Jan 07 2010
The case for neonatal circumcision
Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure. People would hail this simple victory and rush to adopt it… Not exactly. The disease is HIV and the simple surgical procedure is circumcision and anti-circ activists oppose it under almost any circumstances.
In this month’s edition of the Archives of Pediatrics and Adolescent Medicine, Tobian, Gray and Quinn present a compelling case for neonatal circumcision. The paper is entitled Male Circumcision for the Prevention of Acquisition and Transmission of Sexually Transmitted Infections. The authors report:
The American Academy of Pediatrics (AAP) male circumcision policy states that while there are potential medical benefits of newborn male circumcision, the data are insufficient to recommend routine neonatal circumcision. Since 2005, however, 3 randomized trials have evaluated male circumcision for prevention of sexually transmitted infections. The trials found that circumcision decreases human immunodeficiency virus acquisition by 53% to 60%, herpes simplex virus type 2 acquisition by 28% to 34%, and human papillomavirus prevalence by 32% to 35% in men. Among female partners of circumcised men, bacterial vaginosis was reduced by 40%, and Trichomonas vaginalis infection was reduced by 48%. Genital ulcer disease was also reduced among males and their female partners. These findings are also supported by observational studies conducted in the United States. The AAP policy has a major impact on neonatal circumcision in the United States. This review evaluates the recent data that support revision of the AAP policy to fully reflect the evidence of long-term health benefits of male circumcision.
The AAP had long recommended male circumcision for prevention of urinary tract infections in young boys, but backed down in 1999, partly in response to pressure from anti-circumcision activists. According to circumcision.org:
Based on a review of medical and psychological literature and our own research and experience, we conclude that circumcision causes serious, generally unrecognized harm and is not advisable.
Anti-circ activists have employed inflammatory language to express their opinion. Circumcision is “mutilation” and parents who choose to circumcise their sons are “mutilators”. But the benefits of circumcision are real and clinically important. As Tobian, et al. explain:
The biological mechanisms whereby circumcision could reduce viral STIs may be due to anatomic and/or cellular factors. The foreskin is retracted over the shaft during intercourse and this exposes the preputial mucosa to vaginal and cervical fluids.61 It has been hypothesized that viral infections may enter the mucosa through microtears in the preputial mucosa. The moist subpreputial cavity may also provide a favorable environment for viral survival. The inner mucosa of the foreskin is lightly keratinized compared with the epithelium of the shaft, coronal sulcus, and glans, which may facilitate mucosal access of HIV, HSV-2, or HPV. The mucosa of the foreskin also contains a high density of dendritic (Langerhans) cells, macrophages, and CD4_ T cells, which are all targets of HIV …
Anti-circ activists are convinced that circumcision reduces sexual satisfaction. Until recently, it was difficult to study that claim because very few men were circumcised after becoming sexually active, making it almost impossible to determine the sensory effect of circumcision. But recent studies make it clear that sexual satisfaction is not affect by circumcision:
… [T]here were no reported differences in sexual satisfaction in the randomized study arms in either the Ugandan or Kenyan male circumcision trials or among men before and after they were circumcised. In addition, it has been hypothesized that behavioral disinhibition may counteract any protective effects of male circumcision. However, there was no consistent or substantial evidence of change in sexual behavior after circumcision in the Kenyan or Ugandan randomized controlled trials.
Tobian et al. call on the AAP to revise its policy to reflect the latest scientific evidence:
The World Health Organization/Joint United Nations Program on HIV/AIDS has concluded that “the research evidence that male circumcision is efficacious in reducing sexual transmission of HIV from women to men is compelling … and has been proven beyond reasonable doubt.” In 2007, the American Urological Association revised their policy to state that “circumcision should be presented as an option for health benefits.” However, the AAP, American College of Obstetricians and Gynecologists, and American Medical Association are likely to have the greatest influence on parental decisions and insurance coverage for neonatal circumcision in the United States. With the mounting evidence that male circumcision decreases viral STIs, genital ulcer disease, and penile inflammatory disorders in men, and bacterial vaginosis, T vaginalis infection, and genital ulcer disease in their female partners, it is time for the AAP policy to fully reflect these current data.
The AAP should heed the authors’ call.
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Shouldn’t males be entitled to informed consent when it comes to irreversible and non-essential surgical procedures that may affect quality of life in future? Especially so when some evidence suggests that those who undergo the procedure as adults report a loss in sexual satisfaction, despite your cherrypicked assertions otherwise.
And why isn’t the permanent removal of a physical feature for no immediate medical benefit not mutilation and grossly immoral?
“The AAP had long recommended male circumcision for prevention of urinary tract infections in young boys, but backed down in 1999, partly in response to pressure from anti-circumcision activists”
I’m not aware of any evidence that not being circumcised increases the risk of UTIs. Also, it would seem very odd to be advocating circumcision to avoid UTIs in boys when they are so very rare (any case of a UTI in a boy warrants further investigation of their renal tract, not the decision that it was due to the foreskin).
Neonatal circumcision saves lives the same way neonatal leg amputation does. “Hey, it might come in handy some day!”
People can sarcasm-quote the word Mutilation when they’re talking about male circumcision as much as they want, it doesn’t change the fact that’s exactly what it is, both in the linguistic as in the medical sense.
I’m sure if they tried to find “medical benefits” to female genital mutilation as hard as they do with male genital mutilation, they’d find plenty. (http://www.fgmnetwork.org/intro/mgmfgm.php)
All the supposed benefits of this measure are related to sex, but newborns and infants are not supposed to be having sex. Once boys get old enough to start having sex, however, parents and doctors might be fully encouraged to include this discussion in their sex talks, presenting all the available information (http://www.youtube.com/watch?v=1vxeGQe_opU), so the boy can now make an informed and, most important, VOLUNTARY decision.
Apparently “My body, my choice” only counts if you’re a woman.
“”The trials found that circumcision decreases human immunodeficiency virus acquisition by 53% to 60%, herpes simplex virus type 2 acquisition by 28% to 34%, and human papillomavirus prevalence by 32% to 35% in men.”"
I don’t like the way those statistics are worded, especially when you look at the CDC website. There were only about 10,000 cases of HIV in this country in 2007, with just about 400,000 cumulative. Once you factor in race, income level, lifestyle and other factors–my boys are very low risk category. Decreasing that risk by another 50-60% sounds great on the surface, but they are already very low risk already.
So for me, a yes, mutilating, permanent procedure that has all of it’s origins based in religion….I’m still more than 100% confident in my decision to not circ my boys. People flip their lids over female circumcision…why not for males?
I apologize–it’s o-dark-30 here and I didn’t finish my thought. To me, circ’ing boys to prevent STDs seems like a silly (for lack of a better word) reason to do it. We should be looking for other ways to prevent STDs.
Since it is non-reversible it must be VERY effective for it to be forced on babies, it would have to be more effective than a vaccine (essentially there should be almost no circumcised men with HIV).
I do not know anyone who is circumcised, here it is the norm to not circumcise and I have not heard of a difference in HIV infections with other countries where circumcision is the norm.
And what is wrong with elective adult circumcision? If an adult wants to mutilate himself (piercings, scarring, circumcision, …) I have no qualms with that.
You can just grow a spine and deny my comment already. Keeping it “awaiting moderation” is not fooling me.
Oooh, this should be fun.
Disclaimer: I had both my sons circumcised for the usual cultural, ethnic, mumbo jumbo reasons. These are pretty much the only reasons that anyone in my country does infant circumcision. I felt happy in doing so, because I have no difficulty with circumcision per se, and I believe it should be the parents’ decision as to whether to circumcise their son – falling into the same category as the countless other irreversible decisions we make on behalf of our children.
Having said that, I think Dr Amy’s argument around the AAP change of position deserves closer scrutiny.
First, the AAP had “long recommended male circumcision for prevention of urinary tract infections in young boys.” But no mention of whether they were correct in doing so. What does science have to say on this subject? Given that presence of a foreskin is the physiological default, isn’t it for proponents of circumcision to properly demonstrate the benefits of its removal? Had the AAP done so, in their long history of recommending male circumcision? Surely the answers to these questions form part of any science-based discussion on routine infant circumcision.
Second, the AAP “backed down in 1999, partly in response to pressure from anti-circumcision activists”. I would like to see some evidence to support this statement. There may be a correlation between the rise of anti-circumcision activism, and change in AAP position, but can we conclude causation? What other factors may come into play here? Perhaps both ‘activists’ and paediatricians were both responding to a single-cause, for example lack of evidence to support the procedure – which may increase ‘activism’ insofar as many more people come to view their circumcisions as having been ‘unnecessary’ and may change the position of the AAP in an increasingly evidence-based medical context? Or perhaps the activism and AAP change of position are unrelated. Activism tapping into a culture that rewards victim status, while the AAP change of position may reflect a more conservative use of surgery in paediatrics generally (mirroring the decline in tonsilectomy, for example). The above narratives are, of course, entirely speculative. But no more speculative than the narrative presented in the opening post.
While the research into the prophylactic effects of circumcision with regard to HIV is certainly interesting, for a population with low prevalence it doesn’t substantially change the terrain of the discussion about the benefits/risks of circumcision.
I usually back the doctors on SBM but I have to disagree this time. I cannot see the necessity for circumcision. Parents of uncircumcised boys have to teach them a bit more hygiene is all. The basis for most circumcision is religious and cultural, not medical.
A visitor from outer space might be forgiven for concluding that the most important part of the human body is the foreskin. It is, after all, the only part of the body that has multiple organizations devoted to its preservation in the natural state. The visitor might get the impression that the choice of circumcision is a fateful choice with profound implications for the rest of life.
Why does the issue of what other parents choose for their sons generate so much heat? The authors of the article are not proposing that circumcision be mandatory, merely that parents be informed of the benefits as well as the risks.
Why do people attempt to derail the discussion by using inflammatory language like “mutilation”? If you don’t want to circ your sons, don’t do it, but why shouldn’t other parents make their own decisions?
“If an adult wants to mutilate himself (piercings, scarring, circumcision, …) I have no qualms with that.”
So you are equally opposed to piercing babies’ ears? By your definition, that’s mutilation, too?
I didn’t have any male children so never had to make this decision. And, not being a male, I can’t speak from the sexual pleasure state. However, I have found that the glans of an uncirc’d male seems to be softer and more sensitive to touch during foreplay.
I don’t have access to the full article so I don’t know if the studies looked only at the US, or at other countries. If they only looked at the US, I would prefer to see a study comparing STD levels in countries with high circ levels (i.e. the USA and Israel) to countries with very low circ levels (i.e. many of the European countries). Looking at the US, with its dismal record of sex education, use of contraceptives, and lack of health insurance only skews the results, in my mind. Compare the US to Belgium, The Netherlands (where prostitution is legal and controlled), or another European country.
“People flip their lids over female circumcision…why not for males?”
Because the male analogue of female “circumcision” is amputation of the penis. Why do anti-circ activists disingenuously equate male circumcision with clitoridectomy?
“However, I have found that the glans of an uncirc’d male seems to be softer and more sensitive to touch during foreplay.”
If that were the case, wouldn’t that be an argument FOR circumcision since prolonging intercourse seems to be an accepted goal for many men? There are certainly quite a few products out there that claim to let men “last longer” by decreasing sensitivity?
Amy
Why does the issue of what other parents choose for their sons generate so much heat? The authors of the article are not proposing that circumcision be mandatory, merely that parents be informed of the benefits as well as the risks.
Could you deal with the ethical issues of why an irreversible medical procedure of no immediate benefit and of some risk should be carried out on a patient unable to give their consent?
“Because the male analogue of female “circumcision” is amputation of the penis.”
You don’t need the clitoris in order to have intercourse.
“a patient unable to give their consent?”
Infants are unable to give consent to anything. They routinely undergo medical procedures with far more risks than circumcision based solely on parental consent. Why should circumcision be viewed differently?
Why do you gloss over the point of choice in the person being circumcised? What is wrong with actually waiting to perform circumcision in later life?
In medical school now, our profs lecture us on patient and child autonomy. As MDs we need to as much as possible respect that. So what in this case necessitates performing this procedure when we’re doing without individual choice. Certainly, parent have some control over their children’s medical care but this doesn’t give them final say (i.e. parents of female children with severe mental retardation have wanted to have the reproductive organs removed to prevent menstruation as it creates a mess or there are issues with pregnancy from sexual abuse, they haven’t been allowed to do so). It would seem that many of the benefits are realized later in life. So why not wait? And again I don’t understand why don’t address that issue in your post, it’s a huge part of the debate.
I don’t know, Amy. Maybe if the male was having problems with premature ejaculation, decreased sensitivity would help. But, again, since I’m not a male, I won’t make that call!
Can you clarify if the studies looked only at the US for the populations? Certainly, I am all for a procedure that is efficacious, but I want more information before I recommend it. And, were the populations matched for use of condoms, etc? As I said, I can’t get into the study so don’t know what they looked at.
As someone with an intact husband and no sons this isn’t anything I’ve ever had to think about, but the idea of removing body parts just in case of future infection or disease seems a bit odd. Why stop at foreskins? Why not other non-essential bits of anatomy that might go wrong in future? Breasts, anybody? Where I live, lots more people die because of having breasts than because of having foreskins.
BTW I disagree with having babies’ ears pierced …
Amy
Why should circumcision be viewed differently?
Because its not medically necessary.
PS as regards the ear piercings argument, in many countries it is illegal to pierce the ears of a child under the age at which the state considers them capable of giving consent.
Because the male analogue of female “circumcision” is amputation of the penis. Why do anti-circ activists disingenuously equate male circumcision with clitoridectomy?
+++++++++
Actually, that is not completely accurate.
There are many variations of female genital modification, as follows:
Type Ia, removal of the clitoral hood only – this *is* analogous to male circumcision.
Type Ib, removal of the clitoris and hood – as you say, analogous to penectomy.
Type II – removal of clitoris and labia. The analogous structure to the labia is the scrotum, albeit that the contents are located elsewhere women.
Type III – infibulation with excision – the equivalent would be sewing the remaining skin together after removal of the penis and scrotum.
Type IV – “other” (pricking, piercing etc…), but which in a literal sense probably include genital piercings that are fairly widely-practised in the west.
Efforts to eradicate the genital modification of girls typically do not differentiate between the types listed above (e.g. the Maputo protocol mandates signatories to prohibit all forms). One can see why from a legal perspective: if you allow Type Ia, then you can going to see a lot of intentionally ‘botched’ procedures to get around the law, especially given that Type Ia has always accounted for a small percentage of procedures amongst a much more damaging continuum. However, from a scientific standpoint, Type Ia in women is a exact analogue of the removal of the male foreskin, so it is worth asking ourselves (especially those of us who have circumcised our sons!) why we are content for this procedure (Type Ia) to be criminalised.
“since prolonging intercourse seems to be an accepted goal for many men”
I would say that the real goal is to ejaculate. How long it takes for this goal to be achieved depends on many circumstances.
It is a poor argument for pro circ.
Well, when the time comes I think I will be recommending to my son that he make use of condoms rather than editing is anatomy. The slant here seems to be (indirectly) endorsing riding bareback.
Also, this post reads as pretty biased in favour of circ. Perhaps the author should work on her posts of persuasion coming off more impartial and less..well, smug.
I don’t think the case is as self-evident as the author’s tone implies.
Yours,
CBB
“Because its not medically necessary.”
No one claimed it was necessary, merely that it is has medical benefits. In that, it is similar to many other medical decisions that we make for ourselves and our children every single day. It is not “necessary” to be vaccinated, but it is medically beneficial.
I think Harriet’s post on osteoporosis drugs is relevant here. What’s the number needed to treat to prevent one case of these diseases? This, I think, is just as important for a surgical procedure as it is for any drug.
Also, FYI, Harriet has written about this before:
http://www.sciencebasedmedicine.org/?p=269
She mentioned that the NNT for sexually transmitted diseases is 72.
Peter has written on this as well:
http://www.sciencebasedmedicine.org/?p=431
“There are many variations of female genital modification”
And none have any medical benefit at all.
Female genital mutilation is designed to mutilate. The purpose is to deprive women of sexual satisfaction in order to strengthen male power over women.
“It is a poor argument for pro circ.”
I wasn’t making that argument. I was pointing out that what anti-circ activists claim is a downside might just as easily be viewed as an advantage.
“A visitor from outer space might be forgiven for concluding that the most important part of the human body is the foreskin.”
While the reactionary and inflammatory language of the anti-circumcision side is justly identified, so should the condescending language seen here. No one is saying that the foreskin is the “most important” body part.
With respect to the ear-piercing, it’s the same thing, in my personal opinion. I’m against doing anything surgical to my kid(s) that is attractive to me or beneficial in an elective way. When she’s old enough to ask, we’ll talk about it and then deal.
It seems that with the statistics you (Amy) have stated, condoms are better in preventing the STIs and transmission, so they should be used. The exception would be places like Kenya and Uganda where there are wide-spread religious and cultural reasons to not use the most effective modality so to fight HIV, circumcision should be used.
In locations like North America where there are no issues with condom use (apart from personal), the choice to circumcise boys should be the parents’ with the same, unchanged recommendation from the pediatric organizations, again, in my opinion.
“Well, when the time comes I think I will be recommending to my son that he make use of condoms rather than editing is anatomy.”
Great. And other people will make different decisions and different recommendations. The authors of the paper are arguing only that parents be informed of the very real medical benefits of circumcision. You might think those benefits are meaningless, or too small to lead to a decision to circ, but the benefits are real.
“condoms are better in preventing the STIs and transmission, so they should be used.”
Condoms should ALWAYS be used, but unfortunately are often not used. Circumcision provides another form of protection. It doesn’t render condoms unnecessary (particularly for prevention of unwanted pregnancy, obviously) but that doesn’t change the fact that circumcision independently lowers the risk of transmission of HIV and other STDs.
No one claimed it was necessary, merely that it is has medical benefits. In that, it is similar to many other medical decisions that we make for ourselves and our children every single day. It is not “necessary” to be vaccinated, but it is medically beneficial.
Just as long as those benefits aren’t exaggerated, just like breastfeeding benefits are exaggerated at times. And unlike vax diseases, STDs are often contracted due to lifestyle choices (unprotected sex). My sons do not have the choice as to whether or not they sit next to an un-vax’d kid at school or at the playground. They do have the choices as to whether or not to have unprotected sex, or participate in IV drug use.
I would also hate to see us reach a point in this society where a man doesn’t use a condom, thinking that he’s safe because he’s circ’d. Because although the benefit is there, it’s a very small benefit.
And fwiw, dictionary.com defines mutilate as:
1. to injure, disfigure, or make imperfect by removing or irreparably damaging parts: Vandals mutilated the painting.
2. to deprive (a person or animal) of a limb or other essential part.
So while it is certainly a dramatic word, it’s not incorrect to use it.
Also, this phrasing: “”The AAP had long recommended male circumcision for prevention of urinary tract infections in young boys, but backed down in 1999, partly in response to pressure from anti-circumcision activists. “”" makes those of us who don’t circ sound like the anti-vax crowd, when I really don’t think that is an accurate comparison.
“There are many variations of female genital modification”
And none have any medical benefit at all.
Female genital mutilation is designed to mutilate. The purpose is to deprive women of sexual satisfaction in order to strengthen male power over women.
+++++++++++++
Actually, we don’t know that
The possible medical benefits of those forms of female genital modification analogous to male circumcision have not been studied. Since the removal of the male prepuce has been found to have some medical benefits it is quite plausible that the exactly analogous procedure in women might also be found to have some benefits, if it were to be studied.
Moreover, I would have had my sons circumcised even if there were not one shred of evidence that it was medically beneficial since I had it done for purely non-medical reasons. Jews (even cultural ones) are not going to stop circumcising their sons because this or that study shows a statistically significant decrease/increase of this or that – it is a non-medical decision.
Your description of the purpose(s) of female circumcision massively oversimplifies. The proponents of FGM (many of them women) obviously do not regard it as a mutilation, but as something that enhances the status of women. Traditional discourse on male circumcision (e.g. Maimonides) also cite the reduction of sexual pleasure (this is seen as a ‘pro’, since this gives men control over their animal urges). (And if you want a laugh – see Scott Stein here http://whenfallsthecoliseum.com/2008/10/30/circumcision-jewish-conspiracy-theory/ )
Anyway, if you are going to get into this, you do actually have to make the argument and not simply fall back on your cultural prejudices. Many parenting practices are sexist (including the inclusion of male children in the covenant without equivalent recognition of female children) but not criminal. What, specifically, is wrong with Type Ia FGM (removal of the female prepuce) such that it is reasonable to criminalise parents who wish to have this procedure performed?
It has been a major disappointment to see this in sbm.
* There are ‘claims’ that circumsition can somehow reduce the risk of infections the rates’ change seems extremely low however. Condoms are a magnitude more effective and do not involve such change to anatomy.
* How exactly do you do correct trials for circumsition? This is exactly like trialing for acupuncture which has been taken care of by this site multiple times. I think the complaint is still valid in this case.
* “anti-circ” people call it mutilation because it is exactly so. The prepuce is a very sensible sensory organ. The neonats do feel the pain. Besides that this organ is very important in the acquisition of pleasure during intercourse. At the end of the day, I’d rather use a condom…
* This advice sounds exactly like the conservative groups’ advice for abstinence. Instead of recommending the most effective prevention – condoms- we lose time recommending things that , in theory, reduce the risks. But at least we know that abstinence is effective as long as you practice it. In the case of circ, the evidence is still way too blurry and the risk reduction is quite poor.
Possible, but no more dangerous than America’s myriad other deficits of sex ed. Actually, it may provide some comfort that the study above considered this angle, and so far haven’t seen evidence of it, as quoted above:
@Oedipa
“You don’t need the clitoris in order to have intercourse.”
No, only to enjoy it.
Why this phobia of foreskin ? It’s natural part of body.
It’s ridiculous. Circumcision is painful and it’s disturbing. And female circumcision isn’t like removing the entire penis (it’s not even close).
History shows circumcision is a cure in search of a disease. It was supposed to cure :
1832 Nocturnal Emissions
1845 Masturbation
1855 Syphilis
1865 Epilepsy
1870 Proof that circumcision cures epilepsy
1870 Spinal Paralysis
1873 Bed Wetting
1875 Curvature of the spine, Paralysis of the bladder, and clubfoot
1879 Abdominal Neuralgia
1881 Unspecified “eye problems” due to masturbation
1886 Crossed Eyes
1888 Circ as punishment for masturbating
1890 Blindness, Deafness, Dumbness
1894 Keeping blacks from raping whites
1894 Urinary and Rectal Incontinence
1900 Discourage Sexual Immorality
1914 Tuberculosis
1915 Clitoral Hood is the source of neuroses, female circumcision is recommended (Yes. This is the USA)
1918 Female Circ will curb Masturbation
1926 Penile Cancer
1930 Claim of Epilepsy cure from a circumcision (notice the 65 year gap between claim and supposed proof?)
1942 Prostate Cancer
1949 Venereal Disease and Cancer of the Tongue
1951 Male circumcision prevents Cervical Cancer
1954 Cervical Cancer again
1058 “the same reasons that apply for the circumcision of males are generally valid when considered for the female.” CF McDonald
1959 Making Clitoris easier for husband to find
1966 Masters & Johnson claim no difference in sensitivity between intact and severed penises. No proof given.
1969 Nervousness, and of course masturbation (Still with the masturbation and we’re in Viet Nam by now)
1971 Rectal Cancer & Bladder Cancer
1973 Carcinoma
1975 AAP declares circumcision has no medical indications, and does not recommend it
1976 Benjamin Spock: “I strongly recommend leaving the foreskin alone. Parents should insist on convincing reasons for circumcision — and there are no convincing reasons that I know of.”
1985 Urinary Tract Infection
1986 AIDS
1988 Group B Streptococcal Disease
1989 AAP Reverses circumcision policy, and recommends it when Dr Edgar Schoen (known circumcisionist) presides over board.
1991 Schoen tries and fails to get European countries to circumcise en masse
1991 For sand in soldier’s foreskins (Desert Storm time)
1997 Schoen once again tries and fails to chop off european dicks
1996 JR Taylor finds that the average amount of removed foreskin is nearly half of penile skin.
1997 Janice Lender discovers that circumcision without anesthesia is traumatic.
1999 JR Taylor: foreskin “… a primary erogenous tissue necessary for normal sexual function.”
1999 AAP after 40 years of research, reverses policy again..”potential medical benefits of newborn male circumcision… are not sufficient to recommend routine neonatal circumcision.” Hygiene “there is little evidence to affirm the association between circumcision status and optimum penile hygiene.” STDs “behavioral factors appear to be far more important than circumcision status.” Cancer “in a developed country such as the United States, penile cancer is a rare disease and the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, is low.” UTIs “breastfeeding was shown to have a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status.” Ethics “is not essential to the child’s current well-being”
2003 Edgar Schoen tries to pressure AAP to reverse it’s policy his way, claiming it prevents AIDS.
2005 HIV rates are lower in females who have been FGM’d
2007 The infamous Bailey/Auvert study … touting circumcision as a ‘vaccine’ that prevents HIV infection.
2007 Langerhans Cells in the foreskin are found to to be a natural barrier to HIV
2007 M Sorrels releases study that finds the foreskin the most sensitive art of the penis and the glans the least.
Most authors of pro-circumcision studies claim that they have no vested interests in their work. However, when we examine who conducted these studies – their motives become evident. These studies are usually done by circumcised males who try to validate their own circumcision and legitimize the practice. Doctors who circumcise must protect their reputations and careers. Statements to the effect by the authors that they have no vested interest in conducting these studies are merely a facade to provide credibility to their research. It doesn’t take a great genius to see the obvious conflict of interest.
I don’t think it’s up to parents to decide if a child is allowed (or not) to keep healthy and erogenous tissues. Infant circumcision should be banned unless there’s a solid medical reason and all other less invasive treatments have failed.
Most parents are mislead into thinking circumcision is healthier. This isn’t true. Circumcision is medical fraud.
@provaxmom
“1. to injure, disfigure, or make imperfect by removing or irreparably damaging parts: Vandals mutilated the painting.
2. to deprive (a person or animal) of a limb or other essential part. ”
Does removal of the foreskin:
Injure? No, it offers some protection against disease.
Disfigure? I suppose that is a matter of opinion.
Make imperfect? Again, a matter of opinion
Deprive of an essential part? Hardly.
Mutilate is a word used in this context to inflame rather than to explain.
That said, I fail to understand the rush to clip. If the literature demonstrated some huge, positive protection against a plague of dangerous adolescent UTIs then an argument could be mounted in favor of circumcision. But as I understand it the benefits, such as they are, accrue only to the sexually active and their partners.
I for one would be more than disturbed to learn that a 6 year old son was having a hot affair. Circumcision pro and con could as easily be presented as part of sex education at an appropriate age and the choice made by the owner of the aforementioned foreskin.
I think this post shows a fairly clear lack of critical analysis from a cost/benefit perspective. That circumcision has some benefits is fairly clear. The benefits are not, by any measure, earth shattering. Since the benefits are marginal risk reduction, shouldn’t a real look at the risks be offered? I’m not saying specifically that the risks outweigh the benefits, but the fact that there are entirely omitted from this post is a glaring omission.
This doesn’t even touch the ethical basis, in that the majority of the benefits of circumcision do not occur until after a male would be old enough to make this decision for themselves. There is little justification for the loss of autonomy by a parent making a decision for a child as a baby that could be left until they are old enough to at least have input in the decision. This is obviously not true with vaccines, so it is a specious analog to the autonomy issues raised.
There would seem to be some evolutionary advantage to the foreskin, though I can’t imagine what it might be. Does anyone know or care to speculate?
Or perhaps it is simply vestigial?
*If* there are clinically significant benefits (which has not been demonstrated) then the risks of the procedure may be reduced by it being performed in the neonatal period, rather than during adolescence.
“the possible medical benefits of those forms of female genital modification analogous to male circumcision have not been studied.”
And therefore you cannot make claims about their existence.
@Nick
If you’re going to post putative facts complete with dates, how about citing a source so that those of us with a cynical bent can check for ourselves?
Further, when you make statements like:
“Circumcision is painful and it’s disturbing.” Disturbing? To whom and in what way?
and more egregious still:
“And female circumcision isn’t like removing the entire penis (it’s not even close).” Yes Nick, it is in most cases EXACTLY like removing the entire penis.
and from bad to childish:
“1997 Schoen once again tries and fails to chop off european dicks.” The use of gutter slang in a serous discussion is inappropriate.
You mark yourself as someone disinclined to serious discourse.
“Condoms are a magnitude more effective and do not involve such change to anatomy.”
Why do you view it as an either-or choice? The benefits of condoms are only available when they are used. In contrast, the benefits of circumcision are always present.
“How exactly do you do correct trials for circumsition?”
You cannot correct RCTs, but RCTs are not the only studies that provide valuable and valid information.
“This advice sounds exactly like the conservative groups’ advice for abstinence.”
Actually, it is the anti-circ folks who sound most like the abstinence folks. Those advocating abstinence point out that it is 100% effective at preventing pregnancy and STDs. And the rest of us point out that 100% abstinence is not likely to happen in the real world.
Similarly, anti-circ activists point out that condoms are effective in preventing transmission of STDs. However, 100% condom use is not likely to happen in the real world.
Amy,
I can’t help but notice that you STILL haven’t responded to the repeatedly raised question, “why INFANT circumcision?” What is the rationale for circumcision of infants, as opposed to letting them make their own decision later in life?
The fact that parents can make such decisions on behalf of an infant doesn’t necessarily mean that they should. There are clear and compelling benefits to waiting. Therefore there need to be clear and compelling benefits to NOT waiting in order for that to be a justifiable choice. You haven’t provided any.
“I can’t help but notice that you STILL haven’t responded to the repeatedly raised question, “why INFANT circumcision?”
This post is not about defending circumcision. It is an explanation of the current state of research on the reduction in transmission of HIV and other STDs by circumcision.
If you don’t want to circumcise your sons, don’t do it. If you don’t think the benefits outweigh the risks, don’t do it. Just don’t claim that there are no medical benefits when there are real benefits.
I did not make any claims about their existence. I merely observed that since the removal of the male prepuce has some medical benefits, it is plausible that the removal of the analogous structure in women may also have some (as yet unknown) medical benefits.
Contrast with your own statement “And none have any medical benefit at all.” If you had said “And none have been shown to have any medical benefit” you would have been correct. It is also the case that, while we have copious evidence on the harm done by more extensive FGM, no research into the specific harms (and any possible benefits) of the removal of the prepuce only informed the decision to criminalise this procedure.
So, I ask again, what, specifically, is wrong with Type Ia FGM (removal of the female prepuce) such that it is reasonable to criminalise parents who wish to have this procedure performed?
Amy said: “It is not “necessary” to be vaccinated, but it is medically beneficial.”
I would expect that Amy would understand that there is a chasm of difference between a vaccination and a circumcision. For one, a vaccination is typically the cheapest, most efficient, safest, and frequently the only way to gain a particular benefit. Circumcision almost never meets any of these criteria let alone most or all of them.
I don’t, for example, know any other reasonable way to protect a child from measles other than a vaccination. On the other hand, as has alread been pointed out, there are far better ways to protect from STDs.
“This post is not about defending circumcision.”
That is an odd claim to a post titled “The case for neonatal circumcision.”
One of the expectations I’ve always had for this blog is that the views provided are balanced. When an issue is raised, it is covered in a reasonable perspective, discussing things like risk and practical and ethical implications. Many of the posts on here discussing vaccines cover the (albeit small) risks of vaccination. How can you make a balanced case when you say “Here are the benefits, now go form an opinion?”
Please try to be a little more reasonable in your discourse. The ability to see shades of gray and deal with real world complexities is what separates us from the woo peddlers.
Please – can anyone tell me the location(s) of the population studied and whether or not the population was controlled for condom use?
Given the intervening comments, my comment above would have been clearer had I begun
“I did not make any claim that there are medical benefits for Type Ia FGM.”
Amy said: ““the possible medical benefits of those forms of female genital modification analogous to male circumcision have not been studied.”
And therefore you cannot make claims about their existence.”
Actually, Stallings et. al. IAS 2005 did find that “circumcised” women in Tanzinia had a significantly lower risk of contracting HIV too. Couriously, they called this a “conundrum” and nobody cared to follow it up.
@Scott
I also see no compelling reason for ‘infant’. If there is a “benefit” to circumcision then present your case to the individual when they can make an informed choice. Particularly when you’re talking about benefits that have nothing to do with the infant or child’s health. That is the only ethical approach.
@windriven :
If male circumcision wasn’t socially acceptable, common sense should tell you that removing a natural part of body isn’t the right thing to do. (especially without consent)
It’s obvious that this procedure is unnatural. It’s a religious practice that became medicalized.
The foreskin is supposed to be there, it’s not a birth defect and there’s nothing wrong with it. There are a ton of men (including myself) who are unhappy with a circumcised penis. I strongly feel it wasn’t up to my parents to make this decision. I have been restoring my foreskin for almost 2 years now and it enables me to get back a ton of sensitivity :
http://www3.interscience.wiley.com/journal/118508429/abstract?CRETRY=1&SRETRY=0
Also, where did you see that “in most cases”, female circumcision is like removing the entire penis ? Do you have any statistic ? And if removing the clitoral hood is banned because it violates basic human rights, can you tell why infant circumcision is still allowed ? Because the inner foreskin has far more nerve ending than the clitoral hood.
Studies claiming male circumcision has health benefits are debatable at best. It is said that it reduces HIV by 55%. Why the USA has both the highest rates of circumcison and HIV among industrialized countries ? Why other countries like Sweden or Japon have both very low rate of HIV and circumcision ,
If you want more information about history of circumcision in US, you can make your own research. It just takes a couple of minutes to realize it’s cure in search of a problem. You can start by reading that :
http://www.historyofcircumcision.net/index.php?option=content&task=view&id=31
In light of:
I don’t think you can duck the issue that way. The current policy as quoted by the paper:
The change you are endorsing is apparently that the policy should state that the data are sufficient to recommend routine neonatal circumcision. But unless there are data showing that neonatal circumcision has specific benefits that circumcision later in life does not, then that is not true and the current policy remains accurate.
The AMA recommending circumcision prior to becoming sexually active would be justifiable based on the data presented. But not the AAP recommending neonatal circumcision.
there are two issues here
a) the reviewed medical benefits/risks concerning male circumcision
b) the question of whether it is sensible for medical institutions to advise parents to have it performed
Concerning A:
I think that research in recent years has shown that overall (especially in less developed countries) male circumcision does have tangible benefits when it comes to lowering the risks for STD. These effects are clinically relevant when one considers them in the context of unprotected sex. Of course, when one wears a condom these benefits disappear… as has been pointed out previously. Now while it is true that a condom “comes off” but circumcision is forever there is only a special subset of cases where circumcision would make a real benefit to lower the rates of say HIV infections:
- it is certainly not in those who practice safe sex
- it is also not in those who practice unsafe sex regularly with multiple partners (they will get infected perhaps only with somewhat of a temporal delay)
- circumcision would probably help reduce infection rates in groups of people who “occassionally” (rarely) perhaps have unprotected intercourse.
