to genital mutilation for either a boy or a girl however there are many disadvantages and risks.</blockquote><br /><br />With a little interpretation, what SagaciousMama is claiming here is that there are no advantages to circumcision. That's wildly incorrect: there are multiple health benefits to circumcision, including prevention of phimosis, balanoposthitis, urinary tract infection, HIV, HPV and (some) other STDs, penile cancer, etc. Some of these benefits are very minor, some less so, but to say that they don't exist is simply absurd.<br /><br /><blockquote>7) I don’t have the right.</blockquote><br /><br />Actually, you do, but you don't have to exercise that right if you don't want to.<br /><br /><blockquote>8.) Decreases sensitivity. ... This is the most studied and obvious aspect of this topic. Regardless of the volumes of studies on the tissue, the science, etc, the best evidence of this comes from studies of intact men who get circumcised as adults. Regret is almost inevitable. They do this for newly adopted religious reasons, misguided ideas or information on benefits and other reasons.</blockquote><br /><br />What planet is SagaciousMama living on? There's a reasonable overview of study results <a href="http://en.wikipedia.org/wiki/Sexual_effects_of_circumcision#Satisfaction">at Wikipedia</a>. Far from regret being "almost inevitable", high rates of satisfaction are commonplace.<br /><br /><blockquote>The foreskin is full of nerve endings and is the cause of natural lubrication. It is also a protective cover. Removing that cover exposes the glans of the penis to constant stimulation and rubbing against clothing. This idea makes an intact male shudder. Where some people think the exposed glans heightens sensitivity and sexual pleasure, the reverse is actually true. The penis desensitises to cope. The newly cut man will experience heightened sensitivity, however it is usually uncomfortable more than enjoyable and it does not last.</blockquote><br /><br />According to what evidence? Almost none. Studies of penile sensitivity have almost invariably shown no statistically significant differences. See, eg., Masters & Johnson, Bleustein 2003, Bleustein 2005, Payne 2007. None of these studies were performed on recently circumcised men, and none were able to find evidence of this desensitisation.<br /><br /><blockquote>If you ask a circumcised man about sexuality and sensitivity he will usually tell you everything is fine, great, just dandy. However, he doesn’t know it any other way. You can’t miss something you’ve never had. Only those who have been circumcised as adults have that perspective.</blockquote><br /><br />True, and what do they (we, strictly speaking) describe? <a href="http://www.ncbi.nlm.nih.gov/pubmed/19955598">"After the procedure 82% of patients referred an upgrade on the quality of their sexual intercourse, ..."</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/18761593">"Compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," ..."</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/16037710">"Penile sensation improved after circumcision in 38% (p = 0.01) but got worse in 18%, with the remainder having no change."</a><br /><br /><blockquote>9) Causes problems for female partners.</blockquote><br /><br />There's really no reliable evidence that this is the case. SagaciousMama cites a dubious website on the subject, which is full of speculative nonsense but very little evidence.<br /><br /><blockquote>10) The option will always be there when he grows up.</blockquote><br /><br />True, though it's not exactly an argument against circumcision.<br /><br /><blockquote>11) It is irreversible. ... Restoration is not the same.</blockquote><br /><br />This is technically true, but neither is adult circumcision the same as infant circumcision (it almost invariably causes heavier scarring, for example), so whatever choice you make will have lasting consequences.<br /><br /><blockquote>12) Risk of Physical Damage and Death.</blockquote><br /><br />Yes, there are risks, albeit small. These should be considered alongside the risks associated with non-circumcision (such as death due to complications of UTI, for example).<br /><br /><blockquote>13) Babies Tell You They Don’t Want To Be Circumcised.</blockquote><br /><br />This is too silly to deserve a response.<br /><br /><blockquote>14) Interferes With Breastfeeding.</blockquote><br /><br /><a href="http://www.ncbi.nlm.nih.gov/pubmed/17803666">No. It doesn't.</a><br /><br /><blockquote>15) It Goes Against Natural and Attachment Parenting</blockquote><br /><br />I'm going to skip this one because, as far as I can tell, SagaciousMama is basically just saying that it is incompatible with her personal parenting philosophy. That seems a good reason not to circumcise.<br /><br /><blockquote>16) It is Medieval, Shocking Barbaric and Weird. ... and ... 17) Spread eagled restraint is like torture to a baby.</blockquote><br /><br />Not really, no.<br /><br /><blockquote>18.) The historical reasons for it are morality based</blockquote><br /><br />Yikes. This is frighteningly irrational: deciding against something because of the reasons why people used to do it. It's like being opposed to dancing because some tribes, somewhere in the world, perform rain dances in the belief that it will induce precipitation. So what? Given the number of human societies and their longevity, it seems inevitable that sometimes people do good things for stupid reasons.<br /><br /><blockquote>19) 80% of the World’s Males are Intact.</blockquote><br /><br />This isn't a very rational argument. A considerable fraction of the world's population lack clean water, but this doesn't strike me as a compelling argument for having my water supply disconnected. The correct figure is probably closer to 60%, by the way.<br /><br /><blockquote>20) The Foreskin is a Necessary and Amazing Anatomical Structure.</blockquote><br /><br />This is simply nonsense.