This is my personal opinion given what I know of infectious diseases. It would be nice if one could ascribe exact numbers to this and perhaps run a few simulations to see just what kind of an effect circumcision would have in certain countries.
I suspect a generalized circumcision program say in some African country would lower infection rates quite a bit more than say in some European country.. since in the latter condom usage is mostly higher.
Concerning B:
This is more or less a value judgment and one needs to separate it from basic science so you do confuse the issues. In my own personal opinion the supposed benefits of circumcision are not nearly enough to warrant a recommendation for such an operation on infants in, say my region – Europe.
If I were however practicing in Nigeria, I would have to reevaluate this stance based on what the local populus does, how high the rates of STDs are, how much condoms are used etc.
If I were practicing in the US, I also would not recommend such a procedure because just like in Europe, simply educating on safe sex and promoting condom usage is far far more effective in my opinion.
We would have to look at this procedure in terms of NNT (numner needed to treat) – that is how many people do we have to have circumcised to prevent say a certain number of STD infections. I have yet to see decent numbers on this topic. Any formal medical recommendation should be based on the comparison of this NNT against the % of possible circumcision related side effects.
For those who are hopping mad about their circumcision, foreskin restoration is there for you. Rejoice smegmates – let Google Image show you the way…
I am in full agreement with provaxmom. You can’t look at reduction in the disease without also looking at the prevalence of the disease. It is misleading to say that there is a reduction of 60% (or whatever) without also looking at how often the disease occurs. Or Dr. Gorski’s NNTT.
Thankfully, circ rates in Europe are well below 50% and the U.S. I believe are right around 50% and plummeting. And yet, there has been no increase in HIV that I’m aware of. There’s a big difference between STDs in Africa and here.
Furthermore, the authors and Dr. Tuteur are advocating that ACOG, AMA, and AAP change their policies to RECOMMEND infant circumcision. This is not just a matter of presenting it to parents as an option- that is what is done now. And apparently it’s not good enough.
This is just another example of Dr. Tuteur’s extremist, out dated, and unsupported by evidence views on current policies. I have to say that every single doctor who examined by sons (in the early 2000s) said some variation of “Good. It’s not necessary.” or “I’m glad to see you didn’t circumcise.” These were almost exclusively males.
Please see Dr. Hall’s blog for a more reasoned exploration of the debate.
A pertinent point, especially in light of Amy’s reluctance to answer the question about “why *infant* circumcision”? Her title indicates that she is specifically talking about the circumcision of infants, which would suggest that the article would contain something of relevance as far as circumcising as young as possible.
I had no sons, so luckily did not have to make this choice. My husband is in favor of infant circumcision.
Interestingly, my grandfather is also in favor of infant circumcision. He is himself uncircumcised. I have never really felt comfortable asking him for his rationale; it’s an awkward topic to discuss with one’s elders. I am ambivalent about it myself; I would likely have formed a better opinion had ultrasounds not revealed the absence of relevant anatomy on my children. It was something of a relief not to have to think about it, to be honest.
As far as female genital mutilation, numbers are not consistent so it is difficult to tell what the true rate of various procedures are, largely because it is primarily practiced in regions without consistent reporting and usually performed by non-medical personnel. It definitely has higher complication rates than male circumcision. (BTW, I think the term “circumcision” is odd for female genital mutilation, mostly because the word literally means cutting around the circumference, and that’s not really descriptive of the female procedure.)
Both male and female procedures were originally designed to limit sexual desire, for a variety of reasons. Yes, they wanted to reduce *male* sexual desire as well, and a parent wanting to control his sons would want them circumcised if this would help in that effort. There are also factors of ethnic identity, not just in Judaism but in many groups. In some parts of Africa where various forms of genital modification are practiced, it is not done at infancy but rather at puberty as part of a coming-of-age ritual. To become a man or a woman, and ready for marriage.
It is not surprising that there are some modest health benefits. But I still fail to see why it is better to do it as an infant rather than later in life. The one thing I am sure of is that it is absolutely abhorrent that until recently, it was common practice to do it without anesthesia or post-operative pain relief. Okay, I can kinda understand the religious aspects of that, but doctors should not be complicit in that. No, the baby won’t remember the pain ten years later. But the baby feels the pain *now*, and that ought to be significant. If the risks of pain relief and local anesthesia are too great in a newborn, maybe they should consider whether it’s really worth doing it right now anyway.
Dr. Tuteur:
“This post is not about defending circumcision.”
Pattoye:
“That is an odd claim to a post titled “The case for neonatal circumcision.”
LOL! Seriously, this is like the fifth direct contradiction in two months between the blog posts and Dr. Tuteur’s comments. Really bizarre.
I can’t believe all the fallacies I’ve counted reading these comments. I expect more from this audience.
So far (that I’ve noticed):
-False dichotomy (condom vs circumcision)
-Appeal to nature (It’s unnatural to remove the foreskin)
-Appeal to emotion (Calling it mutilation)
-False equivocation (Comparing it to removing a leg or female circumcision)
-Appeals to anecdotes
I suspect that many skeptics are not thinking very rationally on this issue due to its association with religion.
This is a debate worth having, but please try to use valid arguments and avoid inflammatory rhetoric. It really reads like people are taking this issue personally.
Thank you for also adding argument from fallacy to the list.
If condoms are a lot more effective against STDs, specifically AIDS than circumcision. How is it worth doing it? Also, how is it not mutilation? This article is of pseudo-scientific nature first appealing to using AIDS as a scare (which is not too effective as condoms are a lot more effective than that) and at the end trying to appeal to authority and also indures on false equivocation itself by trying to put people who oppose to circumcision in an equal level to anti vaccine nuts. It seriously harms SBM’s reputation.
How can these studies be believable at all? You cannot make double blind tests with circumcision. I also think that exposing humans to having intercourse with people that have infections or AIDS would not be humane. All the studies seem to do is measure infection rates between circumcised people and non-circumcised people which would not really be scientific at all.
What we have here is an article that advices a surgical procedure that removes a part of the body that increases the sensory experience of intercourse stating that there are dubious trials that demonstrate doing this can mildly reduce the rates. While there is already a solution for STDs and AIDS that is a lot more effective and without permanent effects.
You are right though that the only reason humans have started doing it is related to religious beliefs and also some conservative groups that would think it would stop masturbation. It is the only way such great idea would come to pass and we wouldn’t have these ’studies’ if it weren’t for such irrational reasons. It is fairy science all over again.
“That is an odd claim to a post titled “The case for neonatal circumcision.”
That’s the subtitle of the scientific paper.
“False dichotomy (condom vs circumcision)”
Condoms are cheaper and much more effective than circumcision. Not to mention these African studies are flawed in many ways. Please note than infants and children aren’t sexually active so that doesn’t justify neonatal circumcision. HIV is another poor excuse to justify a barbaric procedure (please read my post about history of circumcision).
“Appeal to nature (It’s unnatural to remove the foreskin)”
I don’t see any problem with that. Foreskin is nautral part of body and is supposed to be there.
“Appeal to emotion (Calling it mutilation)”
I don’t have any problems with emotions, we aren’t robots, are we ? Have you ever watched a video of infant circumcision ?
Also appeal to emotion has been also used in this article : “Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure.”
This seems exaggerated, if not completly incorrect.
And circumcision is mutilation.
“False equivocation (Comparing it to removing a leg or female circumcision)”
Please reread the different posts. There are many types of female circumcision. Some types are equivalent or less invasive than male circumcision. But all types of female circumcision are banned because they all violate bodily integrity and cause harm. So why male circumcision isn’t banned yet ?
You could have fooled me. That’s certainly how it came across to me when I read it. Indeed, the wag in me can’t resist asking: If your post isn’t a defense of infant circumcision, why entitle it “The Case for Neonatal Circumcision” even if it is the title of the paper you’re discussing and especially given that there was no discussion of a risk-benefit ratio? I don’t deny that circumcision likely has benefits, but given the aforementioned NNT, are they worth the risks (even relatively small ones) and the need to do 72 circumcisions to prevent one case of STI?
Now, it’s entirely valid to present the case for circumcision in a single post, but isn’t presenting the case for circumcision in essence defending it, particularly given the glowing first sentence about stamping out disease, the dismissive references to the “anti-circ” crowd, and your final sentence, in which you state bluntly that the AAP should heed the authors’ call,” presumably to change its position statement stating that the evidence doesn’t justify recommending routine circumcision of neonates to parents? What is that if not defending neonatal circumcision, at least implicitly? Why deny that that’s what you were doing? There’s nothing wrong with taking a position, as long as it’s clear what your position is and you back it up with evidence.
““That is an odd claim to a post titled “The case for neonatal circumcision.”
That’s the subtitle of the scientific paper.”
That’s dodging the original claim that your post is not in defense of circumcision.
You open with a sentence that all but endorses circumcusion as a minor surgical procedure that can save lives from a dread and often fatal disease. That certainly sounds like a defense of circumcision to me.
You close with the sentence “The AAP should heed the authors’ call” to update its circumcision recommendations to more strongly support circumcision.
I’d say your position is clear. There is nothing wrong with having a clear position. Unless, of course, you then try to say that it isn’t your position at all. I’m baffled as to why you would even make that argument.
I am “anti-circ” as that seems to be the derrogatory term of choice today. However, I think that if these claims were true (and I don’t agree the studies mentioned are doing science right) then it would be an argument for neonatal circumsition since in theory, adult circumcision is a much more complicated and risky procedure.
“HIV is another poor excuse to justify a barbaric procedure ”
It is the single poorest excuse since circumcised males still need to use a condom to protect themselves against AIDS. However, as barbaric as it is it is not necessary to appeal to that fact to show that circumcision is definitely not necessary.
“I don’t have a problem with emotions”
Well the thing is that they aren’t a scientific argument. So appealing to emotions does not really help to justify the argument.
I don’t . I do see that even if the “studies” named were reliable the small rate decrease will require me to still use a condom even if I was circumside.
Unfortunately , the studies have failed to demonstrate beyond doubt that these benefits exist at all. They did demonstrate that even if they did exist I would still need to use a condom when circumcised.
It sounds unnecessary. I also think that maybe there are chances an uncircumcised guy did not receive the important teaching that he needs to clean it up. There are no studies that ensure that we are comparing circumcised males and uncircumcised males that practice hygiene…
JurijD said: “I think that research in recent years has shown that overall (especially in less developed countries) ”
And indeed this is what the recommendation from the WHO and UNAIDS has indicated, that circumcision should be considered as a potential intervention for HIV where there is high prevalence and the epidemic is not focused in a particular population. This would exclude most countries including the US and those in Europe.
One must also consider the ethics of such an intervention, something which Amy in her many posts on this subject consistently ignores.
On the “condom-circumcision” false dichotomy issue
A number of commenters and Amy herself have asserted that bringing condoms into this debate somehow constitutes a case of the false dichotomy fallacy. I do not believe this is the case for how most people formulated the argument (myself included) and here is why:
saying just “circumcision is not warranted as we have condoms that offer more protection” could be considered a false dichotomy as one could argue that performing circumcision alongside wearing a condom is perfectly possible but this ignores all the baggage that comes with both of these two options.
Circumcision is not just an added procedure with no risks to it. As performed usually (religiously) it does cause pain and suffering to infants and while this could be prevented by having the procedure performed only in hospitals under anesthesia there are other risks that are common to all operative procedures: risks of infections, scarring, genital mutilation etc. On top of that I am not convinced that the available literature can give a decent enough guarantee that removing the foreskin does not lessen sexual pleasure in men. It does seem to lean in that direction but we have to set the bar much higher if we plan on cutting away a perfectly functioning part of the male anatomy in the hope of some future benefits.
There is really no false dichotomy here. One cannot just casually perform circumcision with the rationale that it lowers STD risks while claiming that those who point out that we have a more effective way of doing that with no operative risks attached, are making a false dichotomy fallacy.
We DO have an excellent way of preventing STDs – condoms. They do not require us to impose operative risks on children and then also do not require us to possibly risk diminishing their future sexual pleasure to gain what is only a partial decrease of STD infection risk. If this were not the case the circumcision option would be far more appealing.
It can be logically argued then that in light of this non-invasive option, circumcision is simply not justified for the benefits attributed to it and in light of the fact that it is not risk-free.
It would however be greatly beneficial to have hard numbers here: NNT for circumcision related STD risk reduction (in say western countries), % circumcision related adverse effects, and the prevalence of condom usage.
If such data was available and it pointed strongly towards circumcisions lowering the risk of STDs while having only an insignificant number of adverse effects in the whole NNT population IN western countries then a case could be made for a general recommendation to have males circumcised.
The question of whether one is justified in performing this operation on infants is another matter entirely.
But currently I tend to err on the side of caution and not promote an operative procedure with questionable benefits in a real-life European scenario and real adverse effects – in the complete absence of hard data on the issue.
“adult circumcision is a much more complicated and risky procedure.”
Where did you see than it’s much more complicated and risky for an adult ? Do you have some studies to support that position ?
I would think it’s the opposite. During infancy, the foreskin is fused to the glans whereas for an adult, the foreskin is already retracted making the amputation more easier. Also the foreskin is bigger, the procedure can be performed with greater precision, it can be a loose/tight etc… cut whereas for an infant the result is more random. ALso adults are under genral anesthesia, they don’t feel anything during the procedure. So it’s more uncomfortable than painful.
“adult circumcision is a much more complicated and risky procedure.”
Where did you see than it’s much more complicated and risky for an adult ? Do you have some studies to support that position ?
I would think it’s the opposite. During infancy, the foreskin is fused to the glans whereas for an adult, the foreskin is already retracted making the amputation easier. Also the foreskin is bigger, the procedure can be performed with greater precision, it can be a loose/tight etc… cut whereas for an infant the result is more random. ALso adults are under genral anesthesia, they don’t feel anything during the procedure. So it’s more uncomfortable than painful.
Regarding a commenter who pointed out the potential for decreased sexual sensitivity in men, Dr. Teuter responded,
I have to ask by what authority does anyone have that can claim a) how much sensitivity is ideal b) why “lasting longer” is necessarily desirable for all men, c) whose business is it that men should have decreased sensitivity anyway? Some men last too long, and cannot climax because of too little sensitivity. I worry that a forced procedure would contribute to that problem even more.
In contrast, another commenter brought up the (barbaric) practice of female genital mutilation, to which Dr. Teuter (rightly) responded,
I admit to some cognitive dissonance here, and I’m hoping Dr. Teuter could clear this up. Why is decreasing sexual sensation in men okay but not okay in women? I understand that part of it is a level of degree (in women it’s intended as total removal of sexual sensation), but that doesn’t appear to be the argument, which is about having sexual sensation in general.
It seems to border on hypocritical and I’d like this apparent conflict cleared up please. Thanks.
johnnyeh wrote:
“So far (that I’ve noticed):
-Appeal to nature (It’s unnatural to remove the foreskin)”
But it is unnatural. Please give me another socially and medically accepted example of where we surgically remove body parts without serious justification.
Why don’t we just start removing gall bladders, appendices and spleens, and routinely do double mastectomies? Then we would have zero appendicitis, spleen and gall bladder disease, and we could effectively reduce breast cancer to zero. After all, we know that we can live without them, right?
“How can these studies be believable at all? You cannot make double blind tests with circumcision. ”
There are many instances where double blinding cannot occur. Still studies must be done and taken on their merits. It is a limitation sure, but studies shouldn’t be dismissed because of it.
I think the scientifically supported position should be to recommend AGAINST routine newborn circumcision, and discuss it as an option to adults.
You need to watch out for the way comparisons are made between adult and infant circumcision. I remember one study I read on the WHO AIDS page said that adults had more complications but then I looked at the criteria and the adults figures included “pain” while the infants did not!
Also, many infant complication numbers do not include things like metal stenosis or webbed penis.
sorry that should read “meatal stenosis”
“I remember one study I read on the WHO AIDS page said that adults had more complications but then I looked at the criteria and the adults figures included “pain” while the infants did not!”
For a long time doctors used to think infants didn’t feel pain. No, we know it’s untrue. In fact, they may be far more sensitive to pain. There are a decent number of studies showing infant have long term consequences for the future adult :
http://www.sciencedaily.com/releases/1999/08/990816065623.htm
http://www.circumcision.org/response.htm
“Also, many infant complication numbers do not include things like metal stenosis or webbed penis.”
Of course they do.
Amy I see you are an Ob/Gyn.
You do seem to be clutching at straws looking for the benefit.
A reduction in infection rates of 10-15% is not significant enough to allow any scientist to claim a benefit in face of the risks and potential complications. After all you are talking about clinical amputation.
Furthermore, to make the claim that there may be a benefit because men might last longer is nothing short of scandalous from a medical professional.
On the balance of probabilities, it is far more likely that surgical amputation upon the penis is equally or even more likely to create dysfunction.
But given your profession, I see where you’re coming from in this.
Given some people’s stridency on the right to circumcise, I can only see a few justifications:
1) cognitive dissonance – i.e. they have participated in performing it, or themselves have suffered it, and must make the case to themselves that there is nothing wrong with taking knives to any young boy’s penises;
2) religious indoctrination;
3) castration fantasies.
The argument that the child has no right to their body integrity is completely unsupportable. The parent simply does not have a right to circumcise their child, male or female. They should not bind the feet of their child.
We could save a lot of lives if we mandatorily circumcised breasts, and indeed nobody would get HIV at all if you just lopped the entire thing off!
However it is fundamentally a crime against the rights of a child to do body modifications upon them without their consent.
You aren’t saving anyone, you are merely justifying the act of circumcision and violations of the rights of the child post-fact.
Some may see it as quite unfortunate that the scientific evidence is not in line with politically correct thinking on the subject of circumcision, but that doesn’t change the scientific evidence.
Would anyone like to discuss the actual evidence? An argument can be constructed that the benefits in a low risk population do not justify the World Health Organization recommendation for circumcision, but I haven’t seen that argument. Instead there is a lot of opinion on why other people should not circumcise their sons.
Forget the false (and in my judgment misogynistic) attempts to equate FMG and male circumcision. Forget the naturalistic fallacy that the existence of the foreskin means that it must be “good.” Let’s talk about the evidence of whether circumcision decreases the transmission of HIV and other STDs and how that may translate into fewer deaths, less disease, less female infertility, and decreased cervical cancer.
This debate is getting heated because of the lack of proper facts.
1: Raw risk/benefit ratio. How many circumcisions have complications and how often does it result in protections from STI that couldn’t becured with simple antibiotics?
2: Ethics. Does a (possible) medical benefit warrant an ethically questionable practice? Is it OK to steal from the rich if it’s for the poor, or is it still stealing? Would you kill your wife if it could save your child? 5 children? 100 children? Is it OK to clean up our genome by sterilising the genetically sick? It’s a question of utilitarism, and to answer it we need to quantify harm done by circumcising (both physical, psychic, to autonomy, human rights etc) and benefit acquired, and discuss it WITHOUT religious and cultural bias. This is the tough one…
3: Quality of the studies that support circumcisions. How long was the follow-up? Were they based on self-reporting of sexual activity in religious individuals? Difference in condom-use before/after? Bias of the authors? This is the most interresting thing, and it is what I’d come to expect being answered in a SBM entry. I strongly suspect that the studies are questionable at best, but I’d like to see someone smarter than me point it out. If the science isn’t good, then there is no question that the medicalization of circumcision was fueled by religious and cultural bias and should be treated as such (eg. with disdain)
There is a huge amount of bias from both sides. Pro side won’t admit that it would be the same as performing prophylactic neonatal appendectomy, and con side won’t admit that there may be a benefit that would warrant routine circumcision of boys in countries, where it’s the only preventative measure other than abstinence that the church (and therefore state) will allow.
Still, there is no medical reason to do it while they are infants, other than the fact that it would be cheaper, and infants don’t remember pain anyway (Or do they? Studies anyone?)…
Imagine if noone in the world ever thought about cutting off the foreskin – would we begin doing it with the kind of evidence at hand now? That’s how most Europeans feel about this.
“This debate is getting heated because of the lack of proper facts.”
Yes, and I’m waiting for the anti-circ folks to present some numbers, as opposed to personal opinions.
Dr Teuter, I wasn’t equating male and female circumcision (though others certainly were), I was merely asking why you think that decreasing sexual sensation in men is okay (just so that they can supposedly “last longer”) but not okay in women (of course a clitorectomy is barbaric….I don’t think anyone was suggesting that the two are equal procedures). Cognitive Dissonance: I haz it.
“Let’s talk about the evidence of whether circumcision decreases the transmission of HIV and other STDs and how that may translate into fewer deaths, less disease, less female infertility, and decreased cervical cancer.”
what exactly is your evidence that in a western country with a low prevalence of STDs and high condom usage a general circumcision would lead to reduced deaths and less disease ?
What is the NNT for circumcision in say the US (or Europe) to prevent a single HIV infection ?
What are all the possible adverse side effect applied to that NNT ?
What is your data that circumcising infants specifically and not say young adults is needed?
I’ve never seen data like that, if I do perhaps I’ll change my position that circumcision is not justified in countries with low STD rates and good sexual education (high condom usage).
I understand that some complication rate studies do look at meatal stenosis but others do not, which is why I simply said you have to be careful about the comparison and make sure you look at what is included in the numbers.
@Johnny_eh
I’m with you, buddy. This debate has gone off into the weeds where emotion and partisanship prevail.
@DevoutCatalyst
“Rejoice smegmates – let Google Image show you the way…”
I’ll forward my dry cleaning bill to you but a few papers on my desk have been damaged beyond reclaim.
The other issue worth raising is the difference between efficacy as measured in clinical trials, and real-world effectiveness. The risk of transmitting a blood borne infection is present in any surgical procedure, and lots of precautions are taken in light of this fact.
Now translate that not to the context of a well-funded clinical trial, but to the real world of countries with very restricted access to trained health care professionals and disposable/sterile equipment.
“Forget the false (and in my judgment misogynistic) attempts to equate FMG and male circumcision.”
It was already said that there are MANY types of FGM. Some of them are the same and even less invasive than male circumcision. But all forms of FGM are banned.
“Forget the naturalistic fallacy that the existence of the foreskin means that it must be “good.” ”
Why is it fallacy ? It seems logic (like 2+2=4, the basics of science) that if you are born with, it is there for a reason and shouldn’t be removed. Why do you want to forget that ? Why not studying the role of foreskin instead of always finding a new excuse to remove it ?
Do you know the history of circumcision in US ? Why this phobia of foreskin ?
Let’s look at the backgrounds of the doctors who are conducting these studies. How many are long-standing circumcision advocates who have failed to make an association between circumcision and other diseases? How many are Jewish?
Are these people REALLY interested in “HIV reduction,” or are they interested in circumcision evangelization?
I think it’s about time we outlawed all of these circumcision “studies.” They’re not looking for a solution to a problem, they’re looking for problems to legitimize their pre-determined “solution.”
“This debate is getting heated because of the lack of proper facts.”
Even if these pseudo scientific studies claiming circumcision prevent HIV by 55% were true, that still doesn’t justify neonatal circumcision. However, I’ve nothing against adult circumcision with consent if someone thniks it will protect him from AIDS.
My main point here is to question why Dr. Tuteur suggested (and still holds to it) that the AAP change its position with respect to neonatal circumcision when the situation with respect to education and disease prevalance contrasted with certain African countries is obviously different.
Making pre-sexually-active circumcision routine in high HIV-rate/low condom use countries makes sense, but in North America it does not and the AAP’s position statement refects this.
Please clarify the need to change the policy in light of this, if you would.
Would anyone like to discuss the actual evidence?
++++++++++++
Yes, and that’s what I’ve asked from right at the top of this comment thread.
“First, the AAP had “long recommended male circumcision for prevention of urinary tract infections in young boys.” But no mention of whether they were correct in doing so. What does science have to say on this subject?
Second, the AAP “backed down in 1999, partly in response to pressure from anti-circumcision activists”. I would like to see some evidence to support this statement.”
Any chance of a response?
Only a doctor could advise someone to a amputate part of their child’s body to decrease the risk HIV – of a disease for which that child will never be at risk. Amazing!
@Sid Offit
Only a doctor? I can think of a few more professions which advocate it…..some with the precise surgical tools of a Rabbi’s teeth!
http://intactbydefault.blogspot.com/2010/01/dr-amy-tuteurs-cloudy-view-of-newborn.html
Actually, the WHO states that circumcision as it pertains to HIV is a targeted intervention. From the French National Council on AIDS:
http://www.cns.sante.fr/IMG/pdf/2007-05-24_rap_en_politique_internationale.pdf
“The same measures are not applicable to the Northern countries. The recommendations of the WHO state that this strategy is aimed
at countries with high prevalence, and not at countries with low prevalence or in countries where it relates specifically to one part of the population such as in France or the United States.”
This seems a reasonable application of the information I am still waiting to hear though how Amy can believe that such a recommendation would be useful in a country where the prevalence is low and the vast majority of transmission occurs in a population where circumcision has not shown to provided much (if any) benefit.
I agree with others who are posting that this subject was presented without enough reference to the research which might go against circumcision.
However, there is a point I would like to see some of the vociferous opponents to circucision posting here who seem to view this in absolutist terms as human rights issue, address. Most specifically: how do you view the use of routine circumcision in a country where the HIV prevalence rate is more than 25%, anti-virals are expensive and in short supply and culturally, condom use is viewed as taboo and has failed to take hold despite years of effort? There are currently four such countries and many more follow closely behind at 15+%prevalence rates. With rates this high and the lack of condom use, circumcision appears to be a way to save live. There are people who give their lives for the greater good and the the science proves out, I would have no problem with my child giving up his foreskin for the greater good.
And there are significantly less risks/negatives for neonatal vs adult circumcision – if you are going to circumsize. These risks include: increased risk of bleeding, the need to often use general anesthesia and its inherent risk and not to mention cost differences.
The bottom line is that parents should get to recieve ALL the information about potential risks and benefits of a given procedure and then make an informed decision.
I remember your post on the eugenics / “natural” birth connection.
You should use the same vigor to pursue the anti-sex / Victorian mindset behind circumcision.
“Any chance of a response?”
Wouldn’t hold your breath.
Ironically, there was no “science” in the original post. Dr. Tuteur posted a review of previous studies- author opinion. Were these studies conducted in the U.S (no)? Were they even conducted in a first world country or continent? Were the RCTs double blinded (no)? How many subjects were there (I don’t know)? What is the absolute vs relative risk (very low absolute)? What is the NNTT (fairly high)? What are the risks of the procedure (varied)? Should they be done on neonates or adults? How on earth are these not scientific objections?
Dr. Tuteur, did you even read the studies, or did you just post a review (not even a meta-analysis) as confirmation bias? Because, sorry, the review from the Archives was solely author opinion.
Now, I agree that there’s a lot of heated rhetoric from both sides.
But YOU are the one who made the claim that the AAP should revise it’s recco. Well, darn well PROVE it.
I should also add that Amy’s assertion that certain posters are ‘anti-circumcision’ is a bit misleading. I am not certain but I don’t think I saw anyone post that adults shouldn’t be allowed to get themselves circumcised for any or no reason.
You could say that there are posters who are against infant circumcision where there is no clinical need or immediate benefit to the infant or child. That would be accurate. This is in fact the position of many other professional medical organizations
The British Medical Association for examples notes:
http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp
“Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. ”
And this seems to be a reasonable stance, one American’s should adopt.
“Let’s talk about the evidence of whether circumcision decreases the transmission of HIV and other STDs and how that may translate into fewer deaths, less disease, less female infertility, and decreased cervical cancer.”
We could talk about something far more interesting :
It becomes increasingly clear, as more and more studies are done, that the same group of U.S. researchers keep looking for newer ways, and more and more excuses, to promote
circumcision. If it weren’t so serious, it would almost be comical.
These individuals seem to have a fixation with promoting and performing circumcisions. Perhaps the next study should be of these researchers’ brains, to discover why they have
such an unhealthy fascination with cutting off healthy foreskins from others. It almost borders on pathological! (Or, could it be just their way to get more research dollars?)
Perhaps the next study should be a mental health assessment of these researchers, conducted by unbiased psychiatrists and psychologists. Hopefully there’s a treatment for
their disorder.
“Would anyone like to discuss the actual evidence? An argument can be constructed that the benefits in a low risk population do not justify the World Health Organization recommendation for circumcision, but I haven’t seen that argument. Instead there is a lot of opinion on why other people should not circumcise their sons.”
My opinion is based on evidence. Since the ‘beginning of AIDS/HIV’ there have been a half-million Americans reported to have it. Include the unreported cases and the confidentiality issues…and I’ll double that to 1 million. So since the early 80s, only 1 million people in this country have gotten it. We have what, 300 million people. Granted our population hasn’t always been 300 mill, but we have 4 million births, over 2 million deaths each year. I’m not the math major, so I don’t know what that 1 million figure is truly out of, 350 million perhaps?
And out of that one million, only 35% are white, 75% are men. Over half of the cases are due to high-risk activities.
So if you want to call it an emotional decision, so be it. I don’t have a penis, so really it was all about logical deduction for me. Just like I don’t want to be overmedicated or over prescribed antibiotics, I’m not going to subject myself or my kids to what I see as unnecessary medical procedures. Yes, I am agnostic, so the fact that over time this has largely been a religious procedure….I’d be lying if I said that wasn’t a factor. But that *is* how is started. To me, the fact that some very minor (in my son’s situation) health benefits have been found, it wasn’t enough to sway me.
I will agree with you that yes, via scientific analysis, benefits have been found. But for someone in my situation, those benefits are too small for me to consider. My emotions have nothing to do with it.
“Would anyone like to discuss the actual evidence? An argument can be constructed that the benefits in a low risk population do not justify the World Health Organization recommendation for circumcision, but I haven’t seen that argument. Instead there is a lot of opinion on why other people should not circumcise their sons.”
My opinion is based on evidence. Since the ‘beginning of AIDS/HIV’ there have been a half-million Americans reported to have it. Include the unreported cases and the confidentiality issues…and I’ll double that to 1 million. So since the early 80s, only 1 million people in this country have gotten it. We have what, 300 million people. Granted our population hasn’t always been 300 mill, but we have 4 million births, over 2 million deaths each year. I’m not the math major, so I don’t know what that 1 million figure is truly out of, 350 million perhaps?
And out of that one million, only 35% are white, 75% are men. Over half of the cases are due to high-risk activities. (this was all from a UK website, avert)
So if you want to call it an emotional decision, so be it. I don’t have a penis, so really it was all about logical deduction for me. Just like I don’t want to be overmedicated or over prescribed antibiotics, I’m not going to subject myself or my kids to what I see as unnecessary medical procedures. Yes, I am agnostic, so the fact that over time this has largely been a religious procedure….I’d be lying if I said that wasn’t a factor. But that *is* how is started. To me, the fact that some very minor (in my son’s situation) health benefits have been found, it wasn’t enough to sway me.
I will agree with you that yes, via scientific analysis, benefits have been found. But for someone in my situation, those benefits are too small for me to consider. My emotions have nothing to do with it.
“Would anyone like to discuss the actual evidence? An argument can be constructed that the benefits in a low risk population do not justify the World Health Organization recommendation for circumcision, but I haven’t seen that argument. Instead there is a lot of opinion on why other people should not circumcise their sons.”
My opinion is based on evidence. Since the ‘beginning of AIDS/HIV’ there have been a half-million Americans reported to have it. Include the unreported cases and the confidentiality issues…and I’ll double that to 1 million. So since the early 80s, only 1 million people in this country have gotten it. We have what, 300 million people. Granted our population hasn’t always been 300 mill, but we have 4 million births, over 2 million deaths each year. I’m not the math major, so I don’t know what that 1 million figure is truly out of, 350 million perhaps?
And out of that one million, only 35% are white, 75% are men. Over half of the cases are due to high-risk activities. (this was all from a UK website, avert)
So if you want to call it an emotional decision, so be it. I don’t have a penis, so really it was all about logical deduction for me. Just like I don’t want to be overmedicated or over prescribed antibiotics, I’m not going to subject myself or my kids to what I see as unnecessary medical procedures. Yes, I am agnostic, so the fact that over time this has largely been a religious procedure….I’d be lying if I said that wasn’t a factor. But that *is* how is started. The fact that some very minor (in my son’s situation) health benefits have been found, that doesn’t change the fact that the origins are based in religion. And the scientific evidence just wasn’t enough for me to change my mind.
I will agree with you that yes, via scientific analysis, benefits have been found. But for someone in my situation, those benefits are too small for me to consider. My emotions have nothing to do with it.
@moderation
I don’t think anyone here is against circumcision where there is an actual need or an adult is making the decision for themselves. So the term ‘anti-circ’ is misleading.
Quickly, I would say that in the situation you describe, we could consider offering it to mature individuals. Where that line is is open to debate. However, there is a danger in doing this in countries that you describe. Specifically, there is a strong possibility of individuals misinterpreting the level of “protection” provided and shedding the condom altogether. I suspect this phenomenon will be under reported for years but rarely does an article about this issue in Africa get written where they don’t quote a bunch of men who cheer their new ‘virtual condom’. We also have to consider that nonsocial infection is a large and underreported vector in these countries.
As to the supposed higher risk, that is part of the individuals decision. If the benefit is worth the risk he can take it, if not he won’t. It’s up to him. The difference is not significant. Though I will say that I’ve heard of infants (in developed countries) dieing as a result of circumcision, I’ve never heard of an adult dieing of a circumcision (except perhaps in some of those African ritual circumcisions.).
Apparently you can only “see” what you want to “see,” then. You’ve got to be kidding on #3 and hugely exaggerating on #1. #2 may have some validity, but that’s certainly not the “only” reason.
As for castration fantasies? Got any evidence to support that last assertion? I’ll wait, although I suspect I’ll be waiting a long time.
Amy, you said the AAP should heed the authors’ call. The AAP Policy Statement says
“Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.”
I don’t see any reason to change this statement. It is fair and balanced. The new information about STD risks automatically becomes part of the “accurate and unbiased information” given to patients.
I don’t think you are recommending routine neonatal circumcision, but questioning the current AAP policy makes it sound like you are. Perhaps you could clarify exactly what you think the AAP should say differently.
I forgot to bookmark this review and it took a while for me to find it again:
Can Routine Neonatal Circumcision Help Prevent Human
Immunodeficiency Virus Transmission in the United States?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2678848/pdf/nihms98333.pdf
It discusses several reasons why the “African” studies on relative HIV-risk reduction with circumcision are not a decent guide for any kind of health-policy recommendation in the US (or by analogy Europe).
To recap, there are a number of differences and confounding variables that cast serious doubt on whether the US would also benefit from a more generalized circumcision schedule.
1. Different HIV prevalence rates (young adults):
US 0,14 %
Europe <0,1%
Uganda, Kenya 6-7 %
South Africa ~25%
The NNT for circumcision in Europe and the US would be quite significant compared to the 3 African "study" countries in which the recent better-quality studies were performed. A cost benefit analysis should be most revealing. This NNT data must then be compared to the number of adverse effects incurred on all circumcised males.