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com36tag:blogger.com,1999:blog-5654757240979234018.post-12484076000745644432010-03-06T11:48:00.003+00:002010-03-06T11:59:55.384+00:00Circumcision and human rights<a href="http://data.unaids.org/pub/Report/2008/jc1552_circumcision_en.pdf">This</a> is a fascinating article from UNAIDS, entitled "Safe, Voluntary, Informed Male Circumcision and Comprehensive HIV Prevention Programming: Guidance for decision-makers on human rights, ethical and legal considerations".<br /><br />I think this quote captures its essence:<br /><br /><blockquote>Given that it reduces a man’s risk of acquisition of HIV through penile–vaginal intercourse, male circumcision provides an opportunity to reinforce HIV prevention efforts and thereby promote human rights. <b>A human rights-based approach to introducing or expanding male circumcision services requires measures to ensure that the procedure can be carried out safely, under conditions of informed consent, and without discrimination. From a public health and human rights perspective, it also requires that governments implement male-circumcision programmes in the context of a comprehensive HIV prevention framework.</b> This will ensure that “risk compensation” (i.e. increases in risky behaviour sparked by decreases in perceived risk) (Cassell et al., 2006) does not undermine the partially protective effects of male circumcision for men.</blockquote><br /><br />(Emph. added)<br /><br />I'll also add the following quote re infant circumcision:<br /><br /><blockquote>Studies have shown that the circumcision of infants is simpler and carries fewer medical risks than circumcision of older people. Parents considering circumcision of an infant boy should be provided with all the facts so they can determine the best interest of the child. In these cases, determining the best interests of the child should include diverse factors—the positive and negative health, religious, cultural and social benefits. Because the HIV-related benefits of circumcision only arise in the context of sexual activity, and because male circumcision is an irreversible procedure, parents may consider that the child should be given the option to decide for himself when he has the capacity to do so.</blockquote><br /><br />It's an excellent document, worth reading in full.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com5tag:blogger.com,1999:blog-5654757240979234018.post-20168590266693251822010-02-28T11:15:00.006+00:002010-02-28T13:53:59.827+00:00Oh dear: Christiane Northrup on circumcisionChristiane Northrup's <a href="http://www.huffingtonpost.com/christiane-northrup/we-need-to-stop-circumcis_b_470689.html">article</a> entitled "We Need To Stop Circumcision" has already received some <a href="http://forthesakeofscience.wordpress.com/2010/02/25/circumcision/">criticism</a> <a href="http://www.nycskeptics.org/blog/vaccines-circumcision-and-the-huffpo/">from</a> other bloggers. I thought I'd add my own thoughts...<br /><br /><blockquote>In the weeks ahead, the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) are likely to publish a recommendation that all infant boys undergo circumcision. In the weeks ahead, the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) are likely to publish a recommendation that all infant boys undergo circumcision. This is a huge mistake. Circumcision is an unnecessary procedure that is painful and can lead to complications, including death. No organization in the world currently recommends this. Why should we routinely remove normal, functioning tissue from the genitals of little boys within days of their birth?</blockquote><br /><br />Let's address these arguments one by one:<br /><br /><ol><br /><li><i>It's unnecessary, painful, and can lead to complications.</i></li> Yes, it's unnecessary, but parents do many things for their children that aren't strictly necessary, from vaccinations to good diet to education. They may not be <i>required</i>, but that doesn't mean that they aren't beneficial. Painful? Yes, if anaesthesia isn't used. Complications? Yes, there's a risk, but that has to be weighed against the risks associated with lack of circumcision.</li><br /><li><i>No organisation currently recommends it</i>. That's not a rational argument for saying that no organisation should recommend it not. Intact America made the same mistake; I analysed their argument <a href="http://circumcisionnews.blogspot.com/2009/10/analysis-of-intact-america-propaganda.html">here</a>.</li><br /><li><i>Why should it be done?</i> This isn't strictly speaking an argument, so I'll leave it for now.<br /></ol><br /><br /><blockquote>The vast majority of the world's men, including most Europeans and Scandinavians, are uncircumcised. And before 1900, circumcision was virtually nonexistent in the United States as well--except for Jewish and Muslim people, who've been performing circumcisions for thousands of years for religious reasons. Believe it or not, circumcision was introduced in English-speaking countries in the late 1800s to control or prevent masturbation, similar to the way that female circumcision--the removal of the clitoris and labia--was promoted and continues to be advocated in some Muslim and African countries to control women's sexuality. [1]</blockquote><br /><br />The facts: about a third of men — perhaps 40% — are circumcised worldwide. Some physicians advocated circumcision to prevent masturbation in the late 1800s, and anti-circumcision activists are fond of quoting them, but there's no evidence that this was the main reason for the introduction of circumcision, and it certainly wasn't the only one. In fact, Gollaher, in his book "Circumcision: A History of the World's Most Controversial Surgery" (which is one of the more neutral books on the subject) dedicates a mere 12 of his 253 pages to the subject of masturbation.<br /><br /><blockquote>Routine female circumcision, which has been practiced in some cultures, is completely unacceptable. Few people would argue otherwise. In fact, the United Nations has issued a decree against it. Circumcision is a form of sexual abuse whether it's done to girls or boys. We justify male infant circumcision by pretending that the babies don't feel it because they're too young and it will have no consequences when they are older. This is not true. Women who experience memories of abuse in childhood know how deeply and painfully early experiences leave their marks in the body. Why wouldn't the same thing apply to boys?</blockquote><br /><br />As I have explained <a href="http://circumcisionnews.blogspot.com/2009/10/analysing-analysis-of-analysis-of.html">previously</a>: <i>It is not meaningful to compare female genital cutting to circumcision. Female genital cutting is a net harm, with no known medical benefits, immediate risks, and a considerable chance of permanent harm. Society passes laws to protect the vulnerable from harm, and so it makes sense to protect children from female genital cutting. But - applying the same principle - it doesn't make sense to legislate against circumcision, because there is no net harm. Most reasonable people, weighing the risks and benefits, come to the conclusion that it is neutral or beneficial.</i><br /><br /><blockquote>In medical school, I was taught that babies couldn't feel when they were born and therefore wouldn't feel their circumcision. Why was it, then, that when I strapped their little arms and legs down on the board (called a "circumstraint"), they were often perfectly calm; then when I started cutting their foreskin, they screamed loudly, with cries that broke my heart? For years, in some hospitals, surgery on infants has been carried out without anesthesia because of this misconception!</blockquote><br /><br />Doubtless this argument is chosen for emotional appeal, but rationally, there's a strong case against circumcision without anaesthesia, but that's not an argument against circumcision.<br /><br /><blockquote>From the 1980s through today, as the tide has been turning against male circumcision, misleading medical information has begun to surface (yet again) in support of circumcision. This information supports the belief that men with foreskins are more likely to get viral or bacterial infections and pass them on; that the foreskin is tender and thin, and therefore more prone to tiny cuts through which germs can be transmitted. New justifications, such as circumcision to prevent penile and cervical cancer, too often receive the blessing of the medical establishment. But these are justifications that science has been unable to support. Nor is there any scientific proof that circumcision prevents sexually transmitted diseases.</blockquote><br /><br />It's difficult to know how to respond to this. How should one respond to someone who plainly states such falsehoods?<br /><br /><blockquote>This includes the recent studies done in Kenya, South Africa, and Uganda by Ronald H. Gray, a professor at Johns Hopkins University. He recently reported that men who were circumcised were less likely by half to contract HIV virus and less likely by one-third to become infected with HPV and herpes. [2]</blockquote><br /><br />As a point of accuracy, Gray did not perform all three studies.<br /><br /><blockquote>While this sounds promising, I agree with my colleague George Denniston, M.D., who said, "The United States has high rates of HIV and the highest rate of circumcision in the West. The "experiment" of using circumcision to stem HIV infection has been running here for decades. It has failed miserably. Why do countries such as New Zealand, where they abandoned infant circumcision 50 years ago, or European countries, where circumcision is rare, have such low rates of HIV?" [3]</blockquote><br /><br />It's concerning to see this argument made by an educated person. Comparisons between selected countries are meaningless. Consider the following image. It's a simulation of HIV rates in 200 hypothetical countries (a very primitive simulation, for purposes of illustration only). The vertical axis represents HIV rates (you can ignore the horizontal axis). The black points represent countries with high circumcision rates — the average HIV rate is 1. The red points represent countries with low circumcision rates — the average HIV rate is 2. So, on average, countries with low circumcision rates have higher HIV rates. But because of the fact that the ranges overlap, it's easy to find black points that are higher than several red points. Let me make that point more clearly: <i>we should expect to be able to find countries with high circumcision rates that have higher HIV rates than some selected countries with low circumcision rates.</i> This is the case with real HIV rates, too (as well as rates of other diseases), and it happens because, in addition to random variation, there are other factors that affect the rates, such as levels of education, condom usage, sex practices, etc.<br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnh2eF6wJNgIh5_0uZY2WiJMHKYeuTCM77-EFxcNsbzY5FORmMXPfQqT3l4IZ4lxtSrBy5VUq2fKxxGJsDIb5vRzop6uglXcfvCshtDdG4wJmJh038qHwFkKrHrf9xuh6Vt1pCS3_Bf_pB/s1600-h/simulated-hiv.png"><img style="cursor:pointer; cursor:hand;width: 320px; height: 320px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnh2eF6wJNgIh5_0uZY2WiJMHKYeuTCM77-EFxcNsbzY5FORmMXPfQqT3l4IZ4lxtSrBy5VUq2fKxxGJsDIb5vRzop6uglXcfvCshtDdG4wJmJh038qHwFkKrHrf9xuh6Vt1pCS3_Bf_pB/s320/simulated-hiv.png" border="0" alt=""id="BLOGGER_PHOTO_ID_5443260606981461378" /></a><br /><br />Country-level comparisons are extremely weak, even when you use a large sample of countries. They're nothing but a joke when small numbers of selected countries are compared. There's really no substitute for rigorous epidemiological studies.