2. Different HIV modes of transmission:
Africa: predominant mode high-risk heterosexual contact
US: 49% penile-anal mode, 33% high-risk heterosexual
If circumcision has a different protective effect for different HIV transmission modes (which is not all that unlikely) it is difficult to extrapolate from African data.
3. Presence of concurrent STDs
- 5% of all trial participants (young adults) in Kenya had a Chlamydia infection, which is know to increase the risk of HIV transmission
- the US/EU prevalence for the entire population is about 1-3%
any concurrent infection that leads to either ulceration or any kind of genital mucosal damage can obviously lead to a much greater infection risk where the advantages of circumcision might shine through. If these same diseases are not present in the US or Europe to such a degree one can reasonably expect the benefits of circumcision to also be lower – or at the very least that such benefits are not established for the western context.
4. Differing numbers of sexual partners / sexual behavior and condom usage.
Given these reasons it is even more clear that studies conducted in Africa cannot be a serious basis for such a drastic change in health-care policy. Advocating general circumcisions in Europe or the US would requite studies to be performed in these countries or at least in a reasonable analogue.
If you want to go that way, then I feel obligated to point out that I haven’t seen you address the question of risk versus benefit either, quite frankly. The word “risk” doesn’t even appear in your post, and your first paragraph frames circumcision as “saving lives from a dread and often fatal disease simply by performing a minor surgical procedure.” Your post came across to me as a glowing endorsement of circumcision. It’s true that the really emotional anti-circ crowd has come out in force (they always do whenever the post is about circumcision and is not an angry screed against the practice) and it’s easy to dismiss them based many of their dubious arguments, but you haven’t addressed the very point you accuse them of not addressing.
Again, going back to Harriet’s post, the NNT to prevent one case of HIV/AIDS in Africa was estimated by a meta-analysis to be 72. It is not an unreasonable question to ask whether it is worth performing 72 circumcisions in order to prevent one case of HIV/AIDS. The NNT in the U.S. and western nations is, of course, likely to be much higher because the prevalence rate is lower, meaning that the African studies are not well-matched to the question of circumcision’s benefits in the U.S.
In other words, I’m with Harriet on this one. Perhaps you should clarify.
I don’t think this issue can’t just be about medical facts. Quite frankly, I think it is a dangerous practice in most cases. We cannot seperate our health from our cultural, religious and moral beliefs…Nor should we. Health research should always ben interpreted within a cultural context. I will never say ‘circ is bad’. There are many cultures in which it is a critical rite of passage.
Who am I to say than an intact penis is more important than a young boy being able to become a man?
“Yes, and I’m waiting for the anti-circ folks to present some numbers, as opposed to personal opinions.”
Here are some numbers. The risk of a man contracting HIV from a woman, which is the only HIV route circumcision has proven to reduce risk, is .04% or .0004 in the United States. One in every 2,500 sexual acts (http://www.aidsmap.com/en/news/E1249D29-0DDE-4CFF-9CC7-16B3FADB3E59.asp) . Exactly how many men do you think are going to be having sex 2,500 times before the age of 18 when they can make an educated decision for themselves about whether or not the risk reduction is worth it? Even the most conservative risk complication rate of circumcision is WELL above .0004.
Like others have pointed out, there is no need to circumcise infant boys. There are many types of female circumcision, and not all of them are analogous to removing the entire penis of a boy. If girls are protected from even a ceremonial pin prick to their genitals, boys should be protected from having their foreskin removed. I doubt anyone would argue that a single needle prick to the labia of an infant girl carries less risks and is less harmful than removing foreskin from a baby boy. It is unconstitutional to make a human rights law that protects one gender and not the other.
If scientists are correct in speculating that the reason circumcision reduces HIV risk is because of the prevalence of Langerhans Cells in the foreskin, why are they not proposing further study in female circumcision to reduce the risk of HIV since the genitals are where the majority of Langerhans Cells are for females as well? Even if studies proved that female circumcision reduced the risk of HIV and UTIs the law to protect infant girls would not change, because it is a violation of human rights and not the cultural norm.
I really get tired of the argument that male circumcision is Ok because female circumcision is worse. How is that logical? Should raping children be legal because murdering children is worse? Laws don’t work that way. Just because something is worse doesn’t make a lesser offense right. And, as others have pointed out, removing the clitoral hood in females is analogous to removing the foreskin in males, it is not worse. If someone held a man down and cut his pinky off that would be bad. If someone held a man down and cut his entire leg off that would be worse. So should forcibly cutting a man’s pinky off be Ok? I don’t think so.
I’ve only got a few minutes before I leave work to post this.
Having a quick look at the article quoted, this is a review article, mixing data from some RCTs and a meta-analysis.
It’s not clear if there is some crossover between the meta-analysis and the RCTs. The 2 of the 3 RCTs use rates per 100 person years (a dubious concept) and the quoted 60% reduction is a reduction from 1.33 cases per 100 persons years to 0.66. (Not significant enough for me to consider operating on my sons).
Not to mention this is data is from adult males aged 18-24 in high risk countries and should not be extrapolated to infants in low risk countries.
I thought SBM was better than this…
Dr. Tuteur, you sure know how to bring them out of the woodwork.
It seems to me that what is missing from most of the posts (including my own I’m ashamed to say) is any citation of studies or meaningful critical examination of the facts. Instead, we have rants steeped in personal and cultural prejudices.
I would like to understand if the reduction in sexually transmitted diseases in circumsized males has been noted in first world countries as well as in societies with less robust hygienic infrastructures. Do the reduced rates relate to reduced need to carefully clean the genitals? Is there literature to demonstrate this one way or the other?
“I would like to understand if the reduction in sexually transmitted diseases in circumsized males has been noted in first world countries ”
there has been a few studies in this regard and they are mostly negative. – that is they show that in those populations most at risk for HIV infection in developed countries, circumcision does not decrease HIV infection risk.
A recent review of these studies that asses high-risk populations and circumcision (homosexual, bisexual men)
http://jama.ama-assn.org/cgi/content/short/300/14/1674
The problem is that, to my knowledge, there are no good RTCs of circumcision as a preventative measure against HIV infection in developed countries. The observational studies are quite mixed, some report a decrease in risk, some even an increase in risk, but they are difficult to interpret.
“It seems to me that what is missing from most of the posts (including my own I’m ashamed to say) is any citation of studies or meaningful critical examination of the facts. Instead, we have rants steeped in personal and cultural prejudices.
I would like to understand if the reduction in sexually transmitted diseases in circumsized males has been noted in first world countries as well as in societies with less robust hygienic infrastructures. Do the reduced rates relate to reduced need to carefully clean the genitals? Is there literature to demonstrate this one way or the other?”
Here is a site with links to countries and the prevalence of HIV in each of them. (http://hivinsite.ucsf.edu/global?page=cr-00-02)
Of all the western countries including the UK, Australia, New Zealand and Canada, the United States has by far the highest rate of HIV and the highest rate of circumcision. Circumcision rates in those countries are under 20 percent. Also note that the primary means of transmission is the same in all of these countries : Homosexual male intercourse, which circumcision has shown to have no effect in reducing transmission in. In stark contrast is Africa, whose primary means of transmission is male to female sex, which is among the rarest form of transmission in the United States and all western countries.
And multiple commenters who cannot reasonably be termed “anti-circ” are still waiting for you to provide ANY BASIS WHATSOEVER for a central point you are advocating. You haven’t even gotten to the point of presenting personal opinion!
So yet again. In light of the ethical issues of permanent modification of an individual’s body without their consent, from where does the urgency arise to justify neonatal circumcision as opposed to recommending it to the individual when they are old enough to express an opinion, but before they become sexually active?
“Amy, you said the AAP should heed the authors’ call.”
Yes, the authors call on the AAP to revise its policy in light of the latest evidence. I take that to mean advising parents of the benefits of circumcision in preventing transmission of HIV and STDs.
“In stark contrast is Africa, whose primary means of transmission is male to female sex, which is among the rarest form of transmission in the United States and all western countries.”
Sorry I meant to say female to male is the primary means of transmission in Africa, not male to female.
Does the fact than a Kenyan man is in the circumcised arm somehow change his behavior? Did they control for this?
Amy, you know damn well these African studies are flawed in many different ways and not applicable to those living in first-world countries. Studies about cir done in European or American contexts have had very mixed and informative results.
Anyway, it was interesting that those women that answered that sex with their husband was more satisfying post-cir cited “cleanliness” as the reason. Then the authors go on to claim that as a universal applicability. How about if these folks had access to washing everyday and using soap, “cleanliness” either way would not be a problem. We aren’t living in 1st century Israeli or Uganda. This cleanliness issue is no longer a problem.
Dr. Dean Edell has a really good segment on this issue. Look it up on itunes, folks.
Because the male analogue of female “circumcision” is amputation of the penis. Why do anti-circ activists disingenuously equate male circumcision with clitoridectomy?
—————-
Can you reproduce without a clitoris? Can you reproduce without a penis? Bad analogy.
” Yes, the authors call on the AAP to revise its policy in light of the latest evidence. I take that to mean advising parents of the benefits of circumcision in preventing transmission of HIV and STDs.”
———————
but the point we’ve been trying to get you to recognize this whole time is that, the “new” evidence is only a small piece of the puzzle and not in line with some other evidence. Especially when one looks at the bigger picture and asks if it is reasonable to extrapolate from Africa to Europe or the US.
To my knowledge there is no decent evidence to support the contention that generalized circumcision will help reduce HIV infection rates in the US or Europe. Furthermore I have yet to see rigorous analysis of NNT for the US/EU case and a comparison with relevant adverse effects.
On top of that there are review papers published for the case of Europe and US (liked one in my previous post) that conclude that circumcision does not decrease HIV infections for high-risk groups (MSM).
In light of these facts, that you consistently dodge, I cannot see how one can reasonably conclude that recommending routine circumcisions is a good idea and will lead to the desired effect in the US or Europe.
If you want real information on HIV/circumcision :
http://www.youtube.com/watch?v=OlsUg0sdAtE
instead of losing your time with novice doctors from Science-Biased Medecine with all sorts of incomprehensible statistics that come from nowhere : “NNT to prevent one case of HIV/AIDS in Africa was estimated by a meta-analysis to be 72″.
“David Gorski”
She mentioned that the NNT for sexually transmitted diseases is 72.
That’s African data. Let’s bring it back to America where most of us live
If the anti-circ crowds argument is ‘the infant newborn should ahve a say in anything that isn’t immediate medical need” then you must be against the following or you are hypocrite:
‘brushing gums’, later teeth.
Cleaning behind the ears.
Fixing damaged clefts
removing unusable extra limbs (Polydactyly)
separating Siamese twins (some case are immediately medically necessary, but many aren’t)
and so on.
the fact of the matter is circumcision reduce the chance of catching some deadly STDs.
It can be very difficult to have a boy entering puberty ti do proper cleaning.
The study looking at sensitivity showed no los, and the people taking the position thet they have or don’t have more sensitivity aren’t really qualified for the judgment because they have no way to compare, and they will be rife will personal bias. This is logically no different then saying my son got a vaccine, and then was diagnosed with autism and since it happened to me, I must be right.
Not get your child circumcised means you have chose to let your child have a hire risk of dying from STDs. That’s the bottom line no matter how you like to paint it.
On a personal note: as a man I would appreciate less stimulation during intercourse. well, until I turned 45, now I need all I can get~
Windriven:
“It seems to me that what is missing from most of the posts (including my own I’m ashamed to say) is any citation of studies or meaningful critical examination of the facts. Instead, we have rants steeped in personal and cultural prejudices.”
Might it be because this is, at it’s core, an ethical/religious/philosophical debate, at least in the U.S.?
The AAP and most medical organizations in the world (including the WHO, for developed countries, contrary to Dr. Tuteur’s “facts”) do NOT recommend routine infant circumcision. The medical benefits DO NOT justify American neonates being routinely circumcised. A study of the relevant medical literature as a whole don’t present compelling arguments for RIC. If a parent wishes to have a surgical procedure for their infant, that’s fine. The risks are minimal, most likely. But don’t pretend there aren’t cultural issues (on either side). And stop using medicine and science (as was done for the first 90 years of the 20th century) to justify your (general) religious beliefs. A fringe few in the 21st are still at it.
Thus, it’s not a medical issue for most boys born in this country. It’s a cultural/religious one, and people on either side are going to go nuts about it.
@ Geekoid:
Surely you must see the difference between a permanent modification of the body and your cited examples.
As for dismissing anybody who questions what the proper timing for the decision is as “anti-circ” – well, there’s simply zero justification for that.
And in particular:
Unless you have some evidence to support a claim that neonatal circumcision is more effective in this regard than teenage circumcision, this claim is completely false.
Wouldn’t MNTBA be a better metric, as in members needed to be amputated
Lets not for get about female risk as well:
“Among female partners of circumcised men, bacterial vaginosis was reduced by 40%, and Trichomonas vaginalis infection was reduced by 48%. “
Geekoid:
“the fact of the matter is circumcision reduce the chance of catching some deadly STDs.”
This is in fact NOT the whole story. This is likely the case for Africa where the recent 3 good RCTs were done. It is far from certain in the US or European context (see the review I linked previously)
Geekoid:
“It can be very difficult to have a boy entering puberty ti do proper cleaning.”
Really? How difficult can it be to get a boy entering puberty to “play” with himself in the shower ? You must be from some kind of a bizzaro-universe because this is certainly not the case where I’m from
Geekoid:
“Not get your child circumcised means you have chose to let your child have a hire risk of dying from STDs. That’s the bottom line no matter how you like to paint it.”
This is not established in the European or US context at all. Some studies show a decrease in risk but others even an increase in risk. A large review for the MSM group shows no benefit in (mostly) developed countries.
Apart from that you are only looking at one side of the coin. Even if it were established that circumcision does significantly reduce the risk of say HIV infection in the US or European context this would only be ONE side of the decision-equation. You would also have to weight this benefit against the side effects of circumcision especially since the NNT in the US/EU would be huge.
It is therefore not just a choice between exposing your child to an increased risk for STDs or not (even if that were established). You must weight that benefit against other circumcision related operational side effects.
@Geekoid :
You are talking about birth defects or some medical conditions.
The foreskin is neither of them.
FORESKIN ISN’T A BIRTH DEFECT
It’s supposed to be there, there’s no need to remove it despite false claims of non-cleanliness. How the rest of the world has done just fine without lobbing off baby peni, I don’t know. Maybe their kids can clean themselves?
Zoe-
I generally agree though Dr. Tuteur’s post – at least as I read it – was nothing more than an introduction of the study, presumably as a springboard for this sort of discussion. I think there are interesting and legitimate scientific areas of exploration:
- Is the noted decrease in STD transmission fundamentally one of hygiene?
- Is there or was there an evolutionary benefit to having a foreskin and if so, what is/was it?
- Does presence or absence of a foreskin correlate with sexual satisfaction of either partner?
- What are the ethical issues of performing an irreversible (for the most part) surgical procedure on an infant and where and how is that line drawn. This last of course transcends the circumcision discussion but is still, I think, appropriate.
Personally, I don’t have a dog in this fight and I am amused by the level of emotion evident in many of the posts. I had my son circumcised as it was the thing to do at the time. I frankly didn’t give it any thought. If I were making the decision today I would likely leave the decision to be made by him. But as a circumcised male I certainly don’t feel psychologically scarred, maimed, deprived of sexual satisfaction or otherwise hard done by. Much of the heat of this thread seems a tempest in a teapot to me.
I call editing fail on myself, sorry. That should have read “first two cited examples”, and been followed by
The others have real and clear benefits to acting swiftly; unless you can provide evidence of urgency for circumcision they fail as well.
Wind,
I would add cultural significance in there too.
@Geekoid
Last time I checked brushing gums and teeth are an issue of hygiene; if not done, the usual consequence ensues such as tooth decay and gum disease. While not cleaning behind the ears might not lead to the same problems, such a minimally invasive intervention doesn’t seem to raise the same ethical questions.
A damaged cleft, extra limbs and Siamese twins represent birth defects. In the case of a cleft, it might lead to problems with feeding, ear disease, and speech to name a few that springs to mind.
It seems disingenuous to compare necessary hygiene practices and birth defects, which have immediate impacts on the child, to a practice that involves none of these things. And circumcision is significantly different from vaccinations in just about every conceivable way.
There is definitely with Amy Tuteur hen I read her articles.
She obviously hates nature and feels the compulsive need to destroy it using the excuse to protect it :
she is against homebirth
she is against natural birth (preference for c-section)
she is against breastfeeding
she is against natural penis
There is definitely something wrong with Amy Tuteur when I read her articles.
She obviously hates nature and feels the compulsive need to destroy it using the excuse to protect it :
she is against homebirth
she is against natural birth (preference for c-section)
she is against breastfeeding
she is against natural penis
“‘brushing gums’, later teeth.”
- does this remove any healthy tissue from an infant or child? Does this change the function of the teeth or gums of the child? Does brushing teeth cause any permanent change that cannot be undone? Is brushing your child’s teeth legal for one gender and illegal for another?
“Cleaning behind the ears.”
-does this remove any healthy tissue from an infant or child? Does this change the function of the ears of the child? Does cleaning behind the ears cause any permanent change that cannot be undone? Does cleaning the ears permanently change the appearance of the ears?Is cleaning your child’s ears legal for one gender and illegal for another?
“Fixing damaged clefts”
- Are children normally born with damages clefts, or is it a birth defect? Are foreskins a birth defect? Can you fix a damaged cleft for a boy and not for a girl?
“removing unusable extra limbs (Polydactyly)”
- Are children normally born with unusable extra limbs, or is it a birth defect? Are foreskins a birth defect? Can you remove the extra limb from a boy but not from a girl?
“separating Siamese twins (some case are immediately medically necessary, but many aren’t)”
- Are children normally born attached to another human being, or is it a birth defect? Are foreskins a birth defect? Can you separate siamese boys but not siamese girls? Also note that unless there is immediate medical need, siamese twins are not usually separated until much older when they can voice whether or not they want to remain that way. The risk of surgery to separate twins is not worth it if there is no immediate life threatening risk to the twins, and you would be hard pressed to find a doctor that would perform such a surgery if both infants were completely healthy and weren’t at any such risk.
“This is logically no different then saying my son got a vaccine, and then was diagnosed with autism and since it happened to me, I must be right.”
Actually it is very different. Studies have not shown a definitive link to autism and vaccines. Diseases that children are vaccinated against such as polio, smallpox, and measles are not sexually transmitted. They are contracted by such unforeseeable circumstances are unknowingly breathing the same air as someone who is infected. You can’t get sneezed on and contract HIV or herpes or genital warts. Vaccines are also the most effective, least invasive and usually ONLY way of achieving the desired effect, and they show the same risk reduction for everyone. These vaccines are responsible for eradicating the diseases for which they provide immunity for on a global scale. You would never see 4 out of 5 vaccinated people getting polio. Or even 5 out of 10. Circumcision is a risk reduction, vaccination is an immunity. Also, vaccination does not remove healthy functioning tissue, or alter the appearance or function of their body parts, thus their imposition on human rights is minimal at best.
Nick,
you just went off the rails
My baloney meter is going off. Here’s what the AAP policy says about HIV and benefits ALREADY:
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686
And with the following quotes from the blog, and the title, pretending that you aren’t arguing for neonate circumcision is… disengenous at best.
The so called reason why circumcision prevent AIDS is because of Langerhans cells found in the foreskin. Hoever some other studies show that these Langerhans PROTECT against HIV :
http://www.circumcisionandhiv.com/files/de_Witte_2007.pdf
The so called reason why circumcision prevent AIDS is because of Langerhans cells found in the foreskin. However some other studies show that these Langerhans PROTECT against HIV :
http://www.circumcisionandhiv.com/files/de_Witte_2007.pdf
I think we’ve had this debate here a few too many times. The polarization is astounding, it’s almost as strange as with vax vs. anti-vax!
What a load of horse hockey!
I’ve sparred with Amy from time to time in the comments, but what you’re saying is just plain ridiculous. Please, show us where Amy has ever said that she prefers C-sections or that she is against breast feeding or a natural penis. True, she does appear to take a dim view of home birth, but I don’t know that you can characterize her as being totally against it.
A dim view indeed! Have you read homebirthdebate.blogspot.com ?
Amy,
You said “Yes, the authors call on the AAP to revise its policy in light of the latest evidence. I take that to mean advising parents of the benefits of circumcision in preventing transmission of HIV and STDs.”
The AAP policy already says
“To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision.” I think that covers advising parents about the HIV/STD information. Do you disagree?
edgar,
I absolutely agree that cultural bias is a huge component.
That doesn’t necessarily make it right are wrong; I would argue that some scientific truths trump cultural/religious beliefs. But I certainly don’t think this one rises to anything close to that level.
BTW, hope you enjoyed a pleasant holiday season.
@Zetetic
I’m with you. I wonder if the editors might not set up a separate area where the ranters might amuse themselves. There they might while away the hours engaging each other in ad hominem attacks, puerile arguments and hagiographies of their favorite deities, cults, fads, fashions and woo.
@Nick
The link to the de Witte in Nature is interesting but only tangentially related to the issue at hand. De Witte argues that Langevin disrupts the transmission of HIV by Langerhans Cells. Very interesting indeed. But in and of itself, that only means that we know one pathway whereby HIV is NOT transmitted. That is rather different from the epidemiologically noted differential rate of transmission in circumcised v. uncircumcised males.
As Dr Hall points out, the current AAP reccomendation includes the statement, “To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision.”
I’m with Dr Hall: I really don’t see anything that needs changing in that recommendation.
For an informed choice, we would need to know:
1) NNT for the country the boy is born into.
2) NNH (number needed to harm) for infant circumcision.
3) NNH for adult circumcision.
Do you know any of those? Can you guess? Can you explain how you know or don’t know, or why you can or cannot guess? Can you talk about the difficulty in discussing the facts with parents when we don’t know all the facts? That would be Science-Based Medicine at its finest!
According to Dr Hall, the NNT in Uganda seems to be about 72. There are differences between Uganda and the US, the country for which the AAP is making recommendations.
One is prevalence of HIV/AIDS. Prevalence in the US is lower, which means the NNT would be higher in the US. How much higher? Can you estimate it based on relative prevalence rates? (I can’t, by the way. I wouldn’t know what the relevant numbers are. This means I can’t make any assumptions or guesses about whether the US NNT would be extremely reasonably or ridiculously small. But if you could, that would be really interesting, and it would shed some light on what exactly you think should be presented to American parents that is not already.)
Another is patterns of sexual relationships. Serial monogamy is the most frequent pattern in the US. (No, I have no data to say by what degree and I don’t know enough about sexual anthropology to name all the different patterns and discuss them intelligently.) In African countries with a high HIV/AIDS prevalence, serial monogamy is less frequent. (I don’t know how much less frequent. I heard this analysis from a CBC radio inerview with one of the doctors doing one of the Ugandan studies — he did have the data to back up what he was saying — and this assertion made sense to me based on personal anecdotal evidence, so I did not question it. Maybe the statement could be challenged, but I think “less frequent” is a reasonable assessment that makes no claims to degree.) Though the number of lifetime partners may be the same, people tend to return to the same partners over the course of a lifetime. This affects transmission rates. If I have five lifetime partners but never return to an old partner once we have split up, then I can only retransmit any STI I contract to future partners. My exes are safe, and I am only exposed to a partner’s STIs for the time we are together.
If I have five lifetime partners and I reconnect with one of them when I return to my hometown and contract the STI they contracted after splitting up with me, I will then retransmit it to my spouse.
So prevalence of HIV/AIDS is higher in Uganda (greater chance that any given partner will be infected) and likelihood of retransmission is also higher (even with a similar number of lifetime partners to an American, more of one’s lifetime partners are at risk of contracting an STI.)
Given these two differences — one of which is more easily quantifiable (prevalence rates) and one of which is less easily quantifiable (patterns of sexual relationships) — the NNT for the US is not going to be the same; but without a gross estimate of NNT and NNH in the US, we can’t make informed choices.
IN this light, an argument for waiting until adulthood for circumcision would be that the individual would have a better understanding of what their risk factors would be. On average, a gay man’s sexual partners will be taken from a pool with a higher HIV/AIDS prevalence rate. That might affect his decision. And if he knows that serial monogamy is not appealing to him, that might also have an impact. The NNT for a moderately promiscuous gay man in the US might be similar to the NNT for a moderately promiscuous Ugandan of any sexuality.
All these are really interesting numbers to me — even if I don’t know what the numbers are, I know they are out there.
How do doctors use science to decide which ones are relevant to communicate to parents? That would be a really interesting post.
This isn’t physics or chemistry. Medical science is messy.
I am still waiting for a mention of the risks associated with this procedure. No mention of NNH (number needed to harm).
Finally, the 3 commonly cited RCTs were in men. Is there any evidence that this procedure translates into the same benefits (small as they are, and certainly exaggerated by some) when performed on infants or children. (I may have missed it in this long list of posts, if someone has already provided the evidence)
this is a wholly absurd debate.
there appear to be benefits. up to you (your penis and your choice for your children) as to how encouraging those benefits are.
only in the most far fetched of circumstances, will the decision to circ or not impact others.
I do not recall, loath, regret, notice or in anyway consider my own circ. my guess is that if you sampled the population, that sentiment would remain pretty consistent.
the docs are accountable to present the evidence as it is appears. do with it what you will.
always use a condom
sex is just as much mental is it is physical
but, im sure there is some fantastic reason to get all bent out of shape about all of this…carry on
Eric G,
“the docs are accountable to present the evidence as it is appears. do with it what you will.”
Actually, doctors are accountable for interpreting the science for us, not just list PubMed references. This is hard to do. (If it weren’t, the AAP reccomendations would be trivial because everyone would be coming to the same undeniably correct conclusions simultaneously and independently.)
If there are risks and benefits to balance — and there always are — then I need my doctor to explain them to me.
What’s frustrating about Amy is that she doesn’t explain things. She makes a statement without nuance or clarity (vague but not nuanced… , asserts that anyone who disagrees with her is an irrational extremist ninny (without actually quoting anyone who disagrees with her stated opinion and explaining why they are wrong), and sits back and waits for the complaints.
She thinks that lots of complaints about lack of nuance is a sign of an effective educator.
I disagree.
Eric G,
“the docs are accountable to present the evidence as it is appears. do with it what you will.”
Actually, doctors are accountable for interpreting the science for us, not just list PubMed references. This is hard to do. (If it weren’t, the AAP reccomendations would be trivial because everyone would be coming to the same undeniably correct conclusions simultaneously and independently.)
If there are risks and benefits to balance — and there always are — then I need my doctor to explain them to me.
What’s frustrating about Amy is that she doesn’t explain things. She makes a statement without nuance or clarity (vague but not nuanced… , asserts that anyone who disagrees with her is an irrational extremist ninny (without actually quoting anyone who disagrees with her stated opinion and explaining why they are wrong), and sits back and waits for the complaints.
She thinks that lots of complaints about lack of nuance is a sign of an effective educator.
I disagree.
Having read most of the comments posted here I have to say, this discussion would make an interesting sociological experiment. It is quite interesting to note that individuals who would probably discuss vaccination or homeopathy in a quite dispassionate manner seem to devolve into ranting and raving when discussing the aspects and choice of circumcision, especially when the author of this article never calls for an end to parental choice. It does appear to me that the only people arguing against choice are those against circumcision, but I could be wrong.
I think some of Dr. Tuteur’s statements are a little too strongly worded for the data, but certainly agree that parents should be presented with all of the facts, including the information showing a reduction in STD risk. But, if Dr. Hall is correct and the AAP guidelines already make such a statement, then no change in policy is required and this information should simply be added to the information that would be given to parents.
It is also interesting how some parent’s consider their children to be at a lower risk group for STD’s simply because they think they would be. As the child of parents who didn’t know I was gay until I came out to them, I would say that you probably do not understand your own children’s risks as accurately as you may think you do. I certainly never talked to my parents regularly about my sexual experiences (either before or after coming out).
As a “mutilated” male myself I have to say that I am not at all unhappy with my parent’s decision. As a matter of fact I do not even give it any thought whatsoever, nor do I have any sort of memory of the event (but I have not gone for hypnotic memory regression therapy lately, so maybe its there and I’m not sure about it). I am quite happy (sometimes too happy) with my sexual pleasurability (not sure if thats a word). Also, as a gay man I have seen both types in action and, personally, I prefer mine…but that’s just me. I’m glad my parents made the choice they did, when they did. I would rather not have to deal with the pain that I would certainly remember were I to do it now.
Tuteur undermines her credibility completely by lying about the AAP’s position statements. Nowhere in the organization’s history has it recommended newborn circumcision. In reverse chron order:
1999 Position Statement: “data are not sufficient to recommend routine neonatal circumcision”
1989 Addendum to 1975 Statement (did not alter 1975 position): “circumcision… may result in a decreased incidence of urinary tract infection. However, in the absence of well-designed prospective studies, conclusions regarding the relationship of urinary tract infection to circumcision are tentative.”
1975 Position Statement: “There is no absolute medical indication for routine circumcision of the newborn.”
1971 Position Statement: “There are no valid medical indications for circumcision in the neonatal period.”
Tuteur’s bold claim: “The AAP had long recommended male circumcision”
Please disregard anything else she writes.
Well, this is a very interesting case.
let’s start with a sentence like “it is time for the AAP policy to fully reflect these current data.”
is quite a ugly mix up!
let’s replace those “data” with : “removing all boys hands reduce drastically the death rate by gun shot.” (which, you might accept for the sake of the demonstration).
And, thus, start again : “AAP should encourage, hands cut off.”
Sounds ridiculous, isn’t it ?
Be careful to always separate facts (evidence) goals, and means.
“Circumcision reduces STD transmission rate”. It’s a fact.
“Everybody’s goal is to be healthy at any cost ?” it’s a goal, and implicit here.
“We should perform chirurgical procedure to achieve this goal” It’s the mean.
When, someone go and visit doctors, they share the goal (getting better), and doctors propose a mean (or even several ones). But when it comes IRL, there is a trade off between life and health. Do not forget that.
Evidence based “sciences” should never discuss goals, rather discuss (means,goals) couples.
“Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure. People would hail this simple victory and rush to adopt it”
No. Simply because, you have forgotten that not everybody share this goal. You are falling on false assumptions.
You should try evidence-based politics.
Alison: “What’s frustrating about Amy is that she doesn’t explain things. She … asserts that anyone who disagrees with her is an irrational extremist ninny.”
Well indeed. The biggest issue I have with this article is that she clearly endorses *neonatal* circumcision, yet has provided zero evidence to back (circumcision in general, but not neonatal circumcision).
The presentation of evidence is also completely one-sided. Ethical considerations like the right of an individual to choose are completely ignored, as are the medical side-effects of circumcision (aside from sexual performance), as are any recent studies reaching different conclusions.
Anyway, I have written a detailed response here:
Circumcision: A Response to Amy Tuteur
http://layscience.net/node/878
Let’s take a closer look at the scientific issues:
1. There is copious scientific evidence that circumcision lowers the risk of transmission of HIV and a variety of sexually transmitted diseases including herpes and HPV. There is some evidence that circumcision of protective against cervical cancer and penile cancer, both associated with HPV.
There’s really not much doubt about the protective effect of circumcision. So the next issue is whether the impact of circumcision would justify recommending it.
2. What is the estimated benefit of instituting routine circumcision in a high prevalence population?
As mentioned above, the NNT for is 72 circumcision to prevent one case of HIV.
According to Weiss et al (Male circumcision for HIV prevention: from evidence to action?):
“assuming full coverage, male circumcision could avert 2.0 (95% CI 1.1–3.8) million new HIV infections and 0.3 (95% CI 0.1–0.5) million deaths over the next 10 years in sub-Saharan Africa, and 3.7 million (95% CI 1.9–7.5) new HIV infections and 2.7 (95% CI 1.5–5.3) million deaths in the following 10 years.”
Those are not trivial numbers. They would have a major impact on the spread of HIV.
3. What about a low prevalence population?
The answer to that question is not as straightforward as anti-circ activists claim. That’s because countries with low prevalence of HIV tend to have high rates of circumcision already. Such high rates of circumcision may be contributing to the low prevalence.
As Weiss et al. explain:
“Countries with very high or universal coverage of male circumcision have, without exception, relatively low and stable HIV prevalence which has never exceeded approximately 6%. The importance of male circumcision in ‘containing’ the HIV epidemic was highlighted in the Four Cities’ Study [43], which found higher levels of reported risk-taking behaviour in Yaounde,the capital city of Cameroon, where prevalence has been fairly stable at below 7% for many decades, compared with Kisumu, Kenya and Ndola, Zambia where HIV is more prevalent. The authors concluded that biological cofactors
for HIV transmission, notably male circumcision and herpes simplex virus type 2 infection,were likely to be key factors in the HIVepidemic in sub-Saharan Africa and this has been confirmed in subsequent modelling of the data.”
So it far from clear that circumcision does not have the same impact in low prevalence countries. The low prevalence may be a result of high circumcision rates.
4. What are the harms of circumcision, and how do they compare to the benefits?
A Trade-off Analysis of Routine Newborn Circumcision, a study done before the latest data was obtained from Africa reviewed circumcision over over 100,00 male neonates in the US reported:
“Overall 287 (.2%) of circumcised children and 33 (.01%) of uncircumcised children had complications potentially associated with circumcision coded as a discharge diagnosis. Based on our findings, a complication can be expected in 1 out every 476 circumcisions. Six urinary tract infections can be prevented for every complication endured and almost 2 complications can be expected for every case of penile cancer prevented.”
5. Do these data mean that we should recommend routine neonatal circumcision in low risk countries?
In my judgment, at the moment there is no enough data to recommend routine neonatal circumcision in populations with low prevalence of HIV. However, if decreasing rates of circumcision lead to increased prevalence of HIV, that issue would need to be revisited.
In summary, the benefits of neonatal circumcision are real, definitely make a difference in populations with high prevalence of HIV, and may make a significant difference in populations with low prevalence of HIV. That doesn’t even address the benefits that may accrue from decreasing transmission rates of other STDs, particularly HPV, known to be associated with cervical cancer and penile cancer.
snfraser notes: “This isn’t physics or chemistry. Medical science is messy.”
Perhaps, but medical science writing needn’t be messy as this article and the majority of comments are. Kind editorial assistance for the former and some more minutes of thought before the latter hits “submit comment” would do the world a world of good.
Alison Cummins later notes: “What’s frustrating about Amy is that she doesn’t explain things…and sits back and waits for the complaints.”
Some people’s style resembles that of the provocateur. For subjects without so many footnotes available and studies to cite, this is often an effective way to draw attention to something. However, in medical science matters, it’s most often used by those without a firm grasp of their subject matter. I don’t think this is the case with Dr. Tuteur but rather a problem of style not being well suited to the substance. If the intent is to educate then the most effective means should be used. If the intent is to get page hits and “controversy” going then anything goes but goes away quickly without much beneficial long-term impact.