<br /><br /><blockquote>Similarly, one of the main reasons people choose to have their child circumcised is they believe that it's nearly impossible to keep an uncircumcised penis clean. This also isn't true. And people make the mistake of thinking that they have to retract the foreskin to keep it clean. They don't. In fact, retracting the foreskin before it's meant to be retracted creates adhesions and infections. It sometimes doesn't retract on its own until a boy is as old as seven. Often, there isn't an opening between the glans penis and the foreskin. So you gently retract it every year on the child's birthday until it's fully retractable. Only then does it need to be cleaned, and you can teach a boy exactly how to do this.</blockquote><br /><br />It seems to me that Northrup is setting up a straw man here. Nobody is arguing that it is "nearly impossible" to keep an uncircumcised penis clean. But it is difficult to deny that it does require a little more work, and also that a circumcised penis is, on average, cleaner.<br /><br /><blockquote>Emotions run very high around the subject of circumcision, a perfect example of the strength and influence of first chakra cultural programming on our beliefs and emotions. This programming is so ingrained that many people cannot even discuss the subject of circumcision without guilt, denial, or other strong emotions. I know from years of experience that even addressing the subject of the baby boy's bodily integrity, choices, and pain isn't enough to change a belief that's been ingrained in the child's parents from their own birth.</blockquote><br /><br />Reading between the lines a little, I think Northrup is saying that she has been unable to persuade parents of her viewpoint. Maybe that's because it isn't very persuasive?<br /><br />(I'm skipping two paragraphs here.)<br /><br /><blockquote>Circumcision also has profound implications for male sexuality. Studies document that the amount of pleasure a man can receive during intercourse is greater in uncircumcised males. That's because the male foreskin, like the clitoris, is richly innervated for maximum sexual pleasure. Sexual researchers have determined that men with the original configuration (with the foreskin) are more likely to feel the most pleasure when they make love in a certain way. Without getting into details here, as it turns out, this "natural" sex is more likely to enhance a woman's pleasure, too. I've written about this extensively in Women's Bodies, Women's Wisdom.</blockquote><br /><br />Actually, studies have documented no such thing. What they actually indicate, on balance, is that there is basically no difference. It is disturbing that Northrup misrepresents the evidence.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com40tag:blogger.com,1999:blog-5654757240979234018.post-70674541557038049482010-02-16T17:07:00.002+00:002010-02-16T17:15:57.862+00:00CDC consultation report<a href="http://www.publichealthreports.org/archives/issueopen.cfm?articleID=2352">Male Circumcision in the United States for the Prevention of HIV Infection and Other Adverse Health Outcomes: Report from a CDC Consultation</a> has now been published.<br /><br />It is a lengthy document, worth reading in full. I'll just highlight here what I think are the most interesting recommendations:<br /><br /><ul><br /><li>With respect to HIV prevention, MC should be framed as one of several partially effective risk-reduction alternatives for heterosexual men that should be used in combination for maximal protection.</li><br /><li>Recommendations for infant and adolescent/adult MC should be framed as interventions to promote genital health and hygiene, including HIV, STI, and UTI prevention and other outcomes.</li><br /><li>Recommend reimbursement for MC by public and private insurers to ensure equal access across states, to all socioeconomic groups, and in special settings (e.g., military or prisons).</li><br /><li>In collaboration with other HHS agencies and health insurers, assess public and private insurance coverage for elective neonatal MC.</li><br /><li>Medical benefits outweigh risks for infant MC, and there are many practical advantages of doing it in the newborn period.</li><br /><li>Benefits and risks should be explained to parents to facilitate shared decision-making in the newborn period.<br />CDC, AAP, and others should make/update recommendations about infant circumcisions for HIV and broader health concerns.</li><br /><li>Develop educational resources about infant circumcision for parents, practitioners, and the public.</li><br /></ul>Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com2tag:blogger.com,1999:blog-5654757240979234018.post-29041355077126388922010-02-10T22:34:00.002+00:002010-02-10T22:56:01.099+00:00Deliberate distortion from anti-circumcision activistI spent some time trying to decide whether I should post this. It was a difficult decision for me. On one hand, what follows is part of a message to a private mailing list, and those posting to such lists do so with the expectation of privacy. On the other hand, it illustrates <i>intent</i> to mislead on the part of a prominent anti-circumcision activist, and people have a right to know about this sort of thing.<br /><br />In the end, I decided to post it.<br /><br />Hugh Young is a well-known anti-circumcision activist (or "intactivist", as they often call themselves) from New Zealand. He is the owner of the "circumstitions.com" website.<br /><br />INTACT-L is a mailing list run by the anti-circumcision website "cirp.org", for discussion of anti-circumcision issues in general.<br /><br />Recently, participants on INTACT-L have been discussing the anticipated policy statement from the American Academy of Pediatrics. One participant suggests that the anti-circumcision activists write a statement for the AAP:<br /><br /><blockquote>Rather than waiting for them to do the wrong thing, as they surely will, let's tell them what the right thing is.