“Having read most of the comments posted here I have to say, this discussion would make an interesting sociological experiment. It is quite interesting to note that individuals who would probably discuss vaccination or homeopathy in a quite dispassionate manner seem to devolve into ranting and raving when discussing the aspects and choice of circumcision, especially when the author of this article never calls for an end to parental choice.”
I agree (not surprisingly).
I was never particularly supportive of routine neonatal circumcision for health reasons, but new data has challenged my old assumptions. The issue is whether we are willing to go where the scientific evidence takes us.
Oh, lord not yet another forum where American medical industry personnel are trying to convince people that there are any scientifically credible benefits for circumcision–I thought this was debunked at another forum by Harriet Hall.
There, as well, as here, some think merely having a study deems it scientifically credible. Also that OPINIONS by organizations profiting from this unnecessary procedure can hardly be considered EVIDENCE.
Notice also, that the questions of ethics of inflicting an unnecessary procedure on unconsenting infants are not being addressed..nor the proven harm and proven risks of this unnecessary FORCED procedure.
If people here wish to actually defend this practice, they better start with trying to justify it with PROVEN facts and evidence.
Perhaps people might wish to see what REAL science has to say on the subject..
http://mysite.verizon.net/dortfay/science.html
I think Jason is right – I don’t think the AAP ever recommended routine neonatal circumcision.
Amy, when you said “The AAP had long recommended male circumcision for prevention of urinary tract infections in young boys,” did you mean to say they had long acknowledged that it was effective in preventing UTIs?
“I was never particularly supportive of routine neonatal circumcision for health reasons, but new data has challenged my old assumptions. The issue is whether we are willing to go where the scientific evidence takes us.”
What is this SCIENTIFIC EVIDENCE? Specifically evidence that satisfy the criteria for being scientifically credible–merely having flawed and questionable studies does not automatically confer credibility.
PLEASE provide even ONE single scientifically credible benefits for circumcision..scientific, not just medical evidence…they are not the same!
http://mysite.verizon.net/dortfay/science.html
Amy said: “3. What about a low prevalence population?
The answer to that question is not as straightforward as anti-circ activists claim. That’s because countries with low prevalence of HIV tend to have high rates of circumcision already. Such high rates of circumcision may be contributing to the low prevalence.”
Well to start off this is certainly not true. Circumcision outside of the US (and perhaps Canada to an extent too) is practically unheard of. So Amy, which European country, for example, where rates of circumcision in the population are easily below 5%, has higher HIV prevalence than the US?
That’s because countries with low prevalence of HIV tend to have high rates of circumcision already. Such high rates of circumcision may be contributing to the low prevalence.
++++++
Please can you give some evidence for this assertion.
Amy Tuteur, MDon 07 Jan 2010 at 4:29 pm
Perfect! A look at the science and a discussion of how they might relate to the real world. Exactly what I hope for from SBM.
(Well, almost perfect. We have NNT and also NNH—newborn but not NNH—adult.)
Amy, I’m truly curious. If you can write a clear, interesting and informative resumé of the science, why don’t you do it more often? Is your goal with your SBM really just to generate complaints — including complaints from people who agree with you? (In other words: are your posts deliberate trolls?)
“The answer to that question is not as straightforward as anti-circ activists claim. That’s because countries with low prevalence of HIV tend to have high rates of circumcision already. Such high rates of circumcision may be contributing to the low prevalence.”
That’s not true either. Many countries in Europe and Japan have low circumcision rates and low rates of HIV. In fact the US. has one of the highest HIV rates of the developed world. And highest circ rates.
I’m also questioning the confidence intervals in the Weiss report (and whether the data matches the conclusions), but it’ll have to wait until later when I can actually read it.
Interesting about the AAP positions through the years too. Honestly, I’m wondering if Dr. Tuteur said it was raining, I should go outside to check.
Amy said: “The issue is whether we are willing to go where the scientific evidence takes us.”
And if there is data to suggest it is necessary in the neonatal period then we can examine the strength of that data and whether the intervention meets the normal ethical standards practiced in medicine. At this point we are far from that place.
OK, now I am wondering if there is censorship going on here..I posted two comments–one apparently never made it through moderation (yet never even shown as awaiting moderation), and the second is now awaiting moderation–can I expect to see either one make it through your process?
IF they do not make it through moderation, will I be informed as to why not?
I concur. It doesn’t look to me as though the AAP ever recommended routine neonatal circumcision, at least not within the last 40 years.
I’m afraid that’s not the impression you gave with your original post.
@ Allison Cummins
– Eric G,
“the docs are accountable to present the evidence as it is appears. do with it what you will.”
-AC
“Actually, doctors are accountable for interpreting the science for us, not just list PubMed references. This is hard to…”
How about:
the docs are accountable to present *and interpret* the evidence as it appears. do with it what you will. ??
a quibble, but point taken.
i hope no one here thinks that a doctor’s opinion/assessment/advice precludes their own autonomy…given the trivial nature of the issue…well, carry on.
I suspect it’s more that we all want validation that we are “doing the right thing.” No one *wants* to be wrong.
@ archangl508
“As a matter of fact I do not even give it any thought whatsoever, ”
Ditto. much ado about nothing.
Amy Tuteur: “I agree (not surprisingly).”
Then why did you write your post in such an aggressive fashion? You flat-out accuse the AAP of manipulating the evidence on the basis of pressure from “anti-circ activists” in their 1999 policy statement, yet you’ve failed to address that statement, or the evidence in it, and explain where they went wrong.
You must realise that you can’t make these sorts of unevidenced accusations, then claim that it’s just your opponents who are ‘ranting and raving’?
At the very least, you need to address the evidence presented by organizations like the AAP – who based on far more substantial reviews of the current literature than you’ve provided continue to find the totality of the evidence not strong enough to recommend routine circumcision – rather than simply asserting that you’re right on the basis of hand-picked individual studies.
It’s also worth noting that you have still not addressed the question posed by the article’s title, and by a number of commenters – what is the case for *neonatal* circumcision? The last time I checked, most infants don’t have a lot of sexual partners, and won’t do until their mid-to-late teens. Why deny them choice? Why not wait until they’re old enough to decide for themselves what precautions they would like to take?
well, one thing is for sure. Dr. T, you sure know how to generate some traffic!
I do find it interesting that among developed countries the US is the only one that is really thinking about circumcision and HIV with regard to their population. Articles like this give an interesting perspective on how those from countries where circumcision is rare see our zeal to justify the practice:
http://news.bbc.co.uk/2/hi/health/7960798.stm
“Dr Colm O’Mahony, a sexual health expert from the Countess of Chester Foundation Trust Hospital in Chester, said the US had an “obsession” with circumcision being the answer to controlling sexually transmitted infections.”
I’m afraid that’s not the impression you gave with your original post.
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@David Gorski
Surely this is within your remit, as managing editor of this site?
You probably triggered the spam filter somehow. As you can see, I released your comments, as I do nearly all nonspam comments that get caught up in the spam filters.
Be aware, however, that I do not sit at my computer all day doing nothing but moderating comments so that commenters like you do not have to wait one second to see your comment appear. I have a very demanding day job. Generally, during business days I check every few hours if I can. If it’s a day that I happen to be busy in the O.R. or clinic, it can take several hours before I get around to checking the spam filter. Be patient. Just because your comment got hung up for moderation and I didn’t get to it for–gasp!–nearly a whole hour does not mean there is any “censorship.”
Yes, I’m being sarcastic. Commenters insinuating that they are being “censored” (presumably because they are disagreeing with one of our bloggers) brings that out in me. Mea culpa. No, on second thought, I make no apologies. Just be aware that censorship of that sort is a characteristic of CAM blogs and anti-vaccine crank blogs like Age of Autism, not of Science-Based Medicine.
mjrobbins said:
“Why deny them choice? Why not wait until they’re old enough to decide for themselves what precautions they would like to take?”
I think it’s because when you present the issue to most rational thinkers as, to reduce your risk of HIV you should:
Get circumcised, always wear condoms, and be choosy about your sexual partners.
or
Always wear condoms and be choosy about your sexual partners
The first choice isn’t too compelling. “Minor” surgery is always surgery performed on someone else.
So far as I know, the AAP has never recommended non-therapeutic circumcision. It has only adjusted its position on the fence from time to time.
The supposed correlation between intactness and UTIs was only discovered in 1982, long after the custom of circumcision was well-established in the US. Ironically, all the 1982 paper did was quite casually note that “95% of the [male] infants [with UTI] were uncircumcised.” without mentioning that virtually no babies born at that hospital (Parkland in Dallas, Texas) were circumcised. The paper went on: “All infants responded promptly to antimicrobial therapy.”
The main proponent of circumcision to prevent UTIs has been Thomas Wiswell, but his huge sample sizes (in the hundreds of thousands) were not random, being all born in military hospitals, where intactness would have been rare and largely confined to premature babies. In fact the huge sample sizes raise doubts about his methodology.
“parents who choose to circumcise their sons are “mutilators”. In more than 10 years in the Intactivist movement, I have NEVER seen that descriptor for parents, only (rarely) doctors.
A good critique of the three RCTs for HIV is at http://www.futuremedicine.com/doi/full/10.2217/17469600.2.3.193
“These findings are also supported by observational studies conducted in the United States.” Many studies in the US have failed to find any such correlation. For example, Zenilman et al. found “Women with uncircumcised current partners are not at increased risk for B[acterial] V[aginosis].” (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758232/) News stories often headline non-significant correlations, or correlations in small, high-risk subgroups, as though they were significant or generalised.
A flurry of pro-circ studies has come out in the last few years, but strikingly all from the same small group of researchers (Daniel Halperin, Robert Bailey, Stefan Bailis, Stephen Moses, Malcolm Potts, Ronald Gray, Thomas Quinn, Helen Weiss, Brian Morris, Jeffrey Klausner, Edgar Schoen, Thomas Wiswell and a handful of others. Sure enough, this one is by Gray and Quinn.)
The Ugandan study found no difference in sexual satisfaction after circumcision, because it found virtually perfect sex in almost every man both before and after circumcision. This does not correlate with findings in the developed world. Either Uganda is a sexual paradise, or the questions were too insensitive to find any difference.
Though they are inclined to stay silent in the US, men with foreskins generally appreciate having them for the direct sexual pleasure they give (described as not just “more sensitive” but “a symphony of sensation”) and would not willingly give them up.
Stunningly absent from all this is any consideration of the ethics of non-therapeutic surgery on neonates. Judging by the sales of devices, many tens of thousands of men are unhappy about what was done to them, and go to considerable trouble to reverse it. Changing the policy will increase that number.
“Why does the issue of what other parents choose for their sons generate so much heat?”
The reason is because it was not the victims’ choice. It is sexual abuse to amputate sexual tissue from an infant, whether it be male or female. Imagine being the victim of a circumcision you didn’t want. Imagine that your sexuality is affected.
How can you possibly question that sex is important to men? How can you possibly know that circumcision didn’t affect any particular man’s sex life? The only sensible thing is to leave the poor infant alone, and let the man decide when he is of age.
joep,
“The first choice isn’t too compelling.”
I think it depends very much on how many of your friends, relatives and sexual partners have died horribly of AIDS. My understanding is that many Ugandans are actually quite keen on anything that will reduce their risk, including circumcision.
FYI:
If I post a comment that doesn’t immediately show up, and I really want it to be a part of the discussion right way, I can usually figure out what likely triggered the holdup (key words, too many links, etc- it’s not too hard to figure out) and compose a substitute comment to suffice until the original gets approved.
@Allison
Indeed, which is why this is a context sensitive and individual decision. I wouldn’t begrudge a teen or adult in that situation or not to make that decision so long as the choice is his. However, if I noticed my friends dropping dead around me from HIV and knowing the efficiency of condoms, I sure wouldn’t ever forget it.
“where rates of circumcision in the population are easily below 5%”
You need to distinguish between current rates of neonatal circumcision and prevalence of circumcision within sexually active populations. While the rates of neonatal circumcision have been declining in a number of first world countries, prevalence of circumcised adults males is still quite high.
You need to distinguish between current rates of neonatal circumcision and prevalence of circumcision within sexually active populations. While the rates of neonatal circumcision have been declining in a number of first world countries, prevalence of circumcised adults males is still quite high.
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Some citations please!
What are you defining as ’still quite high’? Can you name some of these ‘first world countries’?
Thank you Dr. Tuteur, I enjoyed your article very much! I think parents having boys should be informed and consider both sides before making their decision. As Africa and India face AIDS epidemics, is circumcision being recommended and are rates increasing in these areas? (I read where you said it “should” be recommended in areas with high HIV rates, but was unclear if any of those areas are recommending it).
Amy said: “You need to distinguish between current rates of neonatal circumcision and prevalence of circumcision within sexually active populations. While the rates of neonatal circumcision have been declining in a number of first world countries, prevalence of circumcised adults males is still quite high.”
Current rates in most first world countries haven’t changed in generations because it’s never been common in places like continental Europe among others. Yet they have among the lowest rates of HIV prevalence.
You might be right about England where it was somewhat common until 1948 after which the rates of neonatal and child circumcision declined significantly. Neonatal rates there are easily under 5% and it’s in fact quite difficult to find a doctor willing to do it. I doubt the prevalence in the adult population is much more than 20%, mostly men born before the 1960s. It is perhaps a bit higher in New Zealand (they didn’t start to discourage it until the 1960s) now the neonatal rate is less than 1% and the adult prevalence is perhaps now below 50% and Australia where it is 10% and 50%.
So what you say might be true for Anglican countries but of those who practiced circumcision at one time in the recent past (England, Australia, and New Zealand) most discontinued it and those men at highest risk (say 25 – 35) are predominately not circumcised.
Further most of the relevant medical authorities in those countries don’t seem quite as persuaded by the effectiveness of circumcision in their populations.
“You need to distinguish between current rates of neonatal circumcision and prevalence of circumcision within sexually active populations. While the rates of neonatal circumcision have been declining in a number of first world countries, prevalence of circumcised adults males is still quite high.”
http://hivinsite.ucsf.edu/global?page=cr-00-02
Look at the HIV prevalence in Japan, China, Greece, Finland, Vietnam, Russia. None of these countries have ever routinely circumcised infants and they maintain some of the lowest HIV rates in the world.
The majority of babies haven’t been circumcised in the UK since the 1950’s when campaigns were done to show that there was no medical need to perform them on infants. As it is now 2010, it is safe to say that the majority of men 18-55 are not circumcised in the UK, and they have a lower prevalence of HIV than the US.
@Karl:
Good for you that you can figure it. I have had this happen to me with the most innocuously worded post, without any hyperlink. Possibly it has something to do with the Spam filtering plugin that this version of WordPress is using. But I agree that there is no censorship going on. As David indicated, that is the policy of crank, pseudoscience sites like AoA and AiG.
@Plonit:
In the same vein, all the authors of this SBM blog are responsible for determining the accuracy and veracity of what they post, and any reaction their post generates are to be handled by them, too. It is not David’s function – even as managing editor of the site – to censor or sanction posts. He would rather – heck, I’d rather he did – encourage a debate based on the scientific merit of the post, and argue points of evidence – which he did and does adequately.
@Dr. Tuteur: I am intrigued by the accusation of false equivalences by you towards those who are protesting the reason for routine neonatal circumcision. At random, let me take the figures from a 1990 paper in the American Journal of Epidemiology, which stated that in the US, the lifetime risk of appendicitis was 8.6% for males and 6.7% for females; the lifetime risk of appendectomy is 12.0% for males and 23.1% for females. Going by your logic for advocating neonatal circumcision, would it also not justify neonatal appendectomy?
The issue of circumcision is bound to raise emotions, since it is often firmly linked to religious and cultural practices. Adult circumcision is different; the adults have a choice.
I don’t much buy the lack of neonatal choice argument, since (a) neonates are incapable of conscious, informed consent, making the point moot, and (b) parental consent is considered sufficient for a plethora of difficult decisions in favor of invasive practices when medically warranted. But alone on the off-chance that the person in his adulthood would be exposed to STDs and HIV by engaging in risky behaviour, can the routine deployment of this procedure be justified?
Annabel’s sound question above is IMO very pertinent.
Could you please address this, Dr. Tuteur?
The prevalence in the non-religious circumcision in the UK adult population is estimated to be 6% (UNAIDS figures, 2007).
It is not David’s function – even as managing editor of the site – to censor or sanction posts.
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Sanction is in the form of inviting someone to become a contributor to SBM, which suggests that minimal standards of accuracy and veracity will be upheld as a matter of course.
“At random, let me take the figures from a 1990 paper in the American Journal of Epidemiology, which stated that in the US, the lifetime risk of appendicitis was 8.6% for males and 6.7% for females; the lifetime risk of appendectomy is 12.0% for males and 23.1% for females. Going by your logic for advocating neonatal circumcision, would it also not justify neonatal appendectomy?”
In general, parents choose circumcision for non-medical reasons, often religious, cultural or just to have sons “look like” Dad. Rarely do parents choose circumcision for medical reasons, and I don’t think the data on STD transmission is strong enough to recommend routine neonatal circumcision for public health reasons.
My main point is that the accusation that circumcision has no medical benefit is simply untrue. I have emphasized all along that if individuals don’t wish to circumcise their sons, they shouldn’t do so. But those who do wish to circumcise should not be vilified for “mutilating” their children with no medical benefit.
As regards appendectomy, if removing the appendix were as simple as removing the foreskin, I suspect it would be recommended as a routine preventive health measure.
My gosh, this disinformation just flows out: “While the rates of neonatal circumcision have been declining in a number of first world countries, prevalence of circumcised adult males is still quite high.”
Dr Tuteur has successfully sidestepped the point being made by fudging about ONLY Canada, Australia and New Zealand with the vague phrase “a number of first world countries”. Perhaps she would like to leave visitors with the impression that infant circumcision has been “prevalent” in developed countries at some time in the past. The truth is that infant circumcision has never risen above 2% in any Western European or developed Asian country, except for the England region of the United Kingdom and, of late, South Korea. And in England, neonatal circumcision rates never reached 35% and have been under 2% for more than 50 years.
The comparison suggested was the US with Europe. Tuteur hemmed and hawed something about “a number of first world countries”. No. Circumcision is not practiced in Western Europe. It is disingenuous go to off on a tangent with veiled references to a couple of former British commonwealth countries (which have now followed the lead of the UK in abandoning infant circumcision).
Approximately half of sexually active adult males in Canada and Australia are circumcised, and the percentage declines annually.
The clear trend in developed countries with regard to circumcision is marked movement from low to much lower, with favorable outcomes.
“Look at the HIV prevalence in Japan, China, Greece, Finland, Vietnam, Russia. None of these countries have ever routinely circumcised infants and they maintain some of the lowest HIV rates in the world.”
The prevalence is affect by other factors besides circumcision. Perhaps in low prevalence environments where circumcision is uncommon, increasing circumcision may make no difference. However, that does not change the fact that circumcision does reduce transmission of HIV and other STDs.
To David Gorski and Harriet Hall:
For clarification, the AAP’s 1971 Position Statement on circumcision was its first-ever pronouncement regarding the practice. That is why the chronology provided only went back that far.
Perhaps in low prevalence environments where circumcision is uncommon, increasing circumcision may make no difference.
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And the logical corollary for low prevalence environments where circumcision is common? that decreasing circumcision may make no difference?
“UNAIDS figures, 2007″
Yes, the same report also concludes:
“There is substantial evidence that male circumcision protects against several diseases, including urinary tract infections, syphilis, chancroid and invasive penile cancer, as well as HIV. However, as with any surgical procedure, there are risks involved. Neonatal circumcision is a simpler procedure than
adolescent or adult circumcision and has a very low rate of adverse events, which are usually minor (0.2–0.4%). Adolescent or adult circumcision can be associated with bleeding, haematoma or sepsis, but these are treatable and there is little evidence of long-term sequelae when undertaken in a clinical setting with experienced providers. In contrast, circumcision undertaken by inexperienced providers with inadequate instruments, or with poor after-care, can result in serious complications.”
Indeed, I have read the report. In fact, I commented (upthread) on one of the complexities alluded to in that paragraph: the difference between efficacy in controlled clinical trial settings and effectiveness in’ real life’ situations with lack of access to trained health professionals and safe equipment. A comment that you have chosen not address.
“I have emphasized all along that if individuals don’t wish to circumcise their sons, they shouldn’t do so.”
The problem is, where does that leave the poor victim that wishes to have his foreskin?
Foreskin feels really good, anyone would want theirs, so you can’t preemptively take THEIR choice away.
“In general, parents choose circumcision for non-medical reasons, often religious, cultural or just to have sons “look like” Dad. Rarely do parents choose circumcision for medical reasons, and I don’t think the data on STD transmission is strong enough to recommend routine neonatal circumcision for public health reasons.”
I think this is a major reason why circumcision is unethical. If a mother went to a doctor and said she wanted her some circumcised because she thought the foreskin looked funny that would be a legitimate reason and the doctor would perform it.
So the argument that a girl shouldn’t be circumcised because there is no proven medical benefit is biased. A male can get circumcised for any reason. What if a person thought their daughter’s labia hung too low and it looked funny? Would she be allowed to get it “trimmed”? Just a little snip? it wouldn’t be cutting the clitoris, so little sexual pleasure is lost, so is it Ok? No, it isn’t. The fact that it is legal for infant boys but not infant girls is unconstitutional. It should be illegal for both if it is illegal for one.
A person has the right to practice their religion. They don’t have a right to impose that religion on another person, including their child. If parents from a minority religion said that, in order to please their god, they had to burn a small cross on the leg of their child would that be legal? Why should removing foreskin be any different just because there are more Jewish parents than this hypothetical minority religion? Just as everyone has a right to religion, they also have a right from religion. There is no way of determining whether or not an infant will want to be Jewish as an adult, and his body should not be permanently marked as a result.
These double standards in regards to male circumcision is what adds fuel to the fire. Americans are obsessed with male circumcision, for whatever reason and constantly overlook these double standards.
Amy said: “However, that does not change the fact that circumcision does reduce transmission of HIV and other STDs.”
I don’t see a lot of people directly challenging that statement; it’s all about context. I find it interesting how medical groups in other countries realize this but the US seems to struggle with that concept.
Just as an example the Australian Federation of AIDS Organization: http://www.afao.org.au/view_articles.asp?pxa=ve&pxs=169&pxsc=&pxsgc=&id=633
“African data on circumcision is context-specific and cannot be extrapolated to the Australian epidemic in any way.”
The French as I posted previously:
http://www.cns.sante.fr/IMG/pdf/2007-05-24_rap_en_politique_internationale.pdf
“The same measures are not applicable to the Northern countries. The recommendations of the WHO state that this strategy is aimed
at countries with high prevalence, and not at countries with low prevalence or in countries where it relates specifically to one part of the population such as in France or the United States.”
And there have been a smattering of comments from the British in BBC articles and their BMA policy. Here is one:
http://news.bbc.co.uk/2/hi/health/7960798.stm
“Dr Colm O’Mahony, a sexual health expert from the Countess of Chester Foundation Trust Hospital in Chester, said the US had an “obsession” with circumcision being the answer to controlling sexually transmitted infections.”
So perhaps Amy what you tell parents is that there may be some reduction in risk but it’s relevance is trivial in the US context. You know like most others seem to do.
Dr Tuteur says:
“You need to distinguish between current rates of neonatal circumcision and prevalence of circumcision within sexually active populations. While the rates of neonatal circumcision have been declining in a number of first world countries, prevalence of circumcised adults males is still quite high.”
Dr Tuteur, please provide hard numbers on this. You are the one making the claim. Are you seriously telling me that the prevalence of circumcision in France, Germany, Belgium, Italy, UK is altered post neonatal period, to such an extent that it effects the transmission of HIV? This seems to be a stretch.
What are the adult circumcision figures across Western Europe, and their respective HIV infection rates?
–
I must make a passing comment on my previous comment which referenced “castration fantasy”.
When I read you post these two writings, independently:
“Female genital mutilation is designed to mutilate. The purpose is to deprive women of sexual satisfaction in order to strengthen male power over women.”
“Let’s talk about the evidence of whether circumcision decreases the transmission of HIV and other STDs and how that may translate into fewer deaths, less disease, less female infertility, and decreased cervical cancer.”
You do seem to be discussing women’s issues in your postings here. I cannot overstate how absolutely reprehensible I find the circumcision, and indeed cliterodectomy and female genital mutulation.
However, to be making social comments to say its purpose is to reinforce the male power over women? And then to claim we must discuss the positive effect that male circumcision will have on the transmission of diseases to women?
I would have to be gormless not to detect a rather feminist viewpoint on this.
And my real question is whether the circumcision of male children should ever be an issue for discussion in regards female epidemiology.
Finally, let me make a note on a fair number of posters that say “I was circumcised and I never give it a moment’s thought.”
Well that is absolutely fine, but surely yourselves must understand that personal point of view is not an appropriate place to argue an ethical viewpoint.
A geisha might say she appreciated that her family bound her feet and she suffered no ill from it and even benefited – but this does not validate this, and it does not make it not to be a violation, a risk, and inappropriate.
Some of you on this chat are parents of children that you have had circumcised. It is in your best interests, personally, to not question whether you may have done harm.
The truth is most likely you have. Circumcision routinely excises 70% of the nerves of the infant penis. If you don’t have it then maybe you won’t miss it.
But even paraplegics can have orgasms (surprisingly.) It doesn’t make them whole however.
The main benefit of circumcision is reduced susceptibility to disease, as stated in your post.
Condoms do a better job of preventing the spread of disease.
Also, not performing circumcision completely eliminates any chances of side effects from circumcision, such as coronal penile amputation:
http://www.springerlink.com/content/3wlr08kuj7q5×1a7/
“I would have to be gormless not to detect a rather feminist viewpoint on this.”
A feminist viewpoint? Guilty as charged.
In addition, although I did not spend much time discussing it, I believe that the impact of male circumcision on female health is a legitimate public health topic.
“In addition, although I did not spend much time discussing it, I believe that the impact of male circumcision on female health is a legitimate public health topic.”
Certainly, but how much surgical intervention is ethical for the benefit of females?
Let’s reverse that for a second.
How much unelected surgical intervention should one perform on a female infant for the benefit of males?
“In addition, although I did not spend much time discussing it, I believe that the impact of male circumcision on female health is a legitimate public health topic.”
Then it’s time to start cutting, just a tiny little bit, you understand, off of females, just to SEE if it impacts male health.
Think of the ethics of that. Think of the ethics of what you are saying.
Fact is, the majority of circumcised women say they are happy being circumcised, and that they feel no resentment from being circumcised. Here are some excerpts from a statement made by African Women Are Free to Choose (AWA-FC). I think you will find the uncanny similarity to statements made by circumcised men very interesting.
“Though we do not condone the use of violence or intimidation we are also deeply affected by the inflammatory impact of language such as Female Genital Mutilation (FGM). We declare categorically that this language is offensive, demeaning and an assault against our identities as women, our prerogatives to uphold our cultural definitions of womanhood including determining for ourselves what bodily integrity means to us African women from ethnic groups that practice female and male initiation as parallel and mutually constitutive processes in our societies.
We declare that thus far the representation of female circumcision (FC) – its social and ideological meaning in terms of gender and female sexuality and impact, if any, on reproductive health and psychosexual wellbeing has been over the last thirty years dominated by a small but vocal number of African women that make up the Inter-African Committee (IAC) with the enormous backing, if not outright instigation of powerful western feminist organizations and media personalities.
Thus far, the negative medical or health claims about various forms of FC have been disputed as grossly exaggerated by several independent medical researchers and practitioners. The claims that various forms of FC reduce or eliminate sexual desire and feeling in women have also been disproven by affected women themselves, the researchers who relentlessly question them and medical doctors who examine and treat them. We can provide ample references for anyone who is interested in any of this work.
The assertion that FC violates the rights of children falters in the face of WHO’s promotion of routine neonatal male circumcision (MC) to protect against HIV infection in Southern African. Incidentally, circumcised African women also have some of the lowest rates of HIV infection among women in the world, so why the double standard? ”
You can read the statement in its entirety here : (http://www.thepatrioticvanguard.com/article.php3?id_article=3752)
“Then it’s time to start cutting, just a tiny little bit, you understand, off of females, just to SEE if it impacts male health.
“Think of the ethics of that. Think of the ethics of what you are saying.”
Precisely. Dr Mengele’s assistant.
A person has the right to practice their religion. They don’t have a right to impose that religion on another person, including their child.
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The argument that communal identification should not be ‘imposed’ upon children cannot be sustained, since you cannot be brought up outside of one community or another. Christianity as a religion is characterised by the centrality of individual profession of faith (concordant with the centrality of choice in your assertion above). Most religious communities are not so characterised. Body modification (such as tattooing and scarification) is a very common feature of belonging to an ethnic group. Where there is not strong evidence of harm, I don’t think there is a compelling reason to disallow people ‘imposing’ some kind of ethnic or communal identity on their children, which may include body modification. Where there is strong evidence of harm, then no other considerations need apply. But the standard surely can’t be that children are blank slates until age of majority at which time they fashion their identity from a random selection of the world’s cultures.
@Plonit – are you saying that scarification and tatooing should be legal acts? I see you qualify this with “I think.”
I believe you are at divergence with the legal standards and accepted social norms of Western society.
“Where there is not strong evidence of harm, I don’t think there is a compelling reason to disallow people ‘imposing’ some kind of ethnic or communal identity on their children, which may include body modification.”
The law in the United States does not allow these kinds of modifications on children, especially without their consent. A parent cannot tattoo their child for religious or cultural reasons in the United States. As far as I know, no studies have shown that tattooing a child is any more dangerous than tattooing an adult. You would not be allowed to burn a small symbol on a child either in the United States. You could not ask a doctor to perform a ceremonial pin prick on the labia of a female child for cultural or religious reasons. You could not ask a doctor to remove the clitoral hood from a female child, even if it is part of your religion, unless there is immediate medical need. A parent can, however, have the foreskin removed from a male without immediate medical reason for any reason. See the double standard?
Plonit said: “Body modification (such as tattooing and scarification) is a very common feature of belonging to an ethnic group. Where there is not strong evidence of harm, I don’t think there is a compelling reason to disallow people ‘imposing’ some kind of ethnic or communal identity on their children, which may include body modification.”
Indeed it is a common feature of many ethnic groups and here is how they would be treated in the US:
http://www.bvblackspin.com/2010/01/05/parents-face-charges-for-tattooing-six-of-their-young-children
Sure this was done at home but I don’t think the result would have been different if it was done by a clean professional tattoo parlor. In fact I suspect it would be quite difficult to find a quality tattoo parlor to tattoo a child. Doesn’t this take away their “parental rights” though?
Annebal said: “You could not ask a doctor to perform a ceremonial pin prick on the labia of a female child for cultural or religious reasons.”
This actually happened in the US. The incident was called the Seattle Compromise you can read a legal review about it here:
http://www.law.duke.edu/shell/cite.pl?47+Duke+L.+J.+717
Here is another story of a man getting arrested for tattooing his son, who was seven years old.
“Fresno, CA (KFSN) — It was a shocking form of child abuse … forcing a tattoo on a seven year old boy. It was a small tattoo of a dog’s paw, a symbol of Fresno’s notorious Bulldog Gang.
The boy’s father, Enrique Gonzalez is accused of holding the squirming child down during the painful procedure, while a tattoo artist did the procedure. The tattoo artist was arrested shortly after the April 20th incident. Police have been looking for Gonzalez since then. He was spotted at a motel near the Madera County town of Coarsegold on Wednesday, and police moved in. Police Chief Jerry Dyer described what happened to local news media on Wednesday night.
“The suspect attempted to escape through one of the windows but saw officers in the back of the hotel and surrendered peacefully,” said Dyer.
Gonzalez is charged with six felonies including child abuse. His girlfriend, Mikayla Ramirez was also arrested, charged with harboring a fugitive. Dyer said investigators also discovered a photograph of the tattooed boy, and another unidentified child.”
“See the double standard?”
Absolutely! To even STUDY infant circumcision is completely devoid of ethics. Here we have “science based medicine” studying the sexual abuse of children and infants. Where is the evidence of ALL of what circumcision means?
What does it mean if a lot of skin is taken off versus just a little? It’s just inconceivable that there should be this studying of male circumcision without the preliminary evidence saying that there is anything ethical about it.
Evidence based science should start at the BEGINNING of an atrocity like male circumcision, not after billions are cut.
@ Hugh7
“Though they are inclined to stay silent in the US, men with foreskins generally appreciate having them for the direct sexual pleasure they give (described as not just “more sensitive” but “a symphony of sensation”) and would not willingly give them up.
Stunningly absent from all this is any consideration of the ethics of non-therapeutic surgery on neonates. Judging by the sales of devices, many tens of thousands of men are unhappy about what was done to them, and go to considerable trouble to reverse it. Changing the policy will increase that number.”
1, 2, 3…4…7! bald assertions of considerable size with no evidence. nice!
how could someone who is un-circ describe their experience as “more sensitive?” do they compare to the…circ’ed backup they use?
what if I, a circ’ed male, say that I too experience a “symphony of sensation?” does my anecdote cancel yours? i can only envision the questionnaire
circle 1 for “bummer” 2 for “ho hum”…5 for “fantastic!” and 43,000 for a “symphony of sensation!”
“unhappy about what was done to them…”
linking circs to male “enhancement.” That rubs more as a advertising plug meant to instill insecurity than a response to “mutilation.” how might an “enhancement “pill reverse a circ? might you suggest that doctors who advocate circs are in bed with..wait for it…wait…Big Penis?!
“This actually happened in the US. The incident was called the Seattle Compromise you can read a legal review about it here:
http://www.law.duke.edu/shell/cite.pl?47+Duke+L.+J.+717 ”
Yes, I know. Which is how I know that such a thing would be illegal in the United States, as it should be. All children have the right to an intact body.
geskoi said: “Evidence based science should start at the BEGINNING of an atrocity like male circumcision, not after billions are cut.”
I think it goes without saying that were we in the west innocent of infant circumcision, nothing presented thus far would compel us to start doing it.
I will clarify.
Where there is no compelling evidence of harm, it would be wrong to prevent communities from ‘imposing’ some kind of ethnic or communal identity on the children born into those communities, this may include body modification.
As to whether any specific act was prohibited, my own view would depend on whether there was compelling evidence of harm. Since I don’t view body modification to be intrinsically harmful, the fact that the body is modified would not, in and of itself, be compelling evidence of harm in my opinion. However, many forms of body modification can nonetheless be shown to be harmful in other terms. I am aware that this is not necessarily the legal or social standard in many Western societies with regard to specific forms of body modification. But are we talking about what ‘ought’ or what ‘is’? Just because something is normative, doesn’t mean it is logical or right.
Amy Tuteur – I was taught that circumcision was the right thing to do. I have intentionally sought evidence to support my world view as it would make me uncomfortable to be wrong after so long and especially when I have done so much to encourage the performance of this procedure.
Average creationist – I was taught that the world is 6000 years old. I have intentionally sought evidence to support my world view as it would make me uncomfortable to be wrong after so long and especially when I have done so much to encourage the belief of this knowledge.
The less harm done in this case is to not perform surgury on either boys OR girls without their explicit consent, and to promote condom use and safe sex practises.
@ Plonit -
You say ” I don’t view body modification to be intrinsically harmful…”
That’s fine and dandy, go ahead and modify your own body then. You don’t speak for everyone. If I had been tattooed as a child I would greatly resent it now as an adult, and that is why it is unethical. I am twenty five years old and don’t have any tattoos or any piercings, not even on my ear lobes. Even though piercings and tattoos are socially acceptable, I don’t prefer them for myself. My mother told me that when I turned 16 she would allow me to get mine pierced if I wanted, but I had no desire to, and she was fine with that.
The lack of choice in neonatal circumcision is what the whole debate hinges on. No one cares if an adult circumcises himself, because it would be his choice. The law realizes this basic human right in regards to tattoos and other body modifications, but not circumcision.
“A feminist viewpoint? Guilty as charged.
In addition, although I did not spend much time discussing it, I believe that the impact of male circumcision on female health is a legitimate public health topic.”
It’s good for women that men are given circumcisions instead to being taught to practise safe sex and to use condoms?
That the relatively small improvement in infection rates that circumcision may bring is better than the almost complete protection that condom use brings?
Yeah, you’re a real feminist, protecting patriarchal religious practices in the face of the real solution that education, poverty relief and condom use protect women far more than archaic priestly practices.
Annabel, I really appreciate hearing a woman’s view on this.
It is personal to me, but my mother was advised by the medical profession when she was 18 years old.
Irrespective of myself, and my personal relationship to it, I believe it to be an ethical situation.
There is no proven benefit and it is ultimately ritualistic. Surely this is in utter contravention of the rights of any human being to have their body surgically altered without their consent.
They stretch necks with gold rings in a tribe in Africa. Would that be accepted here? No way.
As I say, it is a revelation to hear you so strident and have such a clarity of thought. It is such a simple issue of election and personal right to me.
I can do anything I want to my body. But I don’t need people in white coats doing utterly unnecessary things to me, and things which are completely invasive to the most innervated part of my body for heaven’s sake.
Female genital mutilation is an utter disgrace and an utter tragedy. It is a great shame that male circumcision is not seen as an equal violation of the right of the child, even if not necessarily as absolutely catastrophic.
If I had been tattooed as a child I would greatly resent it now as an adult, and that is why it is unethical. I am twenty five years old and don’t have any tattoos or any piercings, not even on my ear lobes. Even though piercings and tattoos are socially acceptable, I don’t prefer them for myself. My mother told me that when I turned 16 she would allow me to get mine pierced if I wanted, but I had no desire to, and she was fine with that.
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But presumably you feel that way because you grew up to be all twenty five years old as part of a community in which individual choice and self-expression are highly prized and in which tattooing and piercing is not normative. In other words, you don’t prefer them for yourself because of who you are, and who you are has been shaped by the community you are a part of.
Suppose you are a girl in a community where ear piercing for girls in completely normative, and this distinguishes girl babies from boy babies from day 1. Your parents decide that they don’t go along with all this gender normativity stuff. Without pierced ears every single person in the community assumes you are a boy. Gradually the rest of the community come to realize that you are not a boy after all, instead you are a ‘girl without pierced ears’. Since having pierced ears is an important component of what it means to be a girl in your community, your may have done you a disservice by not getting your ears pierced. Of course, you can say that the community is wrong and that your parents are right, but is it right to impose your will on the entire community over this, for example by criminalising the entire community? Why is it more important for children to have more freedom of action over their ear lobes than over what is between their ears (since you presumably were educated in some form or other, in ways which have permanent ramifications and over which you had little or no control)?
The issues are even more complex when we consider the position of tribal communities and ethnic minorities vis-a-vis dominant cultures. I am perfectly willing for the rights and sensitivities of minorities to be trampled where there is compelling evidence of harm, not so much where evidence of harm is tenuous.
“but is it right to impose your will on the entire community over this, for example by criminalising the entire community”
So we roll back 500 years of science and development because the Mediaeval English thought that soap and taking a bath caused scrofula and the ague?
If something is done without explicit consent, that does not have an immediate benefit, can cause further medical problems, and can later be performed WITH explicit consent and when any benefits may be realised, then it’s wrong.
You vaccinate children because they need it when they’re children. You teach condom use and safe sex to teenagers because they may need it soon. You circumcise when explicit permission has been given by the adult.
If the reason for doing the circumcision in UK or US context is for purported health benefits, then I think the parents are mistaken and should be advised as such. For a medical procedure, the onus is on proponents to show evidence of benefit.
If, however, you are using a surgical technique to cultural ends, then I don’t think your arguments about ‘when benefits may be realised’ apply, since the benefit of the procedure is the inclusion of the child into a community in which that procedure is a mark of membership. To do otherwise is to ‘mutilate’ the person by cutting them off from their community and cultural identity (they become ‘the uncircumcised muslim/jew’ – as in the example above about the ‘girl with unpierced ears’). Can you explain why having a foreskin is more important than having a secure cultural identity?
If there were compelling evidence of harm, I say it trumps all of that. But where is the compelling evidence of harm? Every survey I’ve seen suggests that circumcised and uncircumcised men are satisfied and disastisfied with their bodies, sexuality etc… in equal numbers, which suggests that it really makes no difference.
“Can you explain why having a foreskin is more important than having a secure cultural identity”
Cultural Identities can and do change, often by simply not performing archaic practices that have no modern cultural imperative.
Southern US cultural racism changed, though proor to the civil rights movement, not refering to a blakc person by the n-word resulted in cultural isolation and shunning.
The English considering Catholics to be dangerous and to empathise with a Catholicresulted in expulsion from that culture.
When a cultural belief is wrong, it’s wrong, and often the easiest way to recognise it is when a right ascribed to a culture impinges on the right of the individual.
@ Plonit
I disagree with you that ear piercings and tattoos are not normative. I am in the minority of all women in my family and all my friends by not having my ears pierced.
I also disagree with your idea that just because something is the cultural norm it should be allowed. Slavery used to be the cultural norm in the United States and Europe. Not having slaves usually implied you were not high class, and poor. Does that make slavery right? I don’t think so. What about segregation? Making African americans go to separate schools and sit in certain seats was the cultural norm until very recently. Does that make it right?
Cultural values change. When a cultural value imposes on a human beings constitutional rights, it is unethical.
“The prevalence is affect by other factors besides circumcision. Perhaps in low prevalence environments where circumcision is uncommon, increasing circumcision may make no difference. However, that does not change the fact that circumcision does reduce transmission of HIV and other STDs.”
Fascinatingly, if you look at the circumcision prevalence of the english-speaking countries (England, Australia, Canada, New Zealand, the US), it’s positively associated with HIV/AIDS prevalence. Quick and dirty R2=.4. (No, I do not imagine this proves anything at all. Not even close. I just think it’s fascinating, that’s all.)
These are all countries with an HIV/AIDS prevalence of less than 1% and may have more in common with one another than they do with Scandinavian countries or with African countries.
“My main point is that the accusation that circumcision has no medical benefit is simply untrue.”
I read your post. It seemed very clear that your main point is 1) given that in high-HIV prevalence areas circumcision is almost certainly helpful in preventing HIV/AIDS, 2) the AAP should change their recommendations for routine neonatal circumcision in a low-prevalence country.
Your secondary point seemed to be that the antic-circ movement was successful in causing the AAP to make non-science-based changes to its recommendations.
You have not been clear on exactly how or why you think the AAP should change their recommendations (main point), and you seem to have been mistaken about the history of AAP recommendations (secondary point). So I can understand that you wish you had written the post differently, or that you wish that we would understand what you meant to say instead of what you did say.
On your part, can you understand why people are responding to the post you actually wrote, instead of to some other, more easily defensible post?
Another question: have you ever said “I stand corrected”? If we knew which parts of your statements you revised we could stop arguing about them and move on to more interesting and profitable discussion.
I also disagree with your idea that just because something is the cultural norm it should be allowed.
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I didn’t say that AT ALL. Please do read what I wrote.
The test of whether or not something should be prohibited is not whether it is normative. The test of of whether or not something should be prohibited is whether it is harmful, and whether prohibition reduces succeeds harm without creating greater harms.
Can I ask you a question? Just because something is a cultural norm should it be disallowed?
What I actually wrote was “Where there is no compelling evidence of harm, it would be wrong to prevent communities from ‘imposing’ some kind of ethnic or communal identity on the children born into those communities, this may include body modification.”
I further qualified that by saying that many forms of body modification can be shown to be harmful.
I am fully aware of the ‘double standard’ (see my earlier comments on Type Ia FGM upthread).
The reason I place “imposing” in inverted commas is because cultural identity/ethnicity/belonging to a community is inevitably imposed, how could it be otherwise. You are not kept nice and pure until the age of majority and then choose your culture, like shopping in the supermarket. Yes, it is imposed on you for good and ill. And yes, it is part of you/you are part of it and as people change, culture changes. Nothing wrong with that, and huge amount right with that.
But when majorities decide that the cultural practices of minorities are barbaric and need prohibiting, they need to be sure that the harms of those practices are actually greater than the harm done by the act of prohibition itself.
None of which has anything to do with advocacy for routine circumcision, since medical procedures require evidence of benefit and not just absence of evidence of harm.
prohibition reduces succeeds harm without creating greater harms.
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It’s late! that should be “whether prohibition succeeds in reducing harm without creating greater harms”
“Where there is no compelling evidence of harm, it would be wrong to prevent communities from ‘imposing’ some kind of ethnic or communal identity on the children born into those communities, this may include body modification.”
http://www.circumstitions.com/Restric/Botched1sb.html
*** PICTURES OF BOTCHED CIRCUMCISIONS, VIEW AT YOUR OWN DISCRETION**
There is an inherent risk of complication with EVERY circumcision, many of which aren’t known until a person is an adult. If you think there is no compelling evidence of harm in circumcision, you are wrong. Aside from physical harm, there are thousands of men who greatly resent the removal of their foreskin without their consent. They would have preferred to remain intact if given the choice.
Every year babies die in the United States as a direct result of circumcision. Penises get amputated. These risks are inherent with every circumcision. No one signed off for their child to get circumcised thinking it would be botched, but you don’t know if you will be one of those statistics until it is too late.
I linked this study earlier, but a man has a .04 percent or .0004 of contracting HIV from a woman. That is a 1 in 2,500 chance. Even the most conservative complication risk rate of circumcision is well above that number. HIV is not a spontaneous disease, you have control over your behaviors.
@Amy Teuter: “However, that does not change the fact that circumcision does reduce transmission of HIV and other STDs.”
So what changes that fact in Cameroon, Ghana, Lesotho, Malawi, Rwanda, Swaziland, Tanzania and parts of Uganda, where more of the circumcised men have HIV than the non-circumcised men, according to National Demographic and Health surveys, or New Zealand, where a large cohort study found no significant difference in STDs?
“Adolescent or adult circumcision can be associated with bleeding, haematoma or sepsis…”
So can neontatal circumcision, and with ablatio penis, ablatio glandis and death, not to mention a variety of lesser and aesthetic damage, that can still negatively impact on sexuality. (And any mistake on a baby’s penis is magnified when he grows up, like writing on a balloon before blowing it up vs after.) The big difference is that the adolescent or adult can be informed of these risks before he gives his informed consent to the removal of part of his own body.
@EricG: There have been no scientific studies, but several informal polls have found that non-circumcised men are much more likely to be happy about their condition than circumcised.
When I said “devices” I was referring to devices specifically for foreskin restoration, not penile enlargement. Some men who have been circumcised as adults (not by their own choice or for something that made their sex sub-optimal) describe the difference as “like going colour blind”. I said NOT just ‘more sensation’.” The “symphony of sensation” is perceived as being detected by the foreskin itself. No foreskin, no symphony.
“So we roll back 500 years of science and development because the Mediaeval English thought that soap and taking a bath caused scrofula and the ague?”
There have been many comments so maybe I missed this, but I have not yet seen compelling scientific evidence showing the detriments of circumcision.
As a “victim” of circumcision I question whether I want you speaking for my plight. I am extremely happy with my sexual function and the sensitivity of the various sections of my organ. Who are you to say that I am wrong? Do you have compelling evidence showing that my sexual satisfaction is far below that of uncircumcised individual?
I am quite grateful for the decision my parents had made and would not want someone taking that decision away from them without good evidence of harm (which I have yet to see rationally detailed). I have no memory of the event. If I was given the opportunity now, I would probably choose not too precisely because I would have memory and obvious pain. But seeing as I have no memory of any pain or trauma from the event I am not the least bit unhappy about it. Is there data to suggest that males have residual memory of the trauma sufferred?
Furthermore, being a gay man, and encountering several of both kinds in my travels, I will say that I like the way mine is a little bit more, but that’s just one man’s opinion.
“You vaccinate children because they need it when they’re children. You teach condom use and safe sex to teenagers because they may need it soon. You circumcise when explicit permission has been given by the adult.”
I don’t think you can compare this to vaccination at all. The potential harm of not vaccinating is certainly much higher than the potential harm caused by circumcision. Do you have any evidence to show otherwise?
Bottom line is, parents should be given all the available information, both pro and anti-circumcision and allowed to make the decision for their children. Advocacy groups can make whatever recommendation that they like, but the end result should be allowing parents to decide. That is a responsibility that the parent must bear and one that should not be taken away unless you can show evidence of substantial harm, which I have yet to see presented.
“There have been no scientific studies, but several informal polls have found that non-circumcised men are much more likely to be happy about their condition than circumcised.”
As this is a science based medicine site, I don’t think informal polls should be trusted as accurate sources of information. They wouldn’t be trusted if this was a discussion about vaccines and autism, therefore are not accurate sources of information within this debate either.
“Some men who have been circumcised as adults (not by their own choice or for something that made their sex sub-optimal) describe the difference as “like going colour blind”. I said NOT just ‘more sensation’.” The “symphony of sensation” is perceived as being detected by the foreskin itself. No foreskin, no symphony.”
How do you know its not a developmental issue? When you are born, all your neural connections are not completely developed yet. So an adult with a foreskin may have developed different sensory inputs based on the inputs recieved. However, an neonatal circumcised adult may develop the same experience but from different inputs. Therefore, the removal of the foreskin as an adult, after neural pathways are formed, could result in loss of sensation, whereas a neonatal circumsized adult retains similar sensation to a uncircumcised adult because those pathways were formed from different inputs following circumcization.
That would be a rather difficult question to answer and there has been no evidence presented either way on such a question.
As someone who has lost friends to AIDS, both men and women, I’m appalled that it would ever be used in such an irresponsible and political manner. I’m particularly appalled that an ob/gyn, who will be passing along information about sex and safe sexual conduct to girls and women, would apparently be that incredibly ignorant about AIDS and STDs. (Or unethical enough to ignore the reality of AIDS prevention simply to promote a personal bias masquerading as being about the reality of circumcision and AIDS. You are aware that uncircumcisized men die of AIDS too? And transmit it to partners? To be clear, since I don’t have a penis and I don’t think men should be determining what I do with my body as a woman, I’m neutral about circumcision of adults and wary about ANY unnecessary surgery on babies.)
The way to prevent transmission of STDs and AIDS is to practice safer sex – this means using condoms and barriers. Are you advocating people have unprotected sex and promoting the idea that as long as you’re circumcised that it’s somehow safer to have unprotected sex?
The risk of HIV is irrelevant to the discussion of whether there is compelling evidence of HARM.
Yes, every surgical procedure has a risk attached – accepted. What is the risk of having a botched circumcision? And is your claim that circumcision is wrong because you run the risk of it going wrong? Or that every circumcision is already wrong from the outset?
As for the thousands of men who greatly resent….I think that is very dependent on cultural context. I would expect that men who feel that their circumcision was unnecessary feel badly about it. It’s a consideration for parents thinking of circumcising on tenuous medical grounds. Is there any research on the effects of the promotion of ‘foreskin restoration’, either positively or negatively, on the feelings that men have about being circumcised?
What is the death rate from circumcision?
Amy Tuteur MD:
Still not true. Not even getting warmer. Circumcision was practiced in Queen Victoria “circumcision to prevent masturbation” countries. The U.K. starting declining many years ago (the 1940s) and is somewhere around 6% now. The main countries where circumcisions are done to neonates routinely are Jewish or Muslim ones- religious reasons. Besides the U.S. and Canada and Australia, this remains pretty much exclusively true.
(And I am in total agreement with Plonit about circumcision as religious ritual or cultural identity). I also think the foreskin restoration/outlaw circumcision/amputating penises people are… trying to be nice… exagerrating their case. The risks are minimal. But I also cannot understand, unless you are Jewish or Muslim or living in Uganda, wanting to circumcise your son.
See page 9 and 12.
http://whqlibdoc.who.int/publications/2007/9789241596169_eng.pdf
Annabelle:
Well, to be fair, she did give the example of Cameroon as a high circ-low HIV state. The UK, Netherlands, France, Italy etc etc etc just don’t count.
Dr. Tuteur:
Now, there is one interesting, loaded question. And not suprising from Dr. Tuteur, who once proposed that ALL pregnancies should be induced at 38 weeks to prevent stillbirths at 39 and 40 weeks, if that’s where the science will take us (implying that that is what the science will show in the next few years). I really think that people are underestimating the extremism.
Here’s what the “Pediatrics” study that Dr. Tuteur cited also concluded (for the US):
So, 100 NNT for UTI, 909 NNT for penile cancer, they can’t even make a guess for HIV/ other STDs because of the differing populations. The NNH are small, and so are the NNT.
http://pediatrics.aappublications.org/cgi/content/full/105/1/S2/246/T1
“Furthermore, being a gay man, and encountering several of both kinds in my travels, I will say that I like the way mine is a little bit more, but that’s just one man’s opinion.”
I’m glad that you didn’t mind the choice your parents made for you. Whilst you may not have seen the evidence that circumcision may be detrimental, and may I point you up a couple of posts to Annabel. Any medical procedure has risks, and the side that medicine has fallen on is that you don’t perform a medical procedure unless there is a very good reason to do it there and then. Circumcision can be left till much later, and be chosen by the person involved, with their explicit permission, before any benefits become apparent.
Also, I would like to say, also as a gay man, that I prefer dick however it comes. This isn’t an argument about aesthetics, it’s about risk – the risk of infection and scarring, consent – a decision about surgery where any possible benefits will be seen only decades into the future, and about Ms. Tuteurs belief that you can roll out a shoddy second rate medical procedure where better options already exist.
Circumcision is not a replacement for safe sex and condom use, a minor improvement in infection rates are dwarfed by condoms and safe sex. The supposed medical benefits are a rationalisation for archaic tradition and habit.
“The way to prevent transmission of STDs and AIDS is to practice safer sex – this means using condoms and barriers. Are you advocating people have unprotected sex and promoting the idea that as long as you’re circumcised that it’s somehow safer to have unprotected sex?”
I agree. I myself have not seen or heard of any study or statistic that shows being circumcised and wearing a condom is any safer or provides any increased protection than being uncircumcised and wearing a condom. Circumcision is not the least invasive or best method of reducing your chance of getting AIDS. Condoms and responsible lifestyle choices are the least invasive and most effective method of reducing HIV.
“Circumcision is not the least invasive or best method of reducing your chance of getting AIDS. Condoms and responsible lifestyle choices are the least invasive and most effective method of reducing HIV.”
This certainly sounds sensible, but it depends on where you are. People want to be twice as safe, three times as safe. If you are a monogamous heterosexual in a low-prevalence community and you spend enough time with your partner to know that they couldn’t possibly be stepping out on you, circumcision will seem completely irrelevant to you. You aren’t even using condoms!
Other people who are in high-risk communities (prostitutes; very promiscuous gay men; people who live in Swaziland — HIV/AIDS prevalence of 26%!) are often very keen on using as much protection as possible.
Condoms.
Double-bagging (two condoms). Except, oh dear, using two condoms causes the condoms to rub against eachother and increases breakages. Gah.
Ok then, condoms and microbicides. Nonoxynol-9 is a spermicide and it kills HIV in a test tube. Two for one! Lower the risk of pregnancy and the risk of HIV/AIDS at the same time! Except that nonoxynol-9 causes irritation and small tears in the vagina, actually increasing the risk of contracting an HIV infection. Double-gah!
Having sex only with girls from the country. Mmm… that might have worked in the early 80s. Not any more! And besides, that might work for you but is not so great for the country girls contracting HIV from city boys.
Having sex only with virgins. Yeah, but if everyone’s using that strategy then there are fewer and fewer virgins left, and you end up chasing little girls. No matter where you are in the world, if you have sex with a seven-year-old virgin her parents are going to be very unhappy with you. And if you’re a very promiscuous gay man, that just isn’t an option for you.
The reality is, if 26% of your friends, relatives, fellow-citizens have HIV/AIDS, you’ll be grasping at straws. If your wife or boyfriend has HIV/AIDS you’ll use condoms and be very interested in the possiblity of getting circumcized.
It’s all very well to say that people shouldn’t be very promiscuous gay men, but since when did that stop anyone? If I were a very promiscuous gay man I would certainly think about condoms + circumcison. Likewise, if I were having sons in Swaziland I would be getting me to the mohel lickety-split.
The reason that circumcision as a partial risk-reduction strategy can seem so absurd is that HIV/AIDS seems so easily avoidable in a low-prevalence world. And in a low-prevalence world, circumcision really doesn’t seem to be worth it.
I knew someone who was working in development in Mozambique in the eighties. He went back to Mozambique after two years. All the drivers who had been working for the government ministry were dead. Two years after that, the government officials he had been working with were dead or dying.
You would take a lot of risks to prevent that. Either that, or you would give up.
But if you’ve never met anyone with AIDS? The risk seems so theoretical as to be nonsensical.
“Circumcision is not a replacement for safe sex and condom use, a minor improvement in infection rates are dwarfed by condoms and safe sex.”
I don’t think it was ever claimed to be a replacement for safe sex.
“Circumcision can be left till much later, and be chosen by the person involved, with their explicit permission, before any benefits become apparent.”
But again, why can it not be left to the parents to make the decisions. Parents make many decisions for their children, decisions that are far more important and have much further reaching potential harms than circumcision. Why is it wrong to allow parents to be presented with all of the information and to then make the choice most appropriate to them?
There are many arguments being made that have little evidenciary support, especially those claiming that there is a loss of sensation in circumcised men compared to uncircumcised. I would argue that that comparison, especially one regarding experience, is difficult to make, and that adult circumcision recipients are not the correct control population for infant circumcision recipients.
“This isn’t an argument about aesthetics, it’s about risk – the risk of infection and scarring, consent – a decision about surgery where any possible benefits will be seen only decades into the future, and about Ms. Tuteurs belief that you can roll out a shoddy second rate medical procedure where better options already exist.”
I haven’t seen evidence that it is at all a “shoddy second rate medical procedure”. It does carry risk, but what is the percentage of error rate. What is the actual risk ratio for an individual?
From what I have seen on this blog, those arguing against circumcision appear to use many of the same tactics as the anti-vaccination folks and to me that definitely turns me off from keeping more of an open mind to that side of the debate. Personally, it is not something I ever give much thought to, being quite happy with my “multilation”.
“This certainly sounds sensible, but it depends on where you are. People want to be twice as safe, three times as safe. If you are a monogamous heterosexual in a low-prevalence community and you spend enough time with your partner to know that they couldn’t possibly be stepping out on you, circumcision will seem completely irrelevant to you. You aren’t even using condoms!”
Show me a study that says condom + circumcision offers a greater benefit than condom + being intact. I haven’t seen any, but I could be wrong.
Quite honestly, I can’t believe that someone whose job is meant to be caring for women’s health is promoting unsafe sex (which is what ignoring the absolute necessity of condoms and barriers in AIDS prevention, and preventing the transfer of other STDs, is doing).
This blog seems more to be about attention seeking around a hot/controversial topic and promoting a personal opinion than science-based medicine or reality-based thinking. As a woman, it makes me sad that it’s by a woman whose job it is to care for women’s sexual and reproductive health.
Archangl508 said: “But again, why can it not be left to the parents to make the decisions.”
Why should the decision about my penis be made by my parents when there is no objective need for them to make that decision for me?
Archangl508 said: “I haven’t seen evidence that it is at all a “shoddy second rate medical procedure”. It does carry risk, but what is the percentage of error rate. What is the actual risk ratio for an individual?”
Well it is a shoddy second rate medical procedure. At least the purported benefits can typically be realized in far more effective, safer, and less invasive ways. The risk is not well known because nobody has actually studied it closely. Funny for such a common procedure isn’t it? The AAP low balls the risk at about 0.2% authorities in places like England or Australia estimate about 2% or so. But for a procedure that has no point is any error acceptable?
Archangl508 said: “those arguing against circumcision appear to use many of the same tactics as the anti-vaccination folks ..”
Maybe some but not most. These two issues are distinctly different. There is a chasm of difference between them, vaccines have a purpose circumcision has little if any.
“But again, why can it not be left to the parents to make the decisions.”
It’s a medical procedure. One, that for all the conflating of circumcised adult, the phenomenon studied, and neo-natal circumcision, the completely different phenomenon advocated, in Dr Tuteur’s post, does not have to be done until at least puberty. There hasn’t been a single argument that favours neo-natal circumcision over adult circumcision. The argument is a fig leaf so that some MDs can go on happily surgically removing the foreskin of babies without feeling too guilty about it.
Neo-natal circumcision is a wholly aesthetic choice on the part of the parents and advising physician, and has the risks of any medical procedure. Aesthetic surgery performed on newborns is not good medicine.
“But again, why can it not be left to the parents to make the decisions. Parents make many decisions for their children, decisions that are far more important and have much further reaching potential harms than circumcision. Why is it wrong to allow parents to be presented with all of the information and to then make the choice most appropriate to them?”
Yes, parents make many decisions for their children. Like what to eat, where to go to school etc. But there are limitations. Children are not property. You cannot make the choice to NOT feed your children. You cannot make the choice to NOT educate your children.
Whether or not to circumcise is not a choice parents make for their children, it is a choice a parent make for their sons. Daughters are protected from this “choice” under the law. Even the most minor pin prick or incision is against the law when done to girls. This is unconstitutional. There is no evidence that shows a woman who resents her circumcision is anymore distressed than a man who resents his. The majority of women who are circumcised are happy with it, and claim the harms are grossly over exaggerated. Babies are not having sex. Why the rush? Let the owner of the penis decide if the risks are worth it or not. After the age of about 6 the child is going to be the person who deals with the majority of the cleaning and care of his penis. He is the one who is going to have to look at it every day of his adult life. I am not against circumcision. I am against infant circumcision.
Do you not agree that it is a double standard that parents can choose to circumcise their sons for any reason but can’t circumcise their daughters for any reason? You don’t have to believe or even know that a medical benefit exists to circumcise your son, the fact that you think it “looks funny” is a valid and legal reason in this country to mutilate your baby. I have spoken to women who did not know that not circumcising their babies was even an option. They were just given a consent form and asked to sign. No one explained the risks or benefits to them, it is just the norm.
Ack…”You are aware that uncircumcisized men die of AIDS too? And transmit it to partners?”
That was meant to be “circumcised men”.
The point is that trying to justify circumcision on the grounds that it’s supposed to offer some protection from AIDS and STDs is scientifically ridiculous in this day and age where everyone should be using condoms and barriers unless they’re in a committed partnership. If you’re using a condom being circumcised doesn’t offer any secondary protection – this is meant to be a science-based medicine blog and that is a very poor scientific argument for circumcision considering the reality of how to prevent the transmission of STDs.
Annabel,
“In addition, it has been hypothesized that behavioral disinhibition may counteract any protective effects of male circumcision. However, there was no consistent or substantial evidence of change in sexual behavior after circumcision in the Kenyan or Ugandan randomized controlled trials.”
What this means is that whatever these men were doing to try to keep themselves safe before they were circumcised, they kept doing it. And their infection rates dropped after they were circumcised.
If you are trying the argument that if a foreskin never contacts another human being then HIV/AIDS cannot be contracted through the foreskin, then you are absolutely correct. Very educated and vigilant people can and do maintain sexual relationships with serodiscordant partners without ever seroconverting.
But we all know that over the course of a lifetime, the likelihood of a horny foreskin never making contact with another horny person is… well, small. Condoms break. Young men get overexcited. People are jerks. You know.
It’s kind of like saying that birth control is an unnecessary consideration because all you have to do is just not have sex. Ever. Except when you’re actively trying to conceive a child. And in fact, there are people out there who are models of self-control. They don’t ever have voluntary sex.
However, not only is birth control commonly accepted as helpful, “double-Dutch” is the best birth control out there: birth control pills to prevent pregnancy + condoms to prevent transmission of STIs = very very low rate of abortions in Holland.
Just for the record, if I had a son here in Canada, today, I probably would not have him circumcised. The risk/benefit ratio is just not what it is in Uganda or Swaziland, and foreskins are the default position. I wouldn’t want to mess with it without a compelling reason.
(Then again… with peak oil, condoms might not be easily available thirty or forty years from now. If I had a son today, he might be making do in difficult circumstances very different from the ones I enjoy today. So… never say never.)
“If you’re using a condom being circumcised doesn’t offer any secondary protection – this is meant to be a science-based medicine blog and that is a very poor scientific argument for circumcision”
Actually, I’m not too bothered about circumcision per se. Circumcision of newborns just makes me annoyed.
The problems raised by using circumcision as a method of STD control are completely different. We already have better solutions, condoms are near perfect if used correctly and are available.
This is the real problem, condoms aren’t universally available and education on their correct use is next to non-existent in poor countries and close to non-existent in many developed nations.
So it’s really just a cheap solution for the ravages of STDs. One where you don’t have to raise the standard of living so the people can afford condoms, and where you don’t have to annoy those pesky fundamentalists.
And it’s that that makes me actually angry about circumcision, it’s that it’s the solution for the lazy and the penny pinching.
Like all good snake-oil salesmen, Amy Tuteur leaves out important information. For instance, she doesn’t mention that sexually transmitted infections can be prevented much more effectively by using condoms.
1) If you’re going to make a case for something then please *make a case*. You didn’t. You spoke in favour of something (largely without reference to any data).
You know that there’s more than 3 studies in favour of Homeopathy, right?
2) Your comments regarding “Infants are unable to give consent to anything. They routinely undergo medical procedures with far more risks than circumcision based solely on parental consent. Why should circumcision be viewed differently?” seem disingenuous.
You have “MD” after your name. That implies some familiarity with Medical Ethics, and the thing that the parents give consent to is typically a treatment for something that the child has contracted.
In this case, the child hasn’t contracted anything.
A secondary reason for parental consent for a medical procedure is to prevent (or reduce the risk of) something from occurring during childhood. In the cases listed above, all are to do with sex. Since children aren’t (usually) having sex, this medical procedure offers the child (as a child) no medical benefit.
Why the push to circumcise children?
Or to phrase it more polemically: why the push for an unnecessary medical procedure that will have *zero* medical benefit for the duration of the childhood?
Why aren’t you making the case to *adult men* about why *they* should be circumcised?
As an adult man, why aren’t you trying to convince *me* to get circumcised?
3) Some people (such as myself) consider mutilation to be any damaging of the human body. Yes, that includes ear piercing. Yes, that includes surgery.
In the case of surgery, the medical benefits outweigh the (short-term) damage to the body (usually).
In the case of ear piercings: no, absolutely the parents should not be entitled to turn their kids into walking advertisements for their taste in jewellery. Kids aren’t property…
Demonising people for their choice of precise (though emotive) terms doesn’t address their arguments, or the massive gaping holes in yours.
“The point is that trying to justify circumcision on the grounds that it’s supposed to offer some protection from AIDS and STDs is scientifically ridiculous in this day and age where everyone should be using condoms and barriers unless they’re in a committed partnership.”
Male latex condoms have a 15% “typical use” failure rate preventing pregnancy and a 2% “theoretical” failure rate.
Female polyurethane condoms have a 21% “typical use” failure rate preventing pregnancy and a 5% “theoretical” failure rate.
Let’s assume that the typical users of these barrier methods deserve their high failure rate, deserve unwanted pregnancies and deserve to die of AIDS. Fine. That still leaves a 2% failure rate for condoms when they are used perfectly. Enough of them break that over the course of a year of a loving, respectful relationship, 2 vigilant, careful heterosexual couples out of 100 will have unwanted pregnancies.
There are other birth control methods to double-up with and it’s generally considered sensible to use them. Condoms with spermicide. With birth control pills. With a diaphragm. Something.
There aren’t other STI-prevention methods to double-up with.
Is it not ok to want a backup plan? Even if it’s not a great one?
If the risk that you’re having sex with an HIV positive partner is low, you may not care about a backup plan. If it’s high (26% in Swaziland) or if it’s 100% (your beloved serodiscordant spouse), you will want all the backup plans you can get.
With respect to circumcision generally, the foreskin is the default position. Someone who thinks it should be removed needs to come up with facts to justify themselves.
With respect to doubling-up, intuitively it makes sense that condoms aren’t perfect and people aren’t perfect, so some form of doubling-up would be helpful. It’s documented with respect to pregnancy and there’s some evidence from Uganda and Kenya that it’s true with respect to HIV transmission as well. If you want to say it’s not true, then you need to come up with data showing that someone who wants to try protecting himself, or protecting her sons, should not try.
A mutilated penis is not good, but AIDS is much worse. Balancing a 100% probability of a somewhat-bad thing (mutilated penis) against the possibility of a terrible, horrible, no-good very-bad thing (AIDS) will always be a judgement call but needs to be informed by just how possible AIDS is. If AIDS not very probable in the first place, then why mutilate a perfectly good penis to help avoid it? If AIDS is extremely probable, then yeah, every little bit counts. Too bad, foreskin.
“However, there was no consistent or substantial evidence of change in sexual behavior after circumcision in the Kenyan or Ugandan randomized controlled trials.”
How would the researchers know this? Humans are not lab rats, we have sex in unpredictable ways. This data was gathered by self report, which is an extremely unreliable way of gathering data.
“…they kept doing it. And their infection rates dropped after they were circumcised.”
Perhaps you also know that the trials ended early, by the admission of the researchers. It is very likely that the rate of infection would have caught up to the uncircumcised group if given time to do so. Circumcision is a risk reduction, after all. It is not an immunity. A 60 percent risk reduction to a circumcised man who continues to have unprotected risky sex is minimal. Circumcision is not a vaccine, it is similar to the reduction in risk of getting the flu by washing your hands.
“But we all know that over the course of a lifetime, the likelihood of a horny foreskin never making contact with another horny person is… well, small. Condoms break. Young men get overexcited. People are jerks. You know.”