</blockquote><br />To which Hugh Young replies:<br /><br /><blockquote>From: Hugh Young<br />To: intact-l@cirp.org<br />Subject: Re: The AAP's new position statement on circumcision<br />Date: Feb 10, 2010 7:23:56 AM<br /><br />[...]<br /><br />A good point. Brian Morris drafted his version of a statement for the RACP but it was so over the top they would have laughed at it (though they still haven't issued theirs). We need to make ours something they could/should agree to. <span style="color:red">If it gets published so that people mistake it for the real thing, so much the better.</span> If we can ease them out of legal action for past circumcisions, they'd appreciate that too - that's their big fear if they go straight from "neutrality" to condemnation without giving all present victims time to die off.</blockquote><br />(Emphasis added.)<br /><br />Now, if anti-circumcision activists want to write a "policy statement" for the AAP, that's up to them. It seems a waste of time to me, but it's their time to waste, after all. What I find really alarming here is that Young explicitly indicates that he <i>wants</i> to mislead people. He wants people to believe that the (hypothetical) version authored by the anti-circumcision lobby is the real policy statement.<br /><br />I'm sorry to say that I believe that what's unusual here is the <i>admission</i> rather than the intent, but even so the admission is startling enough. It makes one think: if the anti-circumcision "message" is so strong, why would anyone feel the need to deceive people?<br /><br />Does he not have any concept of ethics? Apparently not.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com7tag:blogger.com,1999:blog-5654757240979234018.post-19718609334127622272010-01-24T16:18:00.002+00:002010-01-24T16:29:22.090+00:00The Effects of Circumcision on the Penis Microbiome<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0008422">Here</a> is an interesting study. Using men from the intervention arm of the Ugandan RCT, the researchers studied the microbiological flora of the penis before and after circumcision.<br /><br />The researchers found that there was a significant change in the types of bacteria found on the penis. In particular, the number of anaerobic bacteria fell significantly following circumcision.<br /><br />The discovery that circumcision alters the penile flora is nothing new. Many studies have investigated this previously (for an overview see refs 12-22 in my letter <a href="http://www.circs.org/library/waskett3/index.html">here</a>), and have come to similar conclusions.<br /><br />The authors speculate that the presence of anaerobic bacteria on the uncircumcised penis might promote inflammatory conditions which activate immune cells that, in turn, act as a magnet for HIV.<br /><br />It also, of course, helps to explain the fact that circumcised males enjoy reduced risk of urinary tract infections and local infections such as balanitis.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com0tag:blogger.com,1999:blog-5654757240979234018.post-56925679657370342942010-01-22T11:31:00.002+00:002010-01-22T11:45:14.173+00:00Cost-effectiveness of newborn circumcision in reducing lifetime HIV risk among US males.<a href="http://www.ncbi.nlm.nih.gov/pubmed/20090910">Here</a> is a fascinating study by researchers from the CDC. Using data from randomised controlled trials, they modelled the effect of neonatal circumcision on lifetime risk of HIV in the United States.<br /><br />The authors assumed (as far as I can tell) that circumcision had an effect <i>only</i> on heterosexual transmission. This is a conservative assumption, so we should bear in mind that the results will also be conservative estimates.<br /><br />They found that neonatal circumcision "reduced the 1.87% lifetime risk of HIV among all males by about 16%" (that is, it reduced by about 0.3% to about 1.6%). This effect varied by race, from 7.9% for white men to 20.9% for black men. They also found "lower expected HIV-related treatment costs and a slight increase in [Quality-adjusted life years]".<br /><br />The CDC's forthcoming recommendations re neonatal circumcision are in the news at the moment (see, for example, <a href="http://www.washingtonpost.com/wp-dyn/content/article/2010/01/15/AR2010011503106.html">Debate on circumcision heightened as CDC evaluates surgery</a> [Washington Post, 19 Jan]), and of course there is much speculation about what those recommendations will be. To my mind, there's an interesting clue in the conclusions of this paper: <br /><br /><blockquote>Racial and ethnic groups who could benefit the most from circumcision may have least access to it due to insurance coverage and state Medicaid policies, <i>and these financial barriers should be addressed.</i> More data on the long-term protective effect of circumcision on heterosexual males as well as on its efficacy in preventing HIV among MSM would be useful.</blockquote><br /><br />(Emphasis added.)Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com0tag:blogger.com,1999:blog-5654757240979234018.post-88118768928159337132009-11-17T11:29:00.002+00:002009-11-17T11:47:49.149+00:00Two new studies assessing the impact of circumcision against genital herpesPubMed 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.<br /><br />Anyway, today's alert included two new studies that investigated the effect of circumcision against genital herpes. <br /><br /><a href="http://www.ncbi.nlm.nih.gov/pubmed/19915236">Jerath and Mahajan</a> 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.<br /><br />Also of interest is a study by <a href="http://www.ncbi.nlm.nih.gov/pubmed/19910861">Van Wagoner</a> 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.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com8tag:blogger.com,1999:blog-5654757240979234018.post-17992504128919462392009-11-02T10:26:00.000+00:002009-11-02T10:27:11.370+00:00Intact America, part 4Tony has <a href="http://www.rollingdoughnut.com/2009/11/science_requires_ethics_part_3.html">responded</a> to my most recent <a href="http://circumcisionnews.blogspot.com/2009/10/in-ongoing-inter-blog-discussion-about.html">post</a> in our ongoing discussion.