And what do you think the risks of those few times that a horny foreskin touches a horny vagina ( since circumcision has no proven benefit in protecting gay men, or protecting heterosexual men when having anal sex with a woman.. so horny person is a bit misleading) that they will get HIV? Minute. “A 1996 Wall Street Journal article on AIDS reports that the chance of contracting HIV from random unprotected sex with non-IV drug using heterosexuals is “smaller than the risk of ever being struck by lightening.” I think it’s safe to say that the risk of dying during a circumcision is greater than the risk of contracting HIV from a horny “slip up” with a non drug using heterosexual female.
“So it’s really just a cheap solution for the ravages of STDs. One where you don’t have to raise the standard of living so the people can afford condoms, and where you don’t have to annoy those pesky fundamentalists.
And it’s that that makes me actually angry about circumcision, it’s that it’s the solution for the lazy and the penny pinching.”
Makes sense to me. I’d be totally with you philosophically, except that “close to” perfect doesn’t help everyone.
However, I suspect all our standards of living, all over the world, will start to fall. Where Africa is today, the rest of the world will be, sooner or later. We’ll be penny-pinching on our own behalfs. If they are coming up with creative solutions then we had better be paying attention. We might need them.
Let’s start with the premise that the male prepuce is a normal, functional body part.
Once this basic and entirely reasonable premise is accepted, one can begin to discuss its removal from an unconsenting minor in the same ethical / potential-benefit context as removing any other healthy tissue; like an earlobe, a finger, a clitoris…
Parental choice should never extend to submitting their children to permanent surgical modification.
Why are people even talking about some dodgy African trials which were never even completed??? It’s not like circumcision is new in the West.
The Great Circumcision Experiment has been run in the West and has failed spectacularly. The US population has inflicted great harm at great cost for zero health benefit. The U.K., Canada, Australia and New Zealand abandoned this cruel and harmful custom and saw in improvement in overall health outcomes of boys.
Perhaps 100 million boys have been circumcised in the U.S. in the past century. Around 80% of the sexually active population is already circumcised. Wouldn’t it be a human tragedy if this was all for nothing?
Is it possible we are circumcising boys and seeking to justify it on the same basis as FGM is justified in other cultures? Cleanliness, health, tradition? The uncomfortable truth is that both are ancient blood rituals, except that western medicine has been turning itself inside out to find new ways to justify the practice and maintain the stream of revenue while continuing to dismiss the obvious harm caused.
Mass circumcision of boys is a most shameful chapter in modern medical history and must end immediately.
“‘A 1996 Wall Street Journal article on AIDS reports that the chance of contracting HIV from random unprotected sex with non-IV drug using heterosexuals is “smaller than the risk of ever being struck by lightening.”’ I think it’s safe to say that the risk of dying during a circumcision is greater than the risk of contracting HIV from a horny “slip up” with a non drug using heterosexual female.”
Right, if your sexual partner is a non-drug-using heterosexual female in a low-prevalence region or country and if you only slip up once.
If your sexual partner is a non-drug-using heterosexual female in Swaziland, there’s a 26% chance she’s HIV positive. And if she’s your wife, you will probably end up slipping up more than once.
That’s why the NNT in Kenya and Uganda (8% and 4% HIV prevalence respectively) is important to consider when you are trying to apply their findings to the US (0.6% HIV prevalance) or Swaziland (26% HIV prevalence).
And what if your partner is not a non-drug-using heterosexual female?
You might not think these other people — Swazis, gay men, hookers and their customers — are important, but I do.
The reason the study was ended early was that the evidence was so clear that circumcision was effective in reducing the transmission rate. They didn’t need to keep going to see that it helped.
You are correct that reducing the transmission rate is different from conferring absolute immunity. It is certainly likely that some of the men who would otherwise have seroconverted during the course of the study still seroconverted later on. But it’s false to conclude that there is no benefit to getting sick later rather than sooner. It gives you a longer useful life and it reduces the number of partners you will infect.
As Akheloios emphasises, the people we think circumcision will help protect the most are people without a lot of options.
For people who are probably at low risk, circumcision is unlikely to change that one way or another.
Personally, I am starting to quite resent the fact that the anti-circumcision folks are deciding what should have been done with my body. If I’m happy with my parent’s decision, why is that a problem? If you aren’t happy with your parent’s decision, take it up with them. Do you have any level of evidence supporting the assertion that circumcised males are unhappier than uncirmcumcised ones?
It seems to me that the evidence for medical need for circumcision is as weak as the evidence of the great harm caused by circumcision. Therefore, without strong evidence on either side, parental choice should stay within the equation. If you had some level of evidence showing that infant circumcision leads to decreased sexual pleasure, then maybe you could convince me, but until then, I resist taking away people’s rights of choice without overt evidence of harm.
“You know that there’s more than 3 studies in favour of Homeopathy, right?”
I don’t know why this was brought up, but if the anti-circumcision folks are also pro-homeopathy, I’m sorry, but that’s definitely a strike against your ability to approach subjects rationally. But I could be misunderstanding the meaning of this particular line as well.
“Right, if your sexual partner is a non-drug-using heterosexual female in a low-prevalence region or country and if you only slip up once.”
It was my impression that we were talking about neonatal circumcision in western countries, so bringing up statistics of the prevalence in Africa isn’t relevant, unless you plan on traveling to Africa and having sex with people there.
“For people who are probably at low risk, circumcision is unlikely to change that one way or another.”
We are in agreement there.
“Personally, I am starting to quite resent the fact that the anti-circumcision folks are deciding what should have been done with my body. If I’m happy with my parent’s decision, why is that a problem? ”
The fact that you are happy with your circumcision is irrelevant. You don’t speak for everyone.
If a person has foreskin and is unhappy about it, he can get circumcised. If a person is circumcised and unhappy about it, he can’t do anything. Best to err on the side of caution, since the baby is the one who will have to live with the results for the rest of his life.
“The fact that you are happy with your circumcision is irrelevant. You don’t speak for everyone. ”
Of course it is entirely relevant. You would like to take that decision away from the people who I believe looked after my best interests, namely my parents. So if I think they acted in MY best interest, why would you not trust other parent’s to act in their child’s best interests. You certainly do not get monopoly on deciding all children’s best interests. You do not get to speak for everyone either.
“If a person has foreskin and is unhappy about it, he can get circumcised.”
What if I would have wanted to event to happen as an infant and to not remember it? Now you have taken that potential decision away from my parents. What if infant circumcisions provide greater sexual pleasure than adult circumcision or even than uncircumcised individuals. You have no evidence in either direction, yet you want to remove the choice from parents, based on an emotional response, certainly not hard data.
“Best to err on the side of caution, since the baby is the one who will have to live with the results for the rest of his life.”
Best to let parents make their own informed choices for their children. You have still not presented significant evidence of the overwhelming harm caused.
“Yes, parents make many decisions for their children. Like what to eat, where to go to school etc. But there are limitations. Children are not property. You cannot make the choice to NOT feed your children. You cannot make the choice to NOT educate your children.”
No, but you can make a choice what to feed your children, how to educate them, how to discipline them, or what religion they should grow up with. I would argue that all of those decisions will have farther reaching effects than circumcision and can certainly be far more detrimental to a child’s life. Will you choose to legally regulate those decisions as well?
I am not saying there should be mandatory circumcision, nor even that it should be considered medically necessary. I simply think that you have not presented sufficient evidence showing that this procedure causes a huge amount of harm to the male population. I think parents should be given appropriate information from both sides of the issue and allowed to make their own choice for their child. You should not make that decision for them anymore than some right-winger should decide to take the abortion decision away from a mother.
Archangl508 said, “Personally, I am starting to quite resent the fact that the anti-circumcision folks are deciding what should have been done with my body.”
That’s not a “fact”, and obviously you are posing the question from feelings of frustration. We’re not trying to frustrate anyone from having the body they want, but neither can we give it to you. We simply don’t do body modification on children, other than trying to provide good nutrition to help them grow to their potential.
The prima facie evidence of harm is the cutting off and disposal of sexual tissue. No other proof is needed, but think about what it is you are trying to accomplish if, by chance, a man’s circumcision actually improved sex for him. Were you trying to create a sex zombie? Did you really want a sex addict on the loose? What exactly are you trying to accomplish?
No, your frustrations cannot be solved by other people, and we cannot allow you to frustrate others at reaching their sexual potential, or to even try to enhance their sexual potential. We don’t do that to children.
Archangl508:
Wow! Is this akin to some kind of Stockholm syndrome?
It is your prerogative if you think post facto that your parents did everything best for you. Good for you. But the point in question is not your feelings, nor a medical decision taken to preserve your life or well-being. The question is about the validity of neonatal circumcision, and if, later in life, you do happen to question the decision to have it done as an infant, all your parents can say is “Oops!” – and the foreskin ain’t coming back or regrowing.
Annabel,
“It was my impression that we were talking about neonatal circumcision in western countries, so bringing up statistics of the prevalence in Africa isn’t relevant, unless you plan on traveling to Africa and having sex with people there.”
It’s not at all clear what we’re talking about! Amy cited research on adult circumcision in Uganda and Kenya to assert that the AAP should change their recommendation on routine neonatal circumcision in the US. (This is quite a stretch, and many of us asked Amy to elaborate on that thought process.)
Since the AAP’s current recommendation is that parents should be educated about the risks and benefits of circumcision and then make their own decisions, the only conclusion to be drawn was that Amy wanted the AAP to switch to recommending routine neonatal circumcision of US infants to reduce the risk of HIV transmission. However, in the comments she appears to claim that she never wanted the AAP to change their recommendations and she states that she does not favour routine neonatal circumcision. She now says in the comments that the only point that she ever wanted to make is that circumcision can be of benefit some times to some people in some circumstances – in Africa and possibly elsewhere, though we don’t know enough to be sure. This is in fact consistent with the evidence.
How often “some times to some people in some circumstances” applies in the US, where the AAP makes recommendations, we are trying to get Amy to help us with. She appears to believe it does apply but isn’t giving a full answer on why she believes that.
I am sceptical that it applies to most groups in the US, but it probably could be important for some people there. How parents and doctors could take that into account could be an interesting Science Based Medicine discussion but Amy doesn’t want to talk about it; she seems to just want to say that the usefulness is different from 0 and then walk away.
So we have been talking a lot about Africa as well as the rest of the world. When you say that “condoms are enough” without qualifying by saying “condoms are usually enough for straight non-drug-using people in the US” it’s not clear that you accept that having a Plan B might be useful for people who are not straight non-drug-using-people in the US.
And since you asked, yes, I have travelled to Africa and had sex with Africans when I was there. With a condom.
So what. If in later life an uncircumcised man happens to question the decision not to circumcise as a neonate (when complications are lower, and he would have no memory of the event), all his parents can say is “Oops!” – and you can’t turn back to the clock to the neonatal period. Circumcising in adulthood is possible but not the same as having been circumcised as a neonate (especially if the ritual to which circumcision is connected is an initiation of newborns).
Obviously, the parents have to consider the likelihood of those two events (”Oops, you’re foreskin is gone” and “Oops, we have deprived you of the possibility of neonatal circumcision”) and the default is that the foreskin exists, so if unsure it makes sense to keep it. On the other hand, there are communities where the latter Oops is overwhelmingly more likely than the former.
Amy Tuteur hasn’t explained yet why performing the procedure on infants and not letting the child decide what he wants to do with his penis when he is old enough.
Ahem!
That’s it. This thread is now officially out of the purview of the AAP!
[Just kidding!]
@Plonit: Just tell me why – WHY is neonatal circumcision necessary in your opinion? Why is it that you are so tenaciously defending this practice?
Also, where did you get the idea that complications in neonatal circumcision are lower, and there is no memory of the pain?
The pro circumcision lobby perfectly knos that if the decision was left to the child when he’s old enough, this useless procedure would dissapear very quickly.
The very idea that someone would be “considering circumcision” is proof that it is a complex decision for an adult to make ABOUT HIS OWN GENITALS !!
I find myself comparing the more emphatic arguments against neonatal circumcision with arguments against childhood Hepititis B and HPV vaccines. In each case, an opponent might argue that an invasive intervention in a child for prevention (and public health) is not justified because perfectly effective alternatives exist in the future adult (condoms, monogamy).
I am certainly not suggesting that circumcision is equivalent to or as compelling as vaccination. Personally, I am unconvinced about neonatal circumcision. This comment is just a reflection on a surprising rhetorical similarity.
For Jews and some variety of Muslims, circumcision is a ritual that should be performed on Day 8. It follows that simply saying “The boy can make the decision when he is an adult” doesn’t work, because no one can make the decision to do something in the past (i.e. no time travel to go back and have circumcision as part of the traditional ritual).
I don’t ‘tenaciously defend’ this practice, I simply say that prohibition (which requires the criminalisation of entire communities) should be based on clear evidence of harm. Obviously, if people within those communities want to change their ritual practice that is fine – but I don’t think there should be legal compulsion to do so, unless there is compelling evidence of harm.
I said “no memory of the event”, not “no memory of pain”. Pain can be ameliorated by local anaesthetic during the procedure and appropriate analgesia post-operatively if required. There is no reason that adequate pain relief cannot be legally mandated if legislatures require it. Bam, there goes that argument.
By “no memory of the event” I mean that people don’t have direct memories of events that occur in the neonatal period. Doesn’t mean those events don’t have effects, but they don’t create memories. But show me the evidence of harmful effects, okay?
The rate of complications for neonatal circumcision (0.2-0.4%) is lower than for adults (2%) – by a factor of 5-10. (UNAIDS, 2007). The muslim circumciser responding to the Royal College of Paediatrics and Child Health comments on the differences between performing neonatal and adolescent circumcision in community-setting, stating that neonatal circumcision has lower rates of complications. Mohels who are also doctors and audit their practice demonstrate very low rates of complications.
Am I imagining things, or has David Gorski deleted his commented in which he disavowed responsibility for Dr Tuteur being a contributor to SBM, and passed the buck to the “SBM team”?
Am I imagining things, or has David Gorski deleted his commented in which he disavowed responsibility for Dr Tuteur being a contributor to SBM, and passed the buck to the “SBM team”?
I’ve read the comments twice today and have seen no such comment (but with 274, could have missed it). Weird…
@Archangl508: “What if I would have wanted to event to happen as an infant and to not remember it?”
Isn’t that rather like wishing to have been born into a rich family? One of the first and hardest lessons of life is that we can’t change the past.
The number of intact men who want to be circumcised is miniscule, especially in societies where it is not customary and convention/conformity is not a reason. So the default supposition is that he will not want to be circumcised as an adult, and his chances of happiness are maximised by leaving his genitals alone. (It’s hardly radical to want nothing to be done.)
“Is there data to suggest that males have residual memory of the trauma sufferred?” Yes, Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys.
Lancet 1995; 345: 291-2. – found that circumcised babies reacted more strongly to the pain of being vaccinated than intact ones, months after their circumcisions.
“When you are born, all your neural connections are not completely developed yet. So an adult with a foreskin may have developed different sensory inputs based on the inputs recieved. However, an neonatal circumcised adult may develop the same experience but from different inputs. Therefore, the removal of the foreskin as an adult, after neural pathways are formed, could result in loss of sensation, whereas a neonatal circumsized adult retains similar sensation to a uncircumcised adult because those pathways were formed from different inputs following circumcization.”
There are ~20,000 highly sensitive, specialised Meissner corpuscles (similar to those in the fingertips and lips) in the foreskin, concentrated in a ridged band that encircles the tip on the inside. They are much more sparse in the glans. Circumcised men generally report that their frenulum remnant under the glans is their most sensitive part. That is all that is left of their ridged band.
It may well be that, after circumcision, nerve endings from the glans and frenulum-remnant invade the part of the brain that has been “waiting in vain” for signals from the foreskin. (Experiments involving [I'm sorry to say] half-blinding kittens have found something equivalent in the optic area.) Thus it is that circumcised men report that their glandes are erogenous while intact men do not.
But it is hard to escape the conclusion that the quality of the sensation, lacking nerves (and a rolling, gliding structure) evolutionarilly “designed” to confer it, must be diminished rather than enhanced. This was the anecdotal consensus for centuries before non-ritual circumcision was customary. (See http://www.circumstitions.com/Pleasure.html and http://www.circumstitions.com/Sexuality.html) It is only in the last century that a curtain of silence has fallen on the subject.
Without resorting to “Nature knows best” (Evolution is a great kludger) to demand scientific evidence that cutting part of the body off does not diminish the function of that part borders on the perverse.
Plonit “Am I imagining things, or has David Gorski deleted his commented in which he disavowed responsibility for Dr Tuteur being a contributor to SBM, and passed the buck to the “SBM team”?”
Zoe “I’ve read the comments twice today and have seen no such comment (but with 274, could have missed it). Weird…”
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Well, I’m sure he responded to my comment on his sanctioning her presence here by saying that his remit as editor extended only to organizing guest posts, planning posting schedule and stuff like that, but that permanent contributors were a decision of the ‘group’. I paraphrase, but it is certainly weird to have read something along those lines and then see it disappear. Perhaps my mind is playing tricks on me.
the default supposition is that he will not want to be circumcised as an adult
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Unless he is part of a culture in which it is customary, surely?
Circumcision is medical fraud :
http://med-fraud.org/
“the default supposition is that he will not want to be circumcised as an adult”
So if an adult will not want to be circumcised, how is ethical to perform this procedure on infants ??
I don’t think David Gorski said anything himself. If he did, it was up so briefly that I missed it.
Plonit on 07 Jan 2010 at 5:20 pm
“Surely this is within your remit, as managing editor of this site?”
The only response I ever saw to that was:
Kausik Datta on 07 Jan 2010 at 6:19 pm
@Plonit:
“Surely this is within your remit, as managing editor of this site?
“In the same vein, all the authors of this SBM blog are responsible for determining the accuracy and veracity of what they post, and any reaction their post generates are to be handled by them, too. It is not David’s function – even as managing editor of the site – to censor or sanction posts. He would rather – heck, I’d rather he did – encourage a debate based on the scientific merit of the post, and argue points of evidence – which he did and does adequately.”
If memory serves Gorski posted in response following my comment responding to Kausik Datta on 07 Jan 2010 at 6:32 pm. Is curious though – maybe my memory is faulty?
Plonit – maybe. Maybe mine is.
Archangl508 said: “Personally, I am starting to quite resent the fact that the anti-circumcision folks are deciding what should have been done with my body. If I’m happy with my parent’s decision, why is that a problem? If you aren’t happy with your parent’s decision, take it up with them.”
And I resent the fact that my parents should be permitted to make a decision on a personal part of my body with no objective need to back up that right. It’s a decision largely based on their subjective whim and nothing more. Taking it up with them does not right the wrong. Though I agree that those who are unhappy should tell their parents; one of the myths that keeps neonatal circumcision alive is that no one could resent it. As others have said, if you were not circumcised and want it done good for you. Like a piercing or a tattoo nobody is going to stop you but the guy on the other side of the coin can do practically nothing about it.
The medical ethicist Margaret Summerville on this issue noted that (and I am paraphrasing) if the case for and against circumcision are evenly balanced, and that is the most favorable position for circumcision, then as an ethical matter the operator (Doctor) cannot proceed. Parents can still be free to want circumcision and even try and seek it out but, especially in the west doctors are not acting in the interest of children or ethics of their profession by performing it.
Margaret Summerville has also had some interesting things to say about the distinction between medically and religiously-motivated circumcision
“the people opposing a practice based on religious beliefs should have to justify any interference with this practice. Therefore, when infant male circumcision is carried out as an absolute religious obligation, the burden of proof, which is usually on those carrying out infant male circumcision to show that the surgical procedure is justified, would shift to those opposing it to show that it should be prohibited.”
Presumably a doctor may also be under a religious obligation to assist members of his or her community to fulfil their religious obligations?
“Margaret Summerville has also had some interesting things to say about the distinction between medically and religiously-motivated circumcision”
There isn’t that much difference between medically and religiously-motivated circumcision.
For a lot of people now, science and medicine are the “new religion”. Circumcision is a ritual act that became a medicalized procedure. The hypothesis (which was based on nothing) that circumcision decreases HIV came from a Jewish doctor.
“If memory serves Gorski posted in response following my comment responding to Kausik Datta on 07 Jan 2010 at 6:32 pm. Is curious though – maybe my memory is faulty?”
Well, he hasn’t denied it, but neither has anybody else confirmed seeing the post. So who knows.
“The hypothesis (which was based on nothing) that circumcision decreases HIV came from a Jewish doctor.”
I wondered how long the anti-semitic strain of anti-circumcision could hold back.
Can we end the thread here? Or do we actually have to wait until someone says that doctors are worse than Nazis to call Godwin?
“And I resent the fact that my parents should be permitted to make a decision on a personal part of my body with no objective need to back up that right. It’s a decision largely based on their subjective whim and nothing more. ”
I was incorrect in my writing my above statment. I allowed emotion to cloud my wording quite a bit, as have many others responding to this posting. I am human. Mea culpa.
However, you are advocating the removal of parental choice, I assume by legislation. Anytime freedom of choice is altered by legislation, in my mind, that is something that requires significant amount of evidence on one side to achieve. As a pro-choice individual myself, I certainly am always hesitant to remove choice from any individual. I would be interested to know where people think this lies on the priority list of important decisions made by parents for their children. I would argue that there are many decisions that parents make that have far more consequences on a child’s existence, compared with a child’s education, affection, or nutrition. Unless circumcision is at the top of the list, should we not also consider legislation of removing choice of those other parental decisions as well. So far, I have yet to see compelling evidence to drive legislation for the removal of parental choice for circumcision is justified.
I will agree that I have seen evidence to claim that this is not a medically necessary procedure, possibly even more than the evidence that claims it is a medically necessary procedure. But one can hardly claim that it is a simple issue with an easy answer, as there is evidence on both sides, that while maybe not equivalent, is certainly similar and not a slam dunk like mandatory vaccination. It is not a purely scientific claim, but also has cultural and relgious significance as well. Hence why parental choice should be allowed. If you provide evidence showing a large proportion of neonatal circumcised men are unhappy about their plight, then I will certainly change my tune. And if it is a small proportion of circumcised men who are unhappy, then I think that information should be provided to the parents are making the choice in order for them to understand the likelyhood that their child is unhappy. By doing that, you would reduce circumcision over time, fading it away to the point where it is virtually non-existent.
“There isn’t that much difference between medically and religiously-motivated circumcision.”
In your mind. To a religiously minded individual there may be a world of difference. If Ms. Summerville’s ethical knowledge and considerations are to be taken in account against medical circumcision, then they must also be taken into account for religious circumcision. You don’t get to pick and choose the ideas of an ethicist to support you claims.
Plonit -
I do recall Dr. Summerville discussing the complication of the religious issue but don’t remember those exact words. Was that taken from the Ethical Canary?
I’ll be honest I don’t support the religious reason either because I find that would be hypocritical, to support religious circumcision and not circumcision for any other whim of the parent. To me that would be strong grounds for a equal protection suit.
In fact, I feel that the current situation, total prohibition of FGM in any form while permitting circumcision already is either an equal protection violation or (in the US) a title 6 violation. Depending on who is filing the complaint.
Things are moving so fast, I think my request was lost in the shuffle.
.as this is called “science-based medicine”.
Could someone please provide me a single SCIENTIFICALLY credible benefits for circumcision–where it meets the requirements for SCIENTIFIC credibility–not just “medical credibility”..since the two are definitely not equivalent?
Since we have now reached parental choice, there are some important questions that must be asked and answered..
WHY SHOULD a parent be allowed to make an unnecessary, proven harmful, and proven risk-laden procedure choice for an infant?
WHY should the parents” choice supersede the choice of the owner of the penis?
Happiness of the victim is immaterial, since there is objective evidence of harm–that is what is paramount.
What it all comes down to is can anyone provide a RATIONAL ethical justification for infant circumcision?–this is the ultimate ethical question that demands to be answered.
Archangl508 said: “However, you are advocating the removal of parental choice, I assume by legislation.”
I would phrase it more like I advocate ensuring that the choice is given to the only one who at this time can evaluate the subjective value of circumcision to themselves. By allowing parents to make that choice in the individuals place you are taking that away from the only one whose opinion matters on this issue. If there are objective clinical needs the matter changes but there are not.
It’s true that parents make many other decisions but it seems to me that by and large these are decisions made because the parents need to meet the objective needs of their child and it is typically a time critical decision. The child must be fed and educated to name a few. Whether the parents made good or bad choices is one thing but the point is that a choice had to be made. That is where it differs.
Joep, this will be my last posting as I actually should be doing work, but thank you for making me consider issues I normally would not. You don’t have a convert, but you have convinced me that there is a valid debate, one worth considering the other side of the issue.
“I would phrase it more like I advocate ensuring that the choice is given to the only one who at this time can evaluate the subjective value of circumcision to themselves. ”
But in reality, you are advocating the legislative removal of parental choice. Having just read the Wikipedia entry on this subject there appear to be bioethicist articles written upon both sides of the issue, so it is hard for me to consider this a settled ethical conclusion. And again, I am hesitant, to remove any level of choice legislatively without clearly settled evidence or ethics.
There is, also, some evidence of potential medical benefits. It is not overall strong and should not be acceptable for mandating circumcision or even for allowing doctors to recommend it. However, it seems to me to be sufficient to allow parents to make the choice themselves when given all of the information including the risks of the procedure, the potential for future resentment, and any other potential harm or benefits from the procedure.
I think you can’t make the argument for waiting til adulthood for the child to make the choice unless you can show that there are no advantages to neonatal circumcision versus adult circumcision. In my mind there are potential advantages including no memory of the event including no memory of pain.
“It’s true that parents make many other decisions but it seems to me that by and large these are decisions made because the parents need to meet the objective needs of their child and it is typically a time critical decision.”
But are there decisions made, not in the objective needs of a child, that could potentially be more damaging or have a greater effect on the child than circumcision? If the answer is yes, then we must also consider legislating those parental choices as well.
Bottom line is, although there is evidence to suggest the procedure is not medically necessary (although there is some as well suggesting the converse). In my opinion, I have yet to see enough evidence of harm to advocate the removal of parental choice from the equation. If such evidence becomes available, then I will certainly change my mind.
“Bottom line is, although there is evidence to suggest the procedure is not medically necessary (although there is some as well suggesting the converse). In my opinion, I have yet to see enough evidence of harm to advocate the removal of parental choice from the equation. If such evidence becomes available, then I will certainly change my mind.”
Sure there is evidence, but simply having evidence does not convey credibility on that evidence. None of the evidence of benefits fulfills the SCIENTIFIC requirements of being without known flaws and fulfilling its predictions.
As for proof of harm, I suggest you read the Taylor and Sorrels papers PROVING the loss of up to 3/5 of the sensation and sensitivity.
There are many studies linking circumcision to erectile dysfunction or impairment.
As for PROVEN unnecessary risks, you might do some research.
1. iatrogenic Phimosis 2.9%
2. Adhesions 71%
3. Meatal ulcers 31%
3. Meatal stenosis 8%
4. infection up to 10%
5. Bleeding <35%
1. JOURNAL OF UROLOGY, Volume 169, Number 6: Pages 2332-2334,
June 2003.
Outpatient Management of Phimosis Following Newborn Circumcision.
H. Jason Blalock, Vijaya Vemulakonda, Michael L. Ritchey, Michaelene Ribbeck
2. JOURNAL OF UROLOGY; Volume 164 Number 2: Pages 495-496, August 2000.
Penile adhesions after neonatal circumcision.
Ponsky LE, Ross JH, Knipper N, Kay R
3. CANADIAN MEDICAL ASSOCIATION JOURNAL, Volume 95: Pages 576-581,
September 10, 1966.
The Problem of Routine Circumcision
And these do not even include the documented deaths from circumcision.
I have to wonder just HOW MUCH proven harm and risk would it take to compel you to accept that parents should not have the right to force this unnecessary harm onto infants.
Archangl508 thanks for the careful consideration. I too should be paying attention to other things but I am sure this conversation will continue; perhaps when it’s more convenient you will continue to contribute. I do enjoy the discussion when the points are well thought out and rational. I’ll say I don’t expect nor endeavor to convince someone (such as yourself) to be unhappy if they were circumcised. Nor do I expect to move anyone’s needle fully to prohibition.
Several months ago I had a similar conversation with an individual that went on for more than a month. He started out supportive of circumcision for a potential son but when he really looked at the issue said he wouldn’t do it but at the same time couldn’t support a prohibition for many of the reasons you cite. That’s good enough for me. My only intent is to get individuals to really think about something they may not have given any thought about before so at least in your case I succeeded.
I don’t see it as taking away a choice from someone but preserving that choice for the only one who can really make it. I also don’t deny that there may be potential benefits but whether or not the potential benefits cited are sufficient to justify an irreversible, non-indicated, intervention can only be adequately evaluated against the associated risks of surgery using the subjective preferences of the individual affected by the circumcision. This includes any concern of pain which can be adequately managed in an adult. I had all four of my third molars removed at 18 and though one might suggest that would be a very painful event, I don’t recall it as such. In my case the intervention was clearly necessary and there for any transient pain that there might have been becomes part of my personal evaluation. There are also benefits to performing this as an adult such as better cosmetic result (if that’s what you’re looking for) and although minor complications (such as bleeding) might occur more frequently I suspect major complications are much rarer in adults. It’s more difficult to accidently sever the entire penis or part of the glands; I’ve also never heard of an adult dieing either though these are complications that occur in infants and children. They occasionally make the news. And to me, any amount of complications when there is no objective reason and no informed consent of the individual is too many.
While I don’t necessary discount the possibility of benefit to some people in some situations neither the author of this post nor the original paper seem to meet the burden to make this an ethical choice, such as a vaccination. As I’ve pointed out previously it is very interesting that all other western agencies that have examined this issue have not seen fit to in any way adjust their recommendations for their local populations which in most cases are far more critical of circumcision than the US. Basically, they recognize the context and ethics something both the article and the post here misses completely.
@joep
“He started out supportive of circumcision for a potential son but when he really looked at the issue said he wouldn’t do it but at the same time couldn’t support a prohibition for many of the reasons you cite. That’s good enough for me.”
If that’s what you are after — that parents be educated and thoughtful — that is consistent with the current AAP recommendations. Neither you nor the AAP seek a prohibition; neither you nor the AAP recommend routine neonatal circumcision.
@ Alison
I do seek prohibition I would like to see the 1998 FGM bill be gender neutural. But from a practical perspective I realize that the social situation as it stands will be unlikely to support that.
What is good enough for me is that in that environment I can move individuals to a position that questions the practice or better yet to say you’re right I won’t impose that on my son yet at the same time I can’t fully support prohibition. I do realize that is perhaps as far as most are willing to go.
Zoe,
I don’t specifically know about Uganda, but many African cultures circumcise (or used to) as a coming of age ceremony…Until of course, colonization.
Now they are being told to do it again.
In this case, I see the benefits of circumcision for a young man (not a neonate) as well as the community in a multiplicity of ways.
I also wonder about the difference in HIV I and HIV II transmission differences.
I think it’s also important to note that the vast majority of intact adult men don’t choose circumcision for themselves, even in the United States. I can’t find the link, but it was around 1 in 250 intact men ever need or want circumcision for themselves in the US, and the number is much lower in countries where circumcision is less common( if someone knows the link, I would appreciate it!). Even though the number is higher in the US than other countries, 1 in 250 is still a great minority of men. So is it ethical to perform a surgery that, statistically speaking, a boy most likely wouldn’t choose for himself given the choice?
I understand that many parents feel that their rights are at stake on this issue. But children have rights, too. Their rights don’t come into effect once they are old enough to talk, they have rights the moment they are born, and the same rights as little girls. Why do I never hear an American parent lament the fact that their right to circumcise their daughter is taken away from them as well? Why do they so want the right to circumcise their son but not their daughter? Here is what the WHO says about FGM :
“FGM is recognized internationally as a violation of the human rights of girls and women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person’s rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.”
They then go on to list the different forms of FGM, a lot of which are understandably more severe than male circumcision. But not all. Here is what type four of FGM reads on the WHO website:
4) Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.
If girls are have the right to physical integrity shouldn’t boys have the same rights?
Hmmmm…. Adult males asking for circumcision. In my 40+ years in healthcare, I’ve only encountered maybe a half dozen cases. Interesting reasons, some clinical and some sociological:
- Girlfriend requested – they liked circumcized penis better (a couple of them)
- An Indian (from India) who thought American girls like the circumcised penis more
- Circ done to remove significant HPV warts
- A phimosis correction
If girls are have the right to physical integrity shouldn’t boys have the same rights?
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It’s a good question.
I expect the explanation lies in the fact that at the time of description and legislation FGM was regarded as a continuum of practice ranging from pricking/incising through to the complete removal of clitoris and labia with infibulation. Law-makers would have found it difficult to proscribe some practices and not others, for fear of creating a range of legal defenses for more extreme practices. As I said upthread “if you allow Type Ia, then you can going to see a lot of intentionally ‘botched’ procedures to get around the law, especially given that Type Ia has always accounted for a small percentage of procedures amongst a much more damaging continuum.”
Contrast this with male circumcision. With the exception of castration (not practised today, AFAIK) there is no continuum of male genital surgery. Or rather the continuum involves removing more or less of the foreskin, making all male circumcisions equivalent to Type Ia. If the practice of penectomy (structurally equivalent to Type Ib FGM) or removal of the penis and scrotum (structurally equivalent to Types II & III FGM) were current and widespread, then I could imagine that removal of the male foreskin might similarly be outlawed, as a by-product of the campaign to erradicate the more extreme practices.
The different treatment of male and female prepuce in terms of legal protection may be more a consequence of this difference in context (i.e. existence of Type Ib, II & III FGM, for which there is no current analogous practice in men) rather than intentionally unequal treatment. Indeed, had all FGM been of the Type Ia variety, I find it hard to believe that it would ever have been outlawed.
“I expect the explanation lies in the fact that at the time of description and legislation FGM was regarded as a continuum of practice ranging from pricking/incising through to the complete removal of clitoris and labia with infibulation.”
I have to disagree with some of your statements. There was a case in the United States where a Somalian family wanted just a ceremonial prick done to their daughter, and it was deemed illegal to do so. (http://www.law.duke.edu/shell/cite.pl?47+Duke+L.+J.+717)
I doubt many would argue that a small needle prick is less dangerous and causes less psychological harm than complete removal of foreskin. A pin prick most likely wouldn’t leave any long term scars or physical markings. I also don’t really see how a pin prick performed by a competent surgeon could result in the accidental removal of the clitoris. Removal of the clitoris would require some sort of scalpel incision. Sure, I can accept that there is an extremely miniscule chance that the pin prick could get infected resulting in the loss of other structures, including the clitoris. I would argue that the chance of that happening is at least as likely and probably smaller than the chance of a penis getting amputated during a routine circumcision. Why is the risk of a clitoris getting amputated unacceptable but the risk of a penis getting amputated acceptable? When parents of females want to have the surgery done on their daughters for many of the same reason parents want the surgery done to their sons? Why the double standard?
I was speculating as to the intent of legislators, that is to say – they wanted to avoid a legal loophole, given the existence of more damaging forms of FGM. In discussing intentional ‘botching’ I was not referring to the risk of complications/errors, but to the risk of creating a legal loophole in which practitioners can deliberately perform Type Ib FGM, while claiming to have intended Type Ia.
I don’t know the ins and outs of legal discussions having to do with the framing of anti-FGM legislation, but the existence of more serious varieties of FGM would seem to be at least part of the answer to your question about double standards.
“In discussing intentional ‘botching’ I was not referring to the risk of complications/errors, but to the risk of creating a legal loophole in which practitioners can deliberately perform Type Ib FGM, while claiming to have intended Type Ia.”
I don’t think there is any evidence to this claim. If you are talking about doctors intentionally botching female circumcision, I don’t think that is very plausible. The legal ramifications for such a thing would be astronomical, just as they would be for intentionally botching a male circumcision, and would not be worth it. It would be very hard for a doctor to explain how a pin prick to the labia resulted in an accidental removal of the clitoris. You would almost have to literally stab it until it was no longer functional.
If you mean parents accidently botching a female circumcision, that already happens. Parents that want their daughter circumcised often resort to family members or local elders, and even fly to their home countries where the risk of complication is significantly higher. If anything, making it legal would be safer for girls from those countries living in the United States. Much like the argument that making abortion illegal would just make abortions more dangerous, as people would always find a way if they want it bad enough.
“He started out supportive of circumcision for a potential son but when he really looked at the issue said he wouldn’t do it but at the same time couldn’t support a prohibition for many of the reasons you cite. ”
That would be the place where I am. If I were to have a child I think I would carefully consider the various information and make the best choice for the child. But I would still want to have that choice to make. If the available information were to swing much farther towards the “harm” side of the issue, then I would join you in favor of prohibition of the practice.
I also thank you for giving me something to think about and your reasoned responses. It was good to see that within a discussion that had previously seen much inflammatory, emotional language (that I was also guilty of; i.e. multilation/victim/etc.). That sort of discussion and use of rhetoric does nothing to help either side of the debate. All that does is inflame passions and shut down reasonable thinking.
I wish you luck in finding better information to more securely prove your case and at that time I would be happy to support your position.
Annabel,
Just going waaay back to one of the numbers you presented.
“Here are some numbers. The risk of a man contracting HIV from a woman, which is the only HIV route circumcision has proven to reduce risk, is .04% or .0004 in the United States. One in every 2,500 sexual acts. Exactly how many men do you think are going to be having sex 2,500 times before the age of 18 when they can make an educated decision for themselves about whether or not the risk reduction is worth it? Even the most conservative risk complication rate of circumcision is WELL above .0004.”
If the chance of of a man’s contracting HIV during a a single, random encounter with a non-injection-drug-using woman is 0.04%, then after 2,500 encounters there’s a 63% percent chance he will have become HIV+.
After 1,250 encounters the chance is 39%.
625 encounters: 22%.
26 encounters: 1%.
But wait! The rate of 0.04% is for a combination of circumcised and uncircumcised men. Circumcision seems to reduce transmission by about 56%, and 75% of American men are circumcised. The rate should be about 0.03% for circumcised men and .07% for uncircumcised men.
A circumcised man would have a 1% chance of contracting HIV after 33 random unprotected encounters with a low-risk woman.
An uncircumcised man would reach a 1% risk after just 15 random unprotected encounters.
There are many, many young men out there who will have had unprotected sex 15 times before their 18th birthdays. Is a 1% chance low enough?
Remember, we are talking about 15 unprotected encounters with low-risk women in the US. We are not talking about high-risk partners or high-prevalence regions, and I’m working with your numbers.
The theoretical, perfect-use level of protection condoms offer against pregnancy is 98% over the course of a year. If a couple are having sex twice a week, that’s 13 acts of intercourse that could have resulted in pregnancy. Working backwards, a perfectly-used condom seems to fail 0.16% of the time.
At that rate, using a condom perfectly during sex with a low-risk female partner will result in 1% of diligent circumcised men seroconverting after 21,500 random encounters; a diligent uncircumcised man would not have to work quite as hard, reaching a 1% risk of seroconversion after 9,200 encounters. That still requires sex twice a week for 88 years, so that’s probably good enough.
Real-world, typical-use failure rates of condoms are higher, however: 15% by the end of a year. So in the real world, at this rate 1% of ordinarily imperfect circumcised men would seroconvert after 2,700 random encounters; an ordinarily imperfect uncircumcised man would reach a 1% risk of seroconversion after 1,150 encounters — 11 years of sex twice a week. (Agreed, very few teenagers will reach 1,150 encounters by the time they are 18, but it’s not impossible.)
Again, this math applies to low-risk partners in a low-prevalence region.
These numbers are based on various assumptions, and they are all calculations. If they are accurate, it’s just by chance. The point is that if you aren’t familiar with probability they can work out to something quite different from what your intuition tells you. An average 0.04% chance of seroconverting after a single unprotected encounter sounds pretty safe. Most people would never think that’s equivalent to a 1% chance of seroconverting after 15 unprotected encounters if you’re uncircumcised. If a parent understands this, it is likely to shape their decision-making.
There are men who remember being frisky and irresponsible teenagers and who think it’s likely their infant son will grow up to be a frisky and irresponsible teen too. Sure, you can lecture your kids about condom use. But there are parents who would be a lot more comfortable with the notion of their son having 33 unprotected encounters versus 15, before reaching a theoretical risk of 1%.
You might not think it’s worth it, or fair, or ethical. But 15 unprotected encounters is not that many. And it would be unreasonable to forbid parents to take that into consideration.
Yes, it would be much better if everyone were a perfect condom user; it would be best of all if young men never had sex before their eighteenth birthdays; and we would avoid the entire ethical dilemma if there were no reason to think that circumcision reduces transmission rates. But they aren’t, they do, and there is, at least for now.
“If the chance of of a man’s contracting HIV during a a single, random encounter with a non-injection-drug-using woman is 0.04%, then after 2,500 encounters there’s a 63% percent chance he will have become HIV+.”
You have misunderstood the study. Here is a paragraph from the study :
“Pooling the data from studies in high-income countries, the researchers calculated that the risk of transmission from an HIV-positive man to his female partner was 0.08% per sexual act: in other words, it was likely to occur once every 1250 sexual acts. When it was the female partner who was HIV-positive, the male partner’s risk of acquiring HIV was 0.04% per sexual act – in other words, once every 2500 sexual acts.”
I really don’t know how you get numbers like “After 1,250 encounters the chance is 39%.”
That is an astronomical number. There isn’t any data from the CDC or WHO that shows a man has a 39 percent chance of getting HIV after 2500 sexual acts. Or that he has a 1 percent chance of contracting HIV after 26 sexual acts. Could you please provide the math or statistics that lead to this number?
C’mon folks, can we have a little logic here..
People who are trying to use the threat of HIV to promote circumcision, need to provide the following:
Scientifically credible studies showing circumcision reduces HIV that have no KNOWN flaws.
The prediction of reducing circumcision reducing fails to manifest itself every time?
THESE are the crucial points that determine if a theory is scientifically credible and/or valid.
Now all studies have many and fatal flaws,
The real world stats show that this reduction does not always exist…in fact in many cases, the exact opposite.
Now, since this supposedly a science-based discussion, we need to actually discuss the scientific aspects–merely repeating over and over the results of flawed studies hardly advances this discussion.
Here is a link that actually looks at the scientific basis..so until and if people actually read and debate the critical points here, all we have is a lot of flooby dust being tossed into the air.
http://mysite.verizon.net/dortfay/science.html
So, can we expect this to be a science-based discussion or the back and forth of bogus and/or questionable science and invalid assertions?
Discussing FGM vs. MGM, there seems to ba a lot of opinions and denial..
Before people dismiss MGM as being less harmful than all of the forms of FGM, they need to include the more drastic forms of MGM..
Subcision–slitting the penis down the length
Yemeni circumcision–amputating the foreskin and flaying all of the skin from the navel to the crotch..
Now can anyone find a form of FGM that is worse than this? If not, then the crucial question remains..
RATIONALLY WHY is any form of FGM illegal yet MGM is legal?
“Before people dismiss MGM as being less harmful than all of the forms of FGM, they need to include the more drastic forms of MGM..
Subcision–slitting the penis down the length
Yemeni circumcision–amputating the foreskin and flaying all of the skin from the navel to the crotch..”
I think this is an interesting point. Especially in light of the arguments that Plonit makes that since more severe forms of female genital mutilation exist, all should be illegal because of the potential of “intentional botched circumcisions” that might be performed as a round about way of getting the desired result of the more severe forms of FGM.
Now, I don’t think that either of those is plausible in the United States, because the legal ramifications that would ensue if a doctor was found to be performing intentional botched circumcisions for boys or girls would be astronomical. Losing a life’s worth of work and medical license and imprisonment for a surgery most doctors in the US would deem unethical seems implausible.
But it does raise and interesting question : Why are ALL forms of female circumcision, even ones equivalent or less severe than complete removal of foreskin, illegal in the United States but not all forms of male circumcision? At least in the context of minors.
@Alison
With regard to chances of HIV infection in non-iv heterosexual men in low prevalence countries, the Australian Federation of AIDS Organizations estimated that the lifetime risk for those men in Australia is approximatly 0.02% which I believe is an upper bound. So the difference circumcision could make for an individual over there lifetime would be on the order of perhaps hundreths of a percent. I will provide the link when I can get it.
I have, in the past, worked out that the risk in the US is about the same, a bit higher though since we don’t seem to do quite as well with regard to STD prevalence. Funny when we have an adult circumcision prevalence of at least 80%. *shrug*
“With regard to chances of HIV infection in non-iv heterosexual men in low prevalence countries, the Australian Federation of AIDS Organizations estimated that the lifetime risk for those men in Australia is approximatly 0.02% which I believe is an upper bound.”
Here is the information from that study :
“An Australian-born man is estimated to have a 0.02% (0.0002) risk of HIV acquisition if he does not
inject drugs or have sex with men.11 This very low risk means that the population health benefit of an
intervention like generalised circumcision programs would be negligible. However it has been argued
by Professor Alex Wodak in the mainstream press, that circumcision would play a valuable role in
assisting to prevent the emergence/development of a heterosexually mediated epidemic in Australia.
This view is not currently supported by a consensus or statement from any organisation currently
involved in Australia’s HIV partnership. ”
11
This estimate was supplied by the National Centre in HIV Epidemiology and Clinical Research in February 2009, based on median lifetime
partners, sexual acts within partnerships over time, estimated prevalence within the female population of 0.03-0.05%, and average transmission
rates and condom use within partnerships
(http://www.afao.org.au/library_docs/policy/BP09_Circumcision.pdf)
Annabel, I didn’t misunderstand the study: I didn’t read it! (I do have to agree with Amy on this one: one needs to read the study oneself!) I relied on your quote of someone else who may have read a study fourteen years ago, and fed your numbers back to you.
“‘A 1996 Wall Street Journal article on AIDS reports that the chance of contracting HIV from random unprotected sex with non-IV drug using heterosexuals is “smaller than the risk of ever being struck by lightening.”’ I think it’s safe to say that the risk of dying during a circumcision is greater than the risk of contracting HIV from a horny “slip up” with a non drug using heterosexual female.”
and
“Here are some numbers. The risk of a man contracting HIV from a woman, which is the only HIV route circumcision has proven to reduce risk, is .04% or .0004 in the United States. One in every 2,500 sexual acts. Exactly how many men do you think are going to be having sex 2,500 times before the age of 18 when they can make an educated decision for themselves about whether or not the risk reduction is worth it? Even the most conservative risk complication rate of circumcision is WELL above .0004.”
If you misrepresent the numbers, then don’t complain when they are fed back to you incorrectly. If you meant to say (you and Amy are alike in this: you complain that people don’t understand what you mean to say, we very annoyingly respond to what you do say) “The risk of an HIV- man contracting HIV from an HIV+ woman, which is the only HIV route circumcision has proven to reduce risk, is .04% or .0004,” then you should have said that. Mentioning 2,500 sexual acts by a teenager is misleading, because those acts would all have to be with HIV+ women to correspond to your figures. If that is accurate, then you are saying that an HIV- man and an HIV+ woman could have unprotected sex twice a week for 24 years and the man would still have only a 63% chance of seroconverting. That’s miniscule. (Why do we even care if straight people in the US use condoms at all, then, since it’s a low-prevalence region? Is it just about the herpes?)
Here is the math, based on your figures. (As I said previously, these are calculations. Reality is messy and may differ.)
A man has a 0.0004 chance of being infected with HIV when he has sex with an HIV+ woman.
He therefore has a 0.9996 chance of not being infected with HIV when he has sex with an HIV+ woman.
To not seroconvert after repeated encounters, he needs to be in the 0.9996 category each time.
After 1 encounter, he has a 0.9996 chance of not seroconverting. (Chance of seroconverting is 1-0.9996, or 0.0004.)
After 2 encounters, he has a 0.9996*0.9996, or 0.9992, chance of not seroconverting. (Chance of seroconverting is 1-0.9992, or 0.0008.)
After 3 encounters, he has a 0.9996*0.9996*0.9996, or 0.9988, chance of not seroconverting. (Chance of seroconverting is 1-0.9988, or 0.0012.)
After 26 encounters, the chance of not seroconverting is 0.9996^26, or 0.9897. (Chance of seroconverting is 1-0.9897, or 0.0103, or 1%.)
After 2,500 encounters, the chance of not seroconverting is 0.9996^2,500, or 0.3678. (Chance of seroconverting is 1-0.3678, or 0.6322, or 63%.)
The math is correct, but the results are only as good as the inputs.
Anabel, plausibility is irrelevant, as is intention and risks..
IF the rationale for the banning of ALL forms of FGM is that MGM is less harmful, then the mere presence of a form of MGM worse than a minor form of FGM negates this rationale..
And worse, if there is a more severe form of MGM than ANY form of FGM, then this is an irrational basis for banning FGM and not MGM..
And the nail in the coffin for this excuse is that there IS a more severe form of MGM than any form of FGM.
I am tired of people playing with numbers and not examining the basic scientific credibility of the claim of circumcision reducing HIV..
Basic tenets of science: These can be used as a litmus test for claimed benefits.
1. Conclusions based solely on known flawed data cannot be considered valid.
2. All studies have known flaws – flaws of commission and/or flaws of Omission.
Flaws = not scientifically compelling
The worth of a theory is determined by its ability to make accurate predictions.
No predicted reduction or elimination is found in the real world.
Failure to fulfill prediction = not scientifically credible.
The rates of these are HIGHER in many circumcising countries than in many intact countries, hence the alleged predictions are contradicted by empirical evidence. Unlike “medical science,” SCIENCE demands that prediction be fulfilled EVERYTIME to be credible.
The link I provided earlier cited links to the flaws in the African studies..
Here is the critical analysis of how well the theory fulfills its prediction..
Failure of prediction-In science, it only takes ONE exception to invalidate a hypothesis or theory.
Circumcision rates:
Japan 10 % in all cultures…
OR
That even though people in Ethiopia can barely afford food and shelter, they can afford 88X the recreational drugs than Japan and 8X that of the USA.
“IF the rationale for the banning of ALL forms of FGM is that MGM is less harmful, then the mere presence of a form of MGM worse than a minor form of FGM negates this rationale..
And worse, if there is a more severe form of MGM than ANY form of FGM, then this is an irrational basis for banning FGM and not MGM..
And the nail in the coffin for this excuse is that there IS a more severe form of MGM than any form of FGM.”
I agree. Was that directed at me? I am a tad confused, because I agree with you.
You said : “If you meant to say (you and Amy are alike in this: you complain that people don’t understand what you mean to say, we very annoyingly respond to what you do say) “The risk of an HIV- man contracting HIV from an HIV+ woman, which is the only HIV route circumcision has proven to reduce risk, is .04% or .0004,” then you should have said that. ”
In my statement that you quoted I said :
Here are some numbers. The risk of a man contracting HIV from a woman, which is the only HIV route circumcision has proven to reduce risk, is .04% or .0004 in the United States. One in every 2,500 sexual acts (http://www.aidsmap.com/en/news/E1249D29-0DDE-4CFF-9CC7-16B3FADB3E59.asp) .
If you notice, I linked the study that I was referring to, so that people could read it if they had questions about the numbers. I obviously wasn’t intentionally trying to dupe people or I wouldn’t have linked the study. If anything, not saying HIV negative man and HIV positive woman would skew the results in favor of the pro circumcision group, as the chance that an average man getting HIV from an average women is lower than studies that show the risk of sexual relations with ONLY HIV positive women.
As far as my question of ” how many men do you think are going to have sex 2,500 times before the age of 18 ” is a valid question. Let’s make up a number that when having sex with an average woman who may or may not be HIV positive a mans chance of contracting HIV is is 1 in 5,000. It makes sense to take the lesser of those two numbers ( 1 in 2500 vs 1 in 5,000) to demonstrate that even the most extreme case ( that every-time a man has sex it will be with an HIV positive individual ) it is still unlikely that he would accumulate that many sexual acts before the age of 18.
But this is silly, why waste all this time over a few words when I linked the study I was referring to?
“I wondered how long the anti-semitic strain of anti-circumcision could hold back.
Can we end the thread here? Or do we actually have to wait until someone says that doctors are worse than Nazis to call Godwin?”
How is it anti-semetic to say that a Jewish doctor advanced the idea that circumcision reduced HIV.
It just shows that there’s a obvious conflict of interest.
“I agree. Was that directed at me? I am a tad confused, because I agree with you.”
No, not at you at all–merely a succinct summation and examination of the rationale for the banning of FGM, and allowing MGM.
I hardly think the rationale holds up to rational examination.
Cochrane report on monogamous heterosexual seroconversion rates:
http://apps.who.int/rhl/reviews/langs/CD003255ru.pdf
If they never use condoms: seroconversion rates of 1.14 per 100 person-years (roughly 2 months to reach 1% risk and 7 years to reach 25% risk).
If they always use condoms: seroconversion rates of 5.75 per 100 person-years (roughly 10.5 months to reach 1% risk and 38 years to reach 25% risk).
If they sometimes or usually use condoms: they weren’t included in the study.
They didn’t break this down by men vs women or by circumcised vs uncircumcised. The “nevers” seemed to have about the same rate of seroconversion in the US, Italy and Africa. The “always” folks varied from study to study, so they used the studies where the couples stayed together longest, which tended to be couples where the HIV+ partners were hemophiliac or transfusion patients.
Whether looked at per act of intercourse or per year, *always* using condoms seems to reduce transmission rates by about 80% compared to *never* using condoms.
Which is interesting to compare to the Kenyan and Ugandan studies where circumcision seems to reduce transmission rates by about 53% to 60%. If you think condoms (80%) are almost perfect, then circumcision (about 56%) is not that bad.
Caveat: I did not read all the Cochrane report studies. Neither have I read the Kenya and Uganda studies.
Nick, I agree, and frankly am tired of people throwing out the antisemitic term just because it is pointed out that a Jewish doctor started the circumcision/HIV speculation. Truth is truth–even if uncomfortable.
If the Pope put out an article on abortion it would automatically be construed as a conflict of interest, so why should not this likely probability in the case of a circumcision speculation by a Jew–why should he get a special exemption?
This whole antisemitic name-calling is simply another attempt to sabotage the discussion.
Would it be more antisemitic to also point out that this speculation was promoted by other Jews?
Sorry my post about the scientific credibility of the claim of HIV reduction by circumcision was truncated..
the gist is that the discrepancy of prediction for the USA, Ethiopia, and Japan is 1100% and 8800% respectively.
and that
The largest acceptable error in science is 1 sigma = 5%
Those advocating circumcision to reduce the incidence of HIV either ignore this empirical and contradicting evidence, or try to dismiss it with various excuses, like: Intravenous drug usage or homosexual activities.
However, they never provide any hard numbers of these factors for various countries or a model that should include them to explain this discrepancy.
For these excuses to be credible, one would need to assume:
That the US has 11X as many homosexuals than Japan; and Ethiopia has 88X as many as Japan—when it is widely accepted that the rate of homosexuality is 5 –>10 % in all cultures…
OR
That even though people in Ethiopia can barely afford food and shelter, they can afford 88X the recreational drugs than Japan and 8X that of the USA.
“Which is interesting to compare to the Kenyan and Ugandan studies where circumcision seems to reduce transmission rates by about 53% to 60%. If you think condoms (80%) are almost perfect, then circumcision (about 56%) is not that bad.”
STILL trying to pretend that the African studies are scientifically credible?
Do you plan to read the link debunking the studies and their prediction? or do you plan on pretending the information was not presented to you, and continue to play the questionable numbers game?
Not reading the critical and crucial analysis of the information is a prime example of ignoring SCIENCE in this discussion.
Until and if the information can be shown to be scientifically credible, all this back and forth is predicated on nothing objective…and essentially useless!
“Which is interesting to compare to the Kenyan and Ugandan studies where circumcision seems to reduce transmission rates by about 53% to 60%. If you think condoms (80%) are almost perfect, then circumcision (about 56%) is not that bad.”
First, I have seen studies that showed numbers higher than an 80 percent effectiveness of condoms. Second, condoms work for everybody. The 50-60 percent risk reduction is only applicable to heterosexual men who have vaginal intercourse with an HIV+ women, which is incidentally one of the rarest forms of HIV transmission in the United States. So 80 percent risk reduction for everybody is significantly better than a 60 percent risk reduction for a very specific group of individuals who are unlikely to get HIV regardless. Just because there is a difference of 20 percent between 60 and 80 doesn’t mean that condoms are only 20 percent better, when looking at the United States as a whole.
I’d like to see studies that show how effective condoms are at preventing HIV when the woman has HIV and a man does not.
Annabel, as I said, I should have read the study myself, but didn’t. I didn’t bother because I assumed (and I shouldn’t assume either) that you were linking to the old WSJ article you’d mentioned previously. (I have just pulled up the aidsmap article you linked to and it’s a plain-language article, not the published study.)
The point I was making, and the reason I wasn’t too worried about where the numbers were coming from, was that even if 0.0004 sounds miniscule it can look surprisingly different when you bring frequencies into it. That’s all. It could have been 0.0001, or 0.00001, and I could have illustrated the same phenomenon.
I am actually quite relieved that random sex with a low-risk woman doesn’t carry a risk of 0.0004 for a serodiscordant man! That would be huge, and the implications were worrying me.
Annabel,
“The 50-60 percent risk reduction is only applicable to heterosexual men who have vaginal intercourse with an HIV+ women, which is incidentally one of the rarest forms of HIV transmission in the United States.”
Yes, you’re absolutely right. The big issue right from the beginning was how and why this finding should be applicable to AAP recommendations. Amy said the Uganda/Kenya studies should result in the AAPs revising their recommendations. It appears that she simply didn’t know what the AAP recommendations are, and was never able to be specific about what she thought should be revised.
The thing is, when somebody says “everybody should be using condoms, condoms are almost perfect, nobody should be considering circumcision,” the words “everybody” and “nobody” mean Swazis and johns too unless you specifically exclude them.
If someone is saying that the entire planet should reject circumcision because they don’t need it, because condoms are almost perfect, they really need to be able to address the figures of 80% vs 56%; the fact that some people are high risk; that some people do live in high-prevalence areas; that some risks can be known or estimated at the time a child is born.
That doesn’t mean they will come to any particular conclusion. But it does mean we have numbers to talk about, which is what Science Based Medicine should be all about.
I really wish Amy were able to come to the table with proper numbers and analyses thereof. I work in business and I’m flying by the seat of my pants. I want to understand the numbers, and I have a little bit of experience with rudimentary statistics, but I don’t know anything about the field. So I look here and there and play with a spreadsheet and talk about If Then (IF the odds are 0.0004 THEN 26 encounters is 15) but I don’t actually know if the odds are 0.0004 or what that means, for who.
From the beginning, I’ve been asking how the Ugandan/Kenyan studies might affect decision making in the US, and I still don’t know. But I have learned that in the real world, the effectiveness of always using condoms appears to be not that far off from the effectiveness of being circumcised in preventing HIV transmission, which is absolutely not something I had expected to learn.
Why nobody talks about that adult circumcision was found to INCREASE the proportion of HIV in partners of subjects in Uganda ? Researchers abandoned the trial because of the “futility” of carrying on with it.
“It was found that a higher proportion of women were infected with HIV in the intervention group (18%) versus the control group (12%).”
Not to mention circumcised men are more likely not to use condoms because they rongly think they are protected from HIV. This is exaclty what is happening in Africa :
http://www.youtube.com/watch?v=OlsUg0sdAtE
It’s obvious that these researchers are more interested in promoting infant circumcision than a better HIV prevention.
“It’s obvious that these researchers are more interested in promoting infant circumcision than a better HIV prevention.”
That’s because the researchers make so much money from circumcision … oh, wait, they don’t benefit in any way.
Maybe it’s because they want lots of people to die of AIDS so they are deliberately recommending useless (and evil) strategies … oh, wait, they don’t benefit in any way from more people getting HIV and dying of AIDS.
What is it you are trying to say?
“But I have learned that in the real world, the effectiveness of always using condoms appears to be not that far off from the effectiveness of being circumcised in preventing HIV transmission, which is absolutely not something I had expected to learn.”
Why don’t you actually look at the fallacies of the African studies that others have linked before you come to this conclusion? the numbers 50 and 60 percent are questionable at best, and medical professionals are divided on the research.
Not one other western country ( UK, New Zealand, Australia, and Canada) have been impressed with the studies done in Africa as it applies to their country.
British Medical Assosiation :
“There is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research”
Royal Australasian College of Physicians revised statement in August 2009:
“Recently there has been renewed debate regarding both the possible health benefits and the ethical concerns relating to routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, and in adults HIV infection and cancer of the penis. The frequency of these conditions, the level of protection offered by circumcision and complication rate of circumcision do not warrant a recommendation of universal circumcision for newborn and infant males in an Australian and New Zealand context.
After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed”
The College of Physicians and Surgeons of British Columbia, September 2009 revised statement :
“Until recently, only public health and religious views were taken into consideration in the debate over infant male circumcision. However, our understanding of medical practice must change as research findings become available. The College is issuing this guide for physicians regarding routine infant male circumcision in light of evidence-based medicine and contemporary principles in ethics, law and human rights.
Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention. From a religious standpoint, infant male circumcision is acknowledged to be an important ritual and an integral part of Jewish and Islamic religions. Male circumcision is also practiced in other parts of the world as a rite of puberty.
Circumcision is painful, and puts the patient at risk for complications ranging from minor, as in mild local infections, to more serious such as injury to the penis, meatal stenosis, urinary retention, urinary tract infection and, rarely, even haemorrhage leading to death. The benefits of infant male circumcision that have been promoted over time include the prevention of urinary tract infections and sexually transmitted diseases, and the reduction in risk of penile and cervical cancer. Current consensus of medical opinion, including that of the Canadian and American Paediatric Societies and the American Urological Society, is that there is insufficient evidence that these benefits outweigh the potential risks. That is, routine infant male circumcision, i.e. routine removal of normal tissue in a healthy infant, is not recommended.”
@ Alison
“They didn’t break this down by men vs women”
This is a very important distinction since efficiency of transmission is far greater from men to women, I’ve seen numbers up to 8 times. It also depends largely on viral load in the positive partner and whether there are coinfections present among other things. In fact, just last year, a group of Swiss researchers in their HIV agency completed a study and made the statement that condoms were not necessary for long term heterosexual couples that were serodiscordant (think married couples) where the positive partner is being treated. That is to say being on anti-virals was enough to make the positive partner non-infectious (other conditions applied such as coinfections status).
If I recall though as far as condom vs. no condom there is at least an order of magnitude difference i believe this was discussed in: Reducing the Risk of Sexual HIV Transmission, Varghese et al, Sexually Transmitted Diseases, January 2002 if I recall.
However, as noted above some organizations such as AFAO have provided lifetime estimations for risk of infection.
“It also depends largely on viral load in the positive partner and whether there are coinfections present among other things.”
Yes, that’s a very good point about the difficulty of assessing risk of seroconversion when the risk doesn’t depend primarily on the diagnosis of HIV/AIDS but on many other factors as well.
“condoms were not necessary for long term heterosexual couples that were serodiscordant (think married couples) where the positive partner is being treated.”
Right, which applies when the HIV+ partner is being treated. What if the HIV+ isn’t being treated, as is too often the case in poor countries? What should they do then?
# Amy Tuteur, MDon 08 Jan 2010 at 5:47 pm
[in response to Nick]
“What is it you are trying to say?”
He’s already said it a couple of times. Circumcision is a Jewish Conspiracy.
Being as I’m of Irish Catholic descent, may I respectfully request that Nick be put on moderation? May I strongly urge it?
“Being as I’m of Irish Catholic descent, may I respectfully request that Nick be put on moderation? May I strongly urge it?”
Why? denying that there are biases in research is ignorant.
““It’s obvious that these researchers are more interested in promoting infant circumcision than a better HIV prevention.”
That’s because the researchers make so much money from circumcision … oh, wait, they don’t benefit in any way.
Maybe it’s because they want lots of people to die of AIDS so they are deliberately recommending useless (and evil) strategies … oh, wait, they don’t benefit in any way from more people getting HIV and dying of AIDS.
What is it you are trying to say?”
The problem with the “studies” and the people behind them is that they’re not focusing on HIV prevention; their stated agenda has always been to legitimize circumcision. These resaerchers (Halperin, Bailey etc…) are known circumcision evangelists.
1. This obsession of circumcision and the very idea that foreskin is something “wrong” is nothing ne in US. Circumcision in US has a long reputation for being a cure in search of a disease. HIV is just the latest candidate. Please read hoistory of circumcision : http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=31&Itemid=54
2. Many reasons can explain this obsession. First : money.
Circumcisions aren’t free. Doctors who circumcise must protect their reputations and careers especially when rates are decreasing in US.
It’s a long chain of money making….first there’s the doctor who pockets the cash from the surgery, then there is the ped who sees the kid for meatal stenosis, who then refers the child to a ped urologist who does another surgery to open up his urethral opening, then there’s the personal lubricant industry who manufacturers something to help restore some gliding action taken away with the foreskin. Not to mention, neonatal foreskin is highly valuable to the medical industry. It is processed and sold in a variety of products ranging from beauty creams to artificial skin grafts.
3. Second reason : tradition and culture. All doctors promoting circumcision are circumcised men. The fact that these men come from cultures where it is INFANTS that are circumcised tells me that the circumcision of infants was the target of their “studies” all along. The fact that the say HIV+ men should be circumcised to avoid having to reveal their status to them, the fact that they explain away the recent studies in women and insist men be circumcised anyway reveals to me that it is circumcision, not the reduction of HIV, with which they are concerned with.
Much of their identity is based on circumcision. There is not a doubt that part of what drives these men is self-validation and a problem of ego.
I don’t think we need to get into the trouble that circumcised men go to deny to themselves the fact that circumcision is needless mutilation, and that they were victims to it.
““It’s obvious that these researchers are more interested in promoting infant circumcision than a better HIV prevention.”
That’s because the researchers make so much money from circumcision … oh, wait, they don’t benefit in any way.
Maybe it’s because they want lots of people to die of AIDS so they are deliberately recommending useless (and evil) strategies … oh, wait, they don’t benefit in any way from more people getting HIV and dying of AIDS.
What is it you are trying to say?”
Amy,
The problem with the “studies” and the people behind them is that they’re not focusing on HIV prevention; their stated agenda has always been to legitimize circumcision. These resaerchers (Halperin, Bailey etc…) are known circumcision evangelists.
1. This obsession of circumcision and the very idea that foreskin is something “wrong” is nothing ne in US. Circumcision in US has a long reputation for being a cure in search of a disease. HIV is just the latest candidate. Please read hoistory of circumcision : http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=31&Itemid=54
2. Many reasons can explain this obsession. First : money.
Circumcisions aren’t free. Doctors who circumcise must protect their reputations and careers especially when rates are decreasing in US.
It’s a long chain of money making….first there’s the doctor who pockets the cash from the surgery, then there is the ped who sees the kid for meatal stenosis, who then refers the child to a ped urologist who does another surgery to open up his urethral opening, then there’s the personal lubricant industry who manufacturers something to help restore some gliding action taken away with the foreskin. Not to mention, neonatal foreskin is highly valuable to the medical industry. It is processed and sold in a variety of products ranging from beauty creams to artificial skin grafts.
3. Second reason : tradition and culture. All doctors promoting circumcision are circumcised men. The fact that these men come from cultures where it is INFANTS that are circumcised tells me that the circumcision of infants was the target of their “studies” all along. The fact that the say HIV+ men should be circumcised to avoid having to reveal their status to them, the fact that they explain away the recent studies in women and insist men be circumcised anyway reveals to me that it is circumcision, not the reduction of HIV, with which they are concerned with.
Much of their identity is based on circumcision. There is not a doubt that part of what drives these men is self-validation and a problem of ego.
I don’t think we need to get into the trouble that circumcised men go to deny to themselves the fact that circumcision is needless mutilation, and that they were victims to it.
4. Trauma of circumcision :
Persons who have lost body parts must grieve their loss.The first stage of grief is denial of the loss. Fitzgerald and Parkes state that “Anything that seriously impairs sensory or cognitive function is bound to have profound psychological effects, not only on the person who is affected but also on family, friends, workmates, and caregivers.” The thought of permanent loss of sensory function is so painful that persons deny their loss in order to avoid facing the painful feelings.41 Denial of loss causes a flight from reality. Parkes et al. state that persons in denial may minimize their loss. Circumcision causes the loss of a body part and all of its functions including a drastic loss of erogenous sensory function, so denial of loss is not uncommon in circumcised males. Van der Kolk identified a compulsion in traumatized persons to repeat the trauma. This frequently results in circumcised fathers adamantly insisting that a son be circumcised. And this is also true for all these circumcised reseaechers that promote “universal circumcision”. HIV is just a poor excuse to achieve their goals and legitimize circumcision.
@ Amy
Also, look up where the majority of erectile dysfunction medications are sold, such as viagra. If you don’t think that circumcising babies is a multi million if not billion dollar a year industry in the US, you are in denial or ignorant of the facts.
“The May 1998 issue of Business Week provided a glimpse into this sadistic industry. “One piece of foreskin can produce four acres of engineered skin”. Skin that sells for more than $3,000.00 a square foot. The February 1998 issue of Wired magazine quotes one of these companies, “The cells from a single foreskin can produce 200,000 units of manufactured skin”. “That’s enough skin to cover about 250 people.”"
“He’s already said it a couple of times. Circumcision is a Jewish Conspiracy.
Being as I’m of Irish Catholic descent, may I respectfully request that Nick be put on moderation? May I strongly urge it?”
I’ve never talked about conspiracy. I just mention that the idea that circumcision prevent HIV came from a Jew : Aaron Fink.
Claiming my posts are anti-semitic is a weak way to avoid a real debate about circumcision.
“The problem with the “studies” and the people behind them is that they’re not focusing on HIV prevention; their stated agenda has always been to legitimize circumcision.”
If it’s there stated agenda, then you should be able to provide their statements. Where are they?
“Doctors who circumcise must protect their reputations and careers especially when rates are decreasing in US.”