<br /><br />Let me address some of his points.<br /><blockquote>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.</blockquote>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 <i>probability x weight</i> 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 <i>not</i> having been circumcised too, but I don't think that such large weights are really justified.<br /><br />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:<br /><blockquote>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.</blockquote>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.<br /><blockquote>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.</blockquote>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.<br /><br />Next, re vaccination:<br /><blockquote>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.</blockquote>So if we consider surgical procedures that do not remove body parts, do they fall on the same side of the line as vaccinations?<br /><blockquote>I believe I've understood him correctly. He is wrong. If there is no medical reason (i.e. need)</blockquote>(I'm not sure that the two terms are actually synonymous. One could have a medical reason without there being an actual need.)<br /><blockquote>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.</blockquote>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 <i>his</i> principles as though they were universal truths.<br /><br />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:<br /><blockquote>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.</blockquote>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.<br /><blockquote>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.</blockquote>Tony is essentially correct when he suggests that my approach would be utilitarian, but that wouldn't involve assessing <i>only</i> 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.<br /><br />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:<br /><blockquote>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.</blockquote>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?<br /><blockquote>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.</blockquote>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.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com0tag:blogger.com,1999:blog-5654757240979234018.post-3315199913964406152009-10-30T14:09:00.002+00:002009-10-30T14:30:41.573+00:00Acceptability of circumcisionBack in 2007, <a href="http://www.ncbi.nlm.nih.gov/pubmed/17053855">Westercamp and Bailey</a> published an interesting review of studies of the acceptability of circumcision in sub-Saharan Africa. Among thirteen studies, they found that "the median proportion of uncircumcised men willing to become circumcised was 65% (range 29-87%)".<br /><br />Interestingly, data from newer studies suggest that these results are not limited to African settings. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2443289/?tool=pubmed">Begley et al.</a>, for example, studied men who have sex with men (MSM) in the US, reporting that 53% were willing to be circumcised. Interestingly, this was especially true among black men. Another paper, by <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743100/?tool=pubmed">Ruan et al.</a>, studied MSM in China. The results were that "16.9% said they were absolutely willing to participate, 26.4% were probably, 28.9% were probably not, and 27.8% were absolutely not". To put that another way, 43.3% were likely to participate in such a scheme - a figure comparable to those mentioned above.<br /><br />In both studies, concerns were noted, these were primarily about surgical pain and complications of the procedure. In the Chinese study, 5.3% of men were concerned about a loss of sexual pleasure. In contrast, in the US study, some men were willing to consider circumcision in part because it might increase sexual pleasure. This must be quite a shock to the anti-circumcision lobbyists who seem to believe that the foreskin is such an amazing thing that nobody could ever part with it!Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com1tag:blogger.com,1999:blog-5654757240979234018.post-70850760301198812142009-10-26T11:25:00.003+00:002009-10-26T11:30:48.875+00:00Intact America, part 3In the ongoing inter-blog discussion about Intact America's advertisement, Tony at RollingDoughnut.com has <a href="http://www.rollingdoughnut.com/2009/10/science_requires_ethics_revisi.html">responded</a> to my <a href="http://circumcisionnews.blogspot.com/2009/10/analysing-analysis-of-analysis-of.html">response</a>. Tony and I have clearly both spent considerable time thinking about these issues, and I suspect that we will never convince each other of the core issues. Nevertheless, I found his response interesting.<br /><br />Regarding his mischaracterisation of my position, Tony writes:<br /><blockquote>I do not accept that I've mischaracterized his position as a pro-circumcision advocate. However, I'll clarify to be as specific as possible. He believes the potential benefits of infant male circumcision outweigh the risks and negatives, a subjective conclusion based on his preferences. Given that he uses his conclusion to encourage parents to circumcise their sons, the difference he states is immaterial.</blockquote><br />I find this a rather peculiar statement. I suppose in a sense that any attempt to weigh benefits against risks will have some subjective qualities, and perhaps that can't be avoided altogether. However, as subjective values are meaningless to another person I would hope that most observers try as objective as is reasonably possible. I certainly try; I can only hope that I succeed.