Can you name EVEN ONE HIV researcher, infectious disease specialist or public health professional who makes even a dollar from circumcision? Of course not.
Do you even know who actually pockets the money from circumcision?
Annabel,
Unless you can show that the people who recommend circumcision for HIV prevention make any money from it, you’re just spouting conspiracy theories.
Are you trying to suggest that it is the HIV researchers, infectious disease specialists and public health officials who are surreptitiously selling foreskins to industry? If so, you need to provide proof for such an outrageous accusation.
Alison said: “Right, which applies when the HIV+ partner is being treated. What if the HIV+ isn’t being treated, as is too often the case in poor countries? What should they do then?”
I agree this is a problem and as I’ve said before under certain situations I am not necessarily opposed to men being offered circumcision in high risk countries. In fact, like tattoos or piercings, I don’t care if men anywhere get circumcised for any or no reason. All I care about if infant/child what an adult does to themselves is their own business and their own problem.
In the poor countries that we are talking about despite the possibility of circumcision being potentially useful I still have significant misgivings and I think there are problems that will get overlooked in the zeal to apply this high tech quick fix. For example:
1. I am significantly concerned about men overestimating the level of protection and abandoning condoms all together. Hardly an article on this issue is written that doesn’t interview a bunch of mopes praising their new virtual condoms.
2. I am concerned about women’s ability to negotiate safe sex when men over estimate the level of protective effect of their circumcision.
3. I am not confident that circumcision at any level can be provided in countries where the doctor patient ratios are measured in the tens of thousands in some cases. Where do those with severe complications go?
4. I am not convinced that this will be successfully combined with “other safe sex messages” such as condoms since as it stands most men in many of these places only have access to a small number of condoms each year. If we can’t deliver condoms how can we deliver circumcisions?
5. I am concerned about the under reported phenomenon of nonsocial infections which is said to be a significant contributor to the HIV problem yet is under reported. A recent string of papers by Potterat et. al. in the International Journal of STD and HIV estimated at least 1 in 5 new infections in these countries are caused by that vector. How is a circumcision champaign in a place where clean water is a luxury going to manage this?
6. One of the reasons stated for starting this champaign was to provide a way to get men into clinics to talk about the more effective strategies and get tested (but only if they want to get tested). If you then move to infants or children, when how will you then get the message to them?
This is just a short list off the top of my head. Like I said I am not saying men shouldn’t be allowed to opt for it but the risk reduction in the west is vanishingly small and I think in poor countries there are a number of hurdles and unforeseen problems that I fully expect to get the bureaucratic push aside.
If they want to go to the trouble of actually getting around to setting up clinics then make sure they have condoms, clean water, and access to testing for the whole population first. We’ve never even come close to that yet but we need all of those things anyway to support the potential of offering circumcision to men.
Since 1995, Dr. Bailey has devoted most of his research activities to the issue of male circumcision as a possible HIV prevention strategy. He has conducted circumcision-related studies in varying communities in Uganda, Kenya, Malawi, Zambia, and the U.S. He has studied adverse events and conducted needs assessments associated with medical and traditional circumcisions in Kenya.
Dr. Bailey is the principal investigator of the randomized controlled trial of male circumcision to reduce HIV incidence in Kisumu, Kenya, and he has served as a consultant to WHO, UNAIDS, UNICEF, the World Bank, USAID, the CDC, and other national and international governmental and non-governmental agencies.
This also wouldn’t be the first study he heads regarding circumcision. Robert Bailey has been trying to find the ultimate alibi for circumcision, and has been trying seriously hard to make HIV circumcision’s cash cow. He is known to get extremely frustrated when countries and municipalities reject his calls to implement mass circumcision. This man has an axe to grind. He is on a mission. He has a vested interest in rigging his “studies” and manipulating his figures, and it is written in plain sight that he has.
“Robert Bailey has been trying to find the ultimate alibi for circumcision”
Where is the evidence that he has received even one dime from circumcisions?
@ Amy
Are you implying that the only bias that could possible exist is one related to money?
Look at this recent report :
“Dr David Shaw, lecturer in ethics at Glasgow University, argues that circumcising boys for no medical reason is unethical.
He wrote in the journal Clinical Ethics that any doctor who does perform circumcision without a medical reason could be guilty of negligence and in breach of the Human Rights Act as the child cannot consent to the operation and it can be argued it is not in their best interests.
Dr Shaw wrote: “Imagine a situation where two adherents of a minority religion ask their doctor to pull off their son’s thumbnails, as this is part of the religion in which they want to bring up their son.
“The pain will be transient, and the nails will grow back, but the parents claim that it is an important rite of passage. I think it is reasonable to say that the doctor would send them packing.
“In the case of non-therapeutic circumcision, the foreskin will not grow back; why should this procedure be treated differently simply because of the weight of religious tradition?”
The controversial view is likely to cause a storm among Jewish populations who routinely circumcise boys when infants.
He said guidance to the medical profession on the issue from the General Medical Council and the British Medical Association are flawed and should be revised.
He added that the only medical reason for circumsing men is that there is some evidence it may prevent HIV in countries where cases are very high but that will not be relevant for doctors working in Britain. ”
“Non-therapeutic circumcision (NTC). The SMF continues its work towards ending NTC in the UK. At the end of November they chaired a meeting combining senior members from several organisations working to develop a joint strategy and action plan.
The Daily Mirror reported on a 20 year old man initiating legal proceedings against the doctor who performed a NTC on him as an infant because of his parents’ religious beliefs. The young man has been in regular contact with the SMF.
The Daily Telegraph reported on a paper recently published in the Journal Clinical Ethics concluding that current GMC and BMA guidance to doctors is itself unethical in that it allows parents to procure a non-therapeutic, irreversible surgical procedure on their children to satisfy their own religious beliefs. The author of the paper, Dr David Shaw, is a lecturer in ethics at Glasgow University.
The SMF will be contacting both the BMA and the GMC asking them to revisit their respective guidelines. Members of the NSS may wish to contact their MPs, NHS trusts and local media to bring these developments to their attention and to raise public awareness. ”
http://www.secularism.org.uk/116437.html
It is a big fear for people of the Jewish faith that if they don’t maintain the idea that circumcision is medically beneficial, numbers will continue to drop and more questions are going to start being asked about the legality of infant circumcision. I think that this could clearly be a bias in research.
Actually, Nick, it was you who said: “Many reasons can explain this obsession. First : money.”
So if money comes first, show me the money.
“It is a big fear for people of the Jewish faith that if they don’t maintain the idea that circumcision is medically beneficial, numbers will continue to drop and more questions are going to start being asked about the legality of infant circumcision.”
That’s baloney, like so much else of what you’ve written. Circumcision is a religious obligation and medical benefit has nothing to do with it.
joep,
Many of the concerns you express relate to the difficulty of providing safe circumcision facilities.
Upthread, Amy quoted a 2007 UNAIDS report as follows:
“There is substantial evidence that male circumcision protects against several diseases, including urinary tract infections, syphilis, chancroid and invasive penile cancer, as well as HIV. However, as with any surgical procedure, there are risks involved. Neonatal circumcision is a simpler procedure than adolescent or adult circumcision and has a very low rate of adverse events, which are usually minor (0.2–0.4%). Adolescent or adult circumcision can be associated with bleeding, haematoma or sepsis, but these are treatable and there is little evidence of long-term sequelae when undertaken in a clinical setting with experienced providers. In contrast, circumcision undertaken by inexperienced providers with inadequate instruments, or with poor after-care, can result in serious complications.”
What this means is that in regions with poor health care, neonatal circumcisions are simple enough that they can be done by the local health care provider, whoever that is.
Adolescent or adult circumcisions are more difficult and need to be done in a properly supplied clinic with trained and experienced staff.
While we might take these more complex health facilities for granted and assume that an adolescent or adult can access them as needed, this may not be true elsewhere. In these situations, the only way of ensuring that circumcision is available is to offer it to infants.
I know many people have said that they “feel” or “think” that adult circumcisions must be easier to do than infant circumcisions, and that they simply disbelieve health care workers who say that really, it is more difficult to circumcise an adult. But nobody has actually cited research to show that circumcision is easier to perform on adults. So far, the information we have is that it’s less complex to circumcise an infant. Presumably it can be done at home by someone with a razorblade and a bottle of alcohol. The elaborate health infrastructure only really needs to be there if you’re going to restrict circumcisions to adults.
No, it’s not perfect. It doesn’t have to be. It just has to be better than the alternative.
Yes, of course there is pain and risk. That’s why it needs to be balanced against the pain and risk of the alternatives. In the US, the balance is not the same as in, say, Rwanda.
“That’s baloney, like so much else of what you’ve written. Circumcision is a religious obligation and medical benefit has nothing to do with it.”
First of all, I am not Nick. Second of all, circumcision is unique in that a parent of any other religious minority would not be allowed to permanently mark their child for religious reasons. Not a tattoo, not a small incision, not a small burn- nothing. A baby cannot say whether or not he is Jewish. There is no way of knowing whether or not he will want to be a part of the Jewish religion as an adult, therefore it is unethical. As long as people believe there is a medical benefit it will most likely continue to be a legal procedure. It would be unethical for doctors to say ” You can only circumcise your son if you are Jewish,” that would be discrimination. Either everyone can or everyone can’t. If there are no medical benefits, the procedure is likely to eventually fall out of favor in America like it has with every other Western country.
@Alison
I disagree with your assessment. Primary concerns focus on overestimation of effect, womens’ issues, and nonsocial infections, and infrastructure. If they may be doing it with a razor blade and a bottle of alcohol as you suggest then it’s worse than I thought.
@Alison
And just to give you a feel for the situation here is a report from last year that discussed the complication rates of circumcisions in medical settings in these ‘deployed’ clinics.
http://www.aidsmap.com/en/news/03B54A29-5328-43FE-80D8-735C78D21F56.asp
18% in medically performed ones.
So how many urologists does this country have to clean up such a mess?
I reiterate in a place where we have failed to provide basic services I don’t see how this will be successfully implemented. If they go after infants, I don’t see how they will “integrate” safe sex messages. And I don’t see how they will manage nonsocial infections.
“That’s baloney, like so much else of what you’ve written. Circumcision is a religious obligation and medical benefit has nothing to do with it.”
The problem isn’t about medical benefits but basic human rights ang bodily integrity. Now, more and more peole are considering circumcision to be an ethical issue. FGM was banned recently in US (in 1996). Scandinavian doctors refuse to perform male circumcision without solid medical reasons. Several parliamentary parties are considering creating legislation that would spare all children from circumcision. Considering these facts, it’s important for religious authorities to find new excuses (like HIV prevention) to legitimize circumcision when it appears that religious reasons aren’t enough to perform infant circumcision.
“So if money comes first, show me the money.”
I’ve already written how circumcision is a long chain of money making. There is money to be made in circumcision, not only for doctors, but also manufacturers of circumcision equipment, such as Gomco clamps, Circumstraints, PlastiBells, etc., not to mention that foreskins are sold to pharmaceutical companies, and not to mention there is a line of products created from the foreskins of children, for example, Oprah Winfrey’s SkinMedica.
I just have to add Alison that with respect to the complications ect. The numbers cited must come from western (US) sources it’s the same figure used by the AAP, the British and Australians site about a 2% rate BTW. I have little doubt it will be higher in Africa as I have no faith in their health care delivery system to execute this plan any better than condom distribution, safe sex education, or really most anything else.
But even given that a complication like minor bleeding might occur less often in an infant, the risk of a major complication for an adult is much less. For example, please provide me an example of an adult death in a western medical circumcision. I know I can find examples of infant deaths but I’ve never heard of an adult death.
Joep,
1. I am significantly concerned about men overestimating the level of protection and abandoning condoms all together.
If men abandoned condoms (more effective) once they were circumcised (less effective), then infection rates would drop. That’s not what has been seen in the studies to date, which is why circumcision is now thought to be a health benefit in high-prevalence areas.
2. I am concerned about women’s ability to negotiate safe sex when men over estimate the level of protective effect of their circumcision.
In my experience, too often men are not worried about what they can transmit nearly as much as they worry about what they might catch. If a woman is thought to be STD-free, there’s a good chance she’ll have trouble convincing a male partner to use condoms no matter where she is in the world. I don’t see circumcision changing that.
3. I am not confident that circumcision at any level can be provided in countries where the doctor patient ratios are measured in the tens of thousands in some cases. Where do those with severe complications go?
Nowhere. Ditto those with AIDS. If you are more likely to get deadly circumcision complications than AIDS, then circumcision is not a good bet for you. If you are more likely to die of AIDS, that changes the equation.
Severe complications requiring a professional clinic are less likely with neonatal circumcision — see my previous comment.
4. I am not convinced that this will be successfully combined with “other safe sex messages” such as condoms since as it stands most men in many of these places only have access to a small number of condoms each year. If we can’t deliver condoms how can we deliver circumcisions?
If condoms aren’t available today, circumcision isn’t going to change that. So that’s an argument for circumcision, not against it.
Circumcision has been performed for thousands of years, long before the existence of medical clinics. See my previous comment about easier infant circumcision.
5. I am concerned about the under reported phenomenon of nonsocial infections which is said to be a significant contributor to the HIV problem yet is under reported. A recent string of papers by Potterat et. al. in the International Journal of STD and HIV estimated at least 1 in 5 new infections in these countries are caused by that vector. How is a circumcision champaign in a place where clean water is a luxury going to manage this?
It will reduce transmission from women who contract HIV from their drinking water to their male partners.
6. One of the reasons stated for starting this champaign was to provide a way to get men into clinics to talk about the more effective strategies and get tested (but only if they want to get tested). If you then move to infants or children, when how will you then get the message to them?
STI clinics. Billboards. Radio.
If they want to go to the trouble of actually getting around to setting up clinics then make sure they have condoms, clean water, and access to testing for the whole population first.
Any public health agency is going to look at what is most cost-effective. If subsidising condoms will get better outcomes more consistently for more people for the same money as promoting infant circumcision, then they will do that. I don’t think you need to worry about other people’s budgets.
Why test? It’s expensive and could reduce motivation to use condoms. Testing is for monogamous people who want to stop using condoms and can pay for the tests.
We’ve never even come close to that yet but we need all of those things anyway to support the potential of offering circumcision to men.
What do you mean “we”?
An African public health organization would need to provide some of those things to support circumcision for adult men. Supporting circumcision for neonates would require less infrastructure. It’s their call.
If they may be doing it with a razor blade and a bottle of alcohol as you suggest then it’s worse than I thought.
How do you think country people do it today, all over the world?
Steve Novella regularly points out that almost everyone has a sacred cow that they won’t have attacked, and that they’ll often go out of their to cherry pick evidence in support of that sacred cow, even when the majority of evidence is either neutral or against.
One of Dr. Tuteur’s sacred cows seems to be neo-natal circumcision. She’s managed to cherry pick a study on adult circumcision which show a marginal improvement in STD transmission rates.
If adult circumcision does in fact reduce transmission rates, why call for neo-natal circumcision? The evidence at hand does not support it in any way, in fact the investigations cited in her post make it clear that we have enough males that were circumcised as adults to have enough data to see if adult circumcision is just as effective.
The call for neo-natal circumcision is not supported by the evidence, and adult circumcision is only supported in circumstances where the almost perfect protection offered by condoms and safe sex is not universal.
As I’ve pointed out above, male circumcision appears only to be of benefit in poor and/or uneducated populations without access to condoms.
As circumcision is far less effective than condom use, the only excuse to use it is where the will to improve education, standard of living and condom availability is lacking.
Dr. Tuteur must know that circumcision is far less effective than poverty relief, education and condom use.
I must conclude that Dr Tuteur is therefore supporting circumcision not for any supposed medical benefits, but for ideological reasons. If she doesn’t want to feel guilty about performing irreversible, unneeded surgery on males unable to give explicit consent, then she should stop doing it, rather than finding fig leaves to cover her suppressed guilt.
You’ve gotten ridiculous in your conspiracy-mongering now, given that the researchers advocating circumcision don’t share in this loot. (Or maybe Oprah and Big Circ bought them off.) Moreover, do you have any idea just how big an industry this is? My guess would be: Not very.
There are reasons to doubt whether the benefits of circumcision are with the high NNT and the potential complications, but Big Circ paying off the researchers isn’t one of them.
@Alison
I’ll have to look at the rest later but this stood out most.
Alison said: “Why test? It’s expensive and could reduce motivation to use condoms. Testing is for monogamous people who want to stop using condoms and can pay for the tests.”
Because a program of testing and then going on antivirals if you’re positive would do far more to alleviate the situation in 10 years than circumcision could do in 20 years.
Link: tinyurl.com/yc23pha
Link: tinyurl.com/ao2aty
The major hurdle sited:
* The ethical problem of implementing a universal HIV testing program;
* The ethical problem of starting treatment when one has contracted HIV but still has a high CD4 count.
An ethical problem? Surely they must be joking.
@Alison
I’ll have to look at the rest later but this stood out most.
Alison said: “Why test? It’s expensive and could reduce motivation to use condoms. Testing is for monogamous people who want to stop using condoms and can pay for the tests.”
Because a program of testing and then going on antivirals if you’re positive would do far more to alleviate the situation in 10 years than circumcision could do in 20 years.
Link: tinyurl.com/yc23pha
Link: tinyurl.com/ao2aty
The major hurdle sited:
* The ethical problem of implementing a universal HIV testing program;
* The ethical problem of starting treatment when one has contracted HIV but still has a high CD4 count.
An ethical problem? Surely they must be joking.
I am not sure if this keeps getting caught in the spam filter or not, I didn’t see a waiting for moderation message so if this pops up more than once I apologize.
“There is no way of knowing whether or not he will want to be a part of the Jewish religion as an adult”
You really need to learn a lot more about Judaism before you make claims about it. Being Jewish is not a choice. It is inherited through the mother. You can convert later if you want, but if your mother is Jewish, you’re Jewish, whether you want to be or not.
“I’ve already written how circumcision is a long chain of money making.”
You’ve accused people by name or by profession and you are obligated to prove it or withdraw it. Saying “some people” make money, is not enough.
“Being Jewish is not a choice. It is inherited through the mother.”
Can you point to the place on the X chromosome where Jewishness resides?
It’s a social construct. You’re no more a Jew at birth than a Catholic or a Republican or a Marxist.
You’re really digging yourself in deeper with these completely innacurate and ideological bugbears.
“You’re no more a Jew at birth than a Catholic or a Republican or a Marxist.”
Clearly you need to do a little more research on religion.
“Clearly you need to do a little more research on religion.”
And you need to do a serious revision of your basic biology textbooks. You can be born with dark skin, left handed, a redehead, or gay, or having any other number of genetically predetermind characteristics.
What you can’t be born as is a part of a social construct. You can only be born to parents who are a member of a social construct, but seeing that has no effect whatsoever on your genetics or even epigentics, you’re a priori born without any political affliation to a social construct.
Religious people might like to imagine that their children are members of their personal religion from birth, but wishing doesn’t make it so. They can force the child to undergo religious indocrination, but that by definition is post birth, and is most definately nothing to do with the child’s state at point of birth.
Just because a religion claims something, doesn’t make it true. This is Science Based Medicine, and you just made a theological claim unsupported by any evidence whatsoever.
Instead of guessing about Judaism and presenting your guesses as facts, why don’t you do a little research and let us know what you find?
Biologically, I suppose you could have a point, but culturally Judaism is passed through the maternal lineage. If your mother is a Jew, you are a Jew. Period.
You’re just plain wrong here. Or you’re intentionally attacking a straw man (that somehow Judaism is genetically inherited through the mother) in order to troll.
“Instead of guessing about Judaism and presenting your guesses as facts, why don’t you do a little research and let us know what you find?”
You’re avoiding the question entirely aren’t you. Can you make one scientific claim that supports your assertion that children are born belonging a priori to any religion because of their birth mother?
Your retreat to theology only makes it clear that you have no grounds on which to support your scientific claims.
Go and read some basic biology textbooks on heredity and see if you can claim that a social construct can be inherited biologically.
I understand your arguments, I can point to any number of societies where legitimacy comes from the matriliniar line. This is a claim based on the fact that a wise person can only know his mother, and in societies where legitimacy is important is a quite clever solution.
Still it does not say any more than about the child than it was born of that woman. Social constructs are not genetic, unless you’re claiming that certain religions are exclusive extended phenotypes, and that is clearly wrong as you can change your religion like any other social construct.
(sorry if this is a double post, I couldn’t see that it had been posted but got a message that it had)
“Biologically, I suppose you could have a point, but culturally Judaism is passed through the maternal lineage. If your mother is a Jew, you are a Jew. Period.”
No, what it says is that the only people who can be considered to be Jews are those born of a Jewish mother. That is something completely different than you are automatically a Jew if your mother is one.
Condom efficacy…
http://www.rho.org/html/cont-male_condoms.htm
Male Condoms
Overview
A male condom is a sheath designed to fit over a man’s erect penis and prevent passage of sperm into the female reproductive tract. Most condoms are made of thin latex rubber; some are made of animal tissue or of polyurethane. Condoms come dry or lubricated with a water-based lubricant or spermicide. (See the condoms and nonoxynol-9 discussion below.) Condoms can be very effective in preventing pregnancy when used correctly and consistently with every act of intercourse (perfect use); however, they are less effective with typical use. A meta-analysis of the male condom in preventing HIV suggests that their effectiveness at preventing HIV is 87 percent (with a range from 60 to 95 percent depending on the incidence among nonusers) (Davis, 1999). Condoms do not affect breastfeeding or have hormonal side effects; no medical condition restricts a client’s eligibility for use of the method except allergy to latex. In addition to preventing pregnancy, latex condoms are effective in protection against sexually transmitted infections (STIs). Male condoms may be less effective in protecting against those STIs that are transmitted by skin-to-skin contact, since the infected areas may not be covered by the condom (WHO, 2001; NIAID/NIH/DHHS, 2001).
Characteristics of condoms
Effectiveness : 3% to 12% failure rate during first year of typical use; 3% failure rate during first year of perfect use.
User issues
Condoms in various forms have been used for centuries. Since the 1930s latex condoms have been used, though generally not extensively, in many parts of the world to prevent both pregnancy and STIs. The promotion of condoms for HIV prevention led to an increase in research and technical knowledge during the past decade and the first substantial modifications in manufacturing of condoms since the 1930s.
If used consistently and correctly, condoms can be very effective. Reviews of literature confirm that condoms can prevent both pregnancy and STIs, including HIV (Lisken, 1990; FHI, 1998; PATH/Outlook, 1994; Gardner, 1999). Laboratory studies show that sperm and disease organisms cannot pass through an intact latex condom. Consistent condom use is very effective at preventing HIV infection, even among serodiscordant couples, where one partner is infected and the other is not. Studies have confirmed that, with consistent condom use, the HIV infection rate among the uninfected partners was less than 1 percent per year (de Vincenzi, 1994). Where one partner is definitely infected, however, inconsistent condom use can be as risky as not using condoms at all.
In actual use, however, couples relying on condoms generally are not as successful at preventing unwanted pregnancy as users of many other methods. Evidence suggests that the individual—not the condom—is usually responsible for most condom failures and to inconsistent use, incorrect use, and breakage due to improper use. Breakage rates for high-quality condoms are quite low (less than 1 to 12 per 100 condoms) during either vaginal or anal intercourse. Substandard products, either manufactured badly or stored badly, may have holes or defects that lead to tearing the condom or leakage. Failure also may be caused by the condom user’s behavior. A recent study found that breakage related to: (1) having a male sexual partner, (2) infrequent condom use, (3) having the condom partially slip, and (4) the technique use to don the condom (Richters, 1995). Slippage was related to: (1) young age, (2) having less lifetime condom experience, *******(3) being circumcised******, and (4) the donning technique. These researchers suggest that condom counseling protocols should acknowledge the complexity of condom use.
Amy, it is getting more than a little boring for you to demand others support each and every claim, yet you never support ANY claim you make..
Incidentally, I am still waiting for YOU to provide a single scientifically credible benefit for circumcision..
Lacking proof for one, it certainly is a double standard for you to demand this from others for every assertion.
As for this Jewish claim of being born a Jew, that is a patently absurd claim made by Jews. NO one is born as any religious group, and chopping off part of their genitals does not make them one either.
This “covenant” claimed by Jews is a made up mandate by Priests circa 550BCE–it was never part of the original covenant.
“This post is not about defending circumcision. It is an explanation of the current state of research on the reduction in transmission of HIV and other STDs by circumcision.”
Then perhaps, you might wish to provide some scientifically credible evidence that circumcision DOES reduce the rates of HIV and STD’s because frankly the empirical evidence in the real world refutes these claims–or are you scientifically illiterate?
If so, then read the link I posted earlier on the scientific process–or choose to remain ignorant and then pretend that you never had the chance to remedy this ignorance.
“You really need to learn a lot more about Judaism before you make claims about it. Being Jewish is not a choice. It is inherited through the mother. You can convert later if you want, but if your mother is Jewish, you’re Jewish, whether you want to be or not.”
Wow, so you’re saying that religion is genetic or not a choice simply because it’s imposed upon a child? If you can convert to Judaism it’s obviously a choice. If you can denounce your birth religion, obviously it’s as much a choice as any other religion. Just because the Jewish religion decides to not recognize children born of a Jewish father and a gentile mother doesn’t mean that being born of a Jewish mother somehow makes you biologically a Jew and not biologically a Jew if only your father is Jewish. Is a child born to a Jewish mother but given up for adoption and raised Catholic still Jewish in your opinion? Do you believe one is born Muslim too? Religion is culture not biology – no matter how hermetic a religion it is and even if intermarrying may have created distinct genetic lineages (as happens in other hermetic religions or cultures, the hermetic culture of the Ashkenazi Jews is responsible for their distinct genetic heritage, not all Jews have the same genetic heritage, it’s specific to a group…people in the Lac St-Jean district of Quebec are also studied because of distinct genetic traits due to hermetic culture, do you believe they’re born Catholic? Icelanders as well.) You really are reaching far here and wandering into some strange territory that is certainly ideological and uncomfortably close to what people who hate Jewish people claim. Do you only have this rule for Jewish people or is everyone defined by the label slapped on them at birth and forever destined to be their parent’s religion?
Seriously, I now suspect you just made your initial blog post in the first place to argue ideology from what your argument has devolved into (particularly since Harriet Hall had already posted about this topic before). You’re making a joke out of this being a science-based blog by clearly promoting an ideological perspective and pretending you’re doing it in the name of science. It’s a shame and I’m doubly appalled that you’ve pushing such ignorant ideas about safe sex and now religion.
@ David Gorski:
I’ve heard of foreskin being used for surgical repairs in the eye (as well as the amniotic sac). How does it get from point A to point B? Legitimate question here. Is it sold? Donated? I would imagine it would be deemed biological waste, but then what…?
This “Jewish” argument has me confused.
I thought that being Jewish was a faith, not genetics. Wikiepedia describes “Jewish people” as “an ethnoreligious group originating in the Israelites or Hebrews of the Ancient Near East.”
Wouldn’t that mean religion.. not genetics?
If you convert to Judaism, you are of the same status as people who were born into the Jewish faith.
So a family who converts to Judaism, and has a son.. circumcises their son who was “born Jewish”who may or may not grow up to worship in the Jewish faith… but isn’t *genetically* an Israelite.
Am I making any sense? Or do I have it completely fudged up?
“You really need to learn a lot more about Judaism before you make claims about it. Being Jewish is not a choice. It is inherited through the mother. You can convert later if you want, but if your mother is Jewish, you’re Jewish, whether you want to be or not.”
Wow. Ok, this takes the cake. That has to be one of the most ignorant things I have read on a circumcision blog or forum ever, and that is saying a lot.
““You’re no more a Jew at birth than a Catholic or a Republican or a Marxist.”
Clearly you need to do a little more research on religion.”
Amy, I suggest you do the same IF you believe that one is born Jewish or that the Jewish deity mandated circumcision.
The first is a logical absurdity–an infant is born human and nothing else regardless of the silly notion that popping out of a womb of someone who follows a certain belief system somehow receives that belief system through her genes.
The second is a completely ignorant assumption.
Please try not to talk down to people who just might be more educated on a subject than yourself.
“If your mother is a Jew, you are a Jew. Period.”
A better illustration. I turn up to Synagogue and say that I’m Jewish, the Rabbi asks me if my mother was Jewish, I say yes. Then I’m Jewish.
Or I turn up to Synagogue and the Rabbi asks me if my mother was Jewish, I say no. Then I’m not Jewish. Fine, it’s an exclusion principle based on matriliniar ancestry.
I turn up the Atheist Alliance annual bake sale and debauchery festival and I’m asked if I’m an atheist and I say that, though my mother and father are Jewish, I’m an Atheist. Then I’m not Jewish.
You can’t claim that just because you are Jewish, and you had children, that they are Jewish. You let them decide for themself.
The same goes for every other religion. I was actually born to Catholic parents, though I have Jewish ancestors on my mother’s side, and now consider myself to be a 6.9 on the Dawkins scale, then I’m certainly not Catholic or Jewish or anything else that someone else may consider me to be just because of their conventions.
Besides, you should really check into why circumcision started to be practiced within the Jewish faith.
Amongst gentiles circumcision really does have roots in wacky anti-sex ideas, including that beloved grandfather of many things woo Kellog who promoted wacky anti-sex and anti-masturbation ideas.The idea it protects from disease – including the disease of sexual pleasure that rots mens’ minds – is equally rooted in antiquity. Really, in 2010 the way to protect oneself from STDs is via using condoms and barriers. Do you even teach women about using barriers other than condoms?
I’m not anti-circumcision – I like a wide variety of penises, it’s who they’re attached to that makes them attractive ultimately – but I do question practicing unnecessary surgery on babies and there are members of the tansgender community that have had to live with doctors’ mistakes and then lies about the mistakes most of their lives (these mistakes are very often covered up). I think you’re entirely discounting their suffering in favor of promoting an ideological perspective (which is simply to say that even if this is an infrequent event – it’s hard to know since it’s often hidden from the victim and not reported historically – that the consequences can be extreme) . At the moment parents can choose whether to circumcise their children or not, why you’d want it to be recommended in the US when people should be using condoms and barriers (and good sense) to prevent getting an STD (fatal or otherwise) is just weird and irrational.
Perhaps you should read about David Reimer
http://en.wikipedia.org/wiki/David_Reimer
“That is something completely different than you are automatically a Jew if your mother is one.”
I’m not sure why you are having such difficulty with this concept. It’s a social construct just like citizenship. Just like citizenship, you are born with it, don’t get to choose, and cannot change it by whim. A boy born in Italy to Italian parents is Italian, whether he has chosen it or not. And no amount of wishing will make him Canadian as an adult.
Really, you can’t entitle something ‘The case for neonatal circumcision’ and make a case for the recommendation of neonatal circumcision and then claim you’re not making a case for neonatal circumcision. You’re not weighing the evidence, you’re making a case for something and cherry picking the evidence and dismiss the reality of AIDS and safer sex and condom use to make your case for neonatal circumcision. Seriously, it’s just idiotic to claim you’re not promoting a particular perspective based upon one study.
What does matrilineal ethnoreligious anything have to do with whether the apparent effectiveness of circumcision of Ugandan adults in reducing transmission of HIV has any bearing on the current AAP recommendations on routine neonatal circumcision?
Judaism is a red herring. Circumcision is either effective or it’s not. If it’s effective, the benefits may or may not outweigh the costs. If they do, it may or may not be possible. If it is, it may or not be ethical. If it is, it may or may not be preferred. That’s science-based medicine.
The studies could have been funded by the Taliban and conducted by the Illuminati. They still have to stand or fall on their own merits. If their findings are correct, then they are correct. If they aren’t, then future studies will demonstrate that.
Someone who has a conflict of interest can be right just as much as they can be wrong. And we all have conflicts of interest somewhere. We’re human. We’re proud. We have friends. Whatever. What science does is provide a discipline for figuring out what’s really going on anyway, even though scientists are human. And this discipline does not involve conspiracy theories.
Actually, if he wants to be a Canadian as an adult he simply has to apply for Canadian citizenship. That’s how it works in Canada, you are then Canadian. You seem to be the one that’s having issues with understanding what a social construct is and how labels work. You do understand that it’s quite possible to be born labeled as a man and then become a woman – as uncomfortable as mutable identities may make you, biological, national and cultural identities are mutable.
“he simply has to apply for Canadian citizenship.”
That’s right, and Canada may or may not decide to grant it after he completes certain requirements. However, he cannot simply announce that he is Canadian and thereby become Canadian.
Moreover, unless he takes specific legal steps to renounce his Italian citizenship, he is still Italian, no matter how much he’d like to be viewed as something else.
The same thing applies to Judaism. You are Jewish until you take specific steps to convert to something else. No amount of claiming to be an atheist changes the fact that you are Jew if you were born a Jew.
Why is this so difficult to understand?
“The studies could have been funded by the Taliban and conducted by the Illuminati. They still have to stand or fall on their own merits. If their findings are correct, then they are correct. If they aren’t, then future studies will demonstrate that.”
Does nobody think it’s kind of biased to be conducting studies centered around legitimizing an ancient religious rite?
Are there any “studies” being done in the FEMALE microbiome and “the effect of female circumcision” on it?
What would we do with studies from African doctors who on the front want to “reduce HIV transmission,” through female circumcision?
What is with this compulsive obsession and fixation by certain researchers to try to discredit the existence of a normal part of the male anatomy since the beginning of mankind? Surely they could find, by their line of research, that excising female labia will give oxygen the chance to kill bacteria that researchers don’t like. Try proposing that! Most of the world laughs at America’s peculiar sexual hangups and notions that foreskins are unworthy. Foreskins are part of mammals, male and female.
I think it’s about time we outlawed all of these circumcision “studies.” They’re not looking for a solution to a problem, they’re looking for problems to legitimize their pre-determined solution.
Amy Tuteur: “You really need to learn a lot more about Judaism before you make claims about it. Being Jewish is not a choice. It is inherited through the mother.”
Your defenses are beginning to cast serious doubt on your objectivity. The semantics of what it means to belong to a religion are irrelevant to the point that Akheloios was making. Just because a child is born to parents of a particular religion does not justify permanently marking the child with the signs of that religion, when it’s obvious that the child didn’t choose that religion.
Amy Tuteur: “Why is this so difficult to understand?”
What does any of this have to do with Akheloios’ original point? Why can’t you address the issue that Akheloios raised, which is how being born to a Jewish mother justifies body modification? Why is this form of religious body modification okay, when others are not? And what does any of it have to do with science based medicine?
David Gorski: “You’re just plain wrong here. Or you’re intentionally attacking a straw man (that somehow Judaism is genetically inherited through the mother) in order to troll.”
I think it’s quite clear what Akheloios’ point was. It was Dr. Tuteur who sidetracked the issue and began obfuscating a viable point with pedantry.
I’ve long been a defender of science based medicine, and for that reason I find this entire thread deeply troubling. The “pro-circ” crowd has revealed itself to be hypocritical, ideological, and anything but scientific.
It