<br /><br />I am uninterested in convincing or encouraging parents to circumcise their sons, and have been careful to avoid making a recommendation either way. Anyone sufficiently interested (not to mention patient) can verify this by working through the many thousands of my public comments over the years - I use the same name everywhere, so it is not difficult to find them via Google. Indeed, I believe that such advocacy would be contrary to my pro-parental choice position: I genuinely believe that parents should make that decision, not me.<br /><br />Skipping over some content, Tony clarifies an earlier point. He writes:<br /><blockquote>If an authority cited directly (e.g. AAP) or indirectly (e.g. CDC) changes its position in a way that then conflicts with the original appeal, the appeal to authority may weaken the case for the target audience. It's an ineffective strategy.</blockquote><br />My first inclination was to agree, but on reflection I think it would depend on the situation. Consider the following hypothetical scenario:<br /><br /><span style="font-style: italic;">PERSON A: Circumcision is awful because the AAP don't recommend it.</span><br /><span style="font-style: italic;">AAP: [Introduces a recommendation in favour of circumcision]</span><br /><span style="font-style: italic;">PERSON A: Oh, the AAP are biased, ignore them.</span><br /><br />Here the appeal to authority is utterly invalid. It is quite apparent that it is a sham: the AAP are being presented as an authority merely because the person hopes to gain an advantage by doing so. The person clearly has no integrity, nor any credibility, and can and should be ignored. Now consider this:<br /><br /><span style="font-style: italic;">PERSON A: Circumcision is awful because the AAP don't recommend it.</span><br /><span style="font-style: italic;">AAP: [Introduces a recommendation in favour of circumcision]</span><br /><span style="font-style: italic;">PERSON A: Okay, the AAP now recommend it, so it's okay.</span><br /><br />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.<br /><br />Regarding Tony's requirement that surgery must be "necessary", which I questioned, Tony writes:<br /><blockquote>His assessment is close, but too neat for this complicated comparison. That is the requirement I set for proxy consent to surgery. The scenario for vaccinations differs.</blockquote><br />I see: Tony applies a different standard for surgery and vaccinations. This doesn't make much sense to me, for several reasons. Firstly, from an admittedly pedantic point of view, is there really that much of a difference? Surgery involves risk. Vaccinations involve risk. Surgery involves cutting the skin. Vaccinations (as delivered by a needle) also involve cutting the skin, albeit in a minor way. So I have to ask, where exactly would you draw the line?<br /><br />Secondly, does it make sense to create multiple standards? To my mind, no. But I may be biased: I'm trained as an engineer, and when I observe lots of different little rules I see a situation in which there ought to be one, more general rule. Special cases are usually an indication that the general rule needs some more attention. Maybe one shouldn't apply engineering principles to ethics. I don't know, but I can't see any reason why one shouldn't...<br /><br />In response to my comment that "Children grow up to become adults, and yes, that includes having sex", Tony writes:<br /><blockquote>Of course, to which I reply as a start: condoms. Condoms are among the many possibilities short of circumcision as an infant available to adult males, including circumcision as an adult, to reduce the risk of HIV transmission.</blockquote><br />And from slightly further on:<br /><blockquote>Assuming voluntary adult circumcision is shown to reduce the risk of all forms of HIV transmission through sex, parents can't know that their sons will be irresponsible and "need" this intervention. It's a speculation that does not need to be made for a child. He can choose it later.</blockquote><br />To both points, I agree. Nevertheless, it seems difficult to deny that <i>if it were performed during infancy</i>, circumcision would help to reduce this risk when the child became an adult.<br /><blockquote>Ultimately the comparison to vaccines must rest on diseases like HIV rather than the other potential benefits used to justify circumcision. They roughly share some of the same characteristics. The comparison fails because, as I wrote, the way in which the diseases spread differ. For most vaccines, it is the most effective and least invasive way to stop the spread of the targeted disease. With comparable diseases, circumcision is neither the most effective or the least invasive method available.</blockquote><br />There are differences in the way in which the diseases spread, certainly, but I disagree with Tony that the comparison fails as a result. As far as I can tell, the difference has no bearing on the validity of the comparison in the specific context in which it was made.<br /><blockquote>There is no need, so "most effective/least invasive" doesn't apply? Jake is begging the question he wants to answer rather than addressing objective facts. He's saying that the standard for surgical intervention on a child should be stricter when the child is sick than when he is healthy. Parents can be more speculative and exploratory with surgery for their healthy (male) children? That's ridiculous. Without objective need for an intervention, proxy consent for surgery can't be valid. With objective need, it can be valid because the child needs some form of decision made and he is incompetent to make that decision.</blockquote><br />Here I believe Tony has misunderstood, or at least has not considered the issue with sufficient care. If there is a <i>medical</i> problem to address, then the physician's responsibility is to solve that problem while exposing the patient to the least risk. That's the essence of the "most effective/least invasive" standard. But if there is no medical reason for considering circumcision, then it is meaningless to even consider the "most effective" solution. If circumcision is being considered for non-medical reasons then it is in all probability the <i>only</i> solution to the problem (that being that the child is not circumcised). So it is the wrong standard to apply.<br /><br />At this point Tony declined to list '"surgeries we recognize as offensive" that are valid when benefits and risks are properly weighed', stating:<br /><blockquote>I am not citing any particular science or surgeries because that was not my point.</blockquote><br />This is a shame. I had hoped that Tony would at least try. I cannot think of any, and my suspicion is that this is because none exist. And if none exist, then Tony's earlier objection that "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" seems a rather empty objection.<br /><br />Tony continues:<br /><blockquote>But to his retort, if a study were to find potential health benefits for genital cutting in a study of adult female volunteers, would that be acceptable to apply to healthy female minors? I've had this discussion with Jake previously, so I know he'd have no problem with it if parents subjectively valued the benefits more than the risks. He is wrong. Society would be (correctly) outraged at the suggestion of violating the child's rights in favor of her parents' "rights". Our anti-FGM laws would not be overturned. Those results would never be applied, regardless of the science.</blockquote><br />In an ideal world, I wish I could say that anti-FGC laws would indeed be overturned if scientific knowledge changed significantly. However, I'm sorry to say that Tony is probably right in that they wouldn't be. I don't think that this has anything to do with rights, though: it's a simple case of collective prejudice. The notion that FGC is horrific is deeply ingrained into modern, Western society, and it takes an awful lot to dislodge that notion. I know this from personal experience: I have to make a conscious effort to think about FGC objectively, and have to fight the knee-jerk reaction. And I consider myself very open-minded.<br /><br />On a related note, Tony writes:<br /><blockquote>That paragraph is clear. We apply different standards to boys and girls. A female minor's risk of UTI is higher than that of a male minor's, yet we do not vigorously seek proof that genital cutting is the answer, nor, as I said above, would we apply it to infant girl if we could find such results. Now replace UTI with cancer. Ethically, we'd have the same approach to girls. Their genitals would be off-limits.</blockquote><br /><a href="http://www.ncbi.nlm.nih.gov/pubmed/16485592">Evidence</a> actually suggests that female genital cutting actually increases the risk of UTI...<br /><blockquote>Jake establishes a straw man here. I made a statement of fact about HIV transmission in the United States. His rebuttal is that I should be willing to have sex with an HIV+ woman because I state that voluntary, adult circumcision applied to infant males is not what we need. Presumably he means without a condom. Where have I said that unsafe sex - of any kind, with or without a foreskin - is wise? Jake's scenario is a stupid diversion.</blockquote><br />Perhaps I should have made my point more clear (or, arguably, made a better point). Let me explain. My words were in response to Tony's statement that "Our risk is male-to-male transmission and shared needles during IV drug use", which seemed to be saying "there is no risk of female-to-male transmission in the US". That isn't true. The absolute risk may be small, but it exists and shouldn't be ignored.<br /><br />Tony continues:<br /><blockquote>It is meaningful to compare female genital cutting to male genital cutting because, ethically, they involve the same issue. Unnecessary surgery on a non-consenting individual is wrong.</blockquote><br />If you take that last sentence as axiomatic, then you will probably see the two issues as similar (although, presumably, there's no reason to focus on genital surgery in particular). Those of us who adopt a different ethical principle - something like "harmful surgery on a non-consenting individual is wrong" see no problem with circumcision, and a problem with female genital cutting.<br /><blockquote>America's anti-FGM law makes no exemption for potential benefits or parental opinion.</blockquote><br />This is true, and in that respect it does make itself rather inflexible in the face of possible scientific developments in future.<br /><blockquote>The former is, as Jake points out, not shown by studies. The latter is all that informs infant male circumcision, since an evaluation of potential benefits is opinion absent any objective indication for the child's healthy genitals.</blockquote><br />Here Tony is making a mistake. Evaluation of potential benefits should not be dismissed as mere opinion. The literature contains a relatively large amount of data, which can be summarised in the form of objectively quantifiable data.<br /><blockquote>There is an obvious double standard. Girls may not have their healthy genitals cut for any reason. Boys may have their healthy genitals cut for any reason. That's the valid comparison.</blockquote><br />That's not even correct. Try getting a surgeon to perform a glansectomy on a healthy boy. Or castrate him. Or perform any number of other surgeries on his genitals. He or she will refuse. Most such surgeries are a net harm (except when actually needed, in which case the benefits are considerably greater, thus making them a net benefit), and cannot therefore be ethically performed. Circumcision is unusual precisely because it is a surgery which is neutral or (depending who you ask) a net benefit. And that's why the reason for a specific circumcision doesn't really matter.Jakehttp://www.blogger.com/profile/16079606157046664850noreply@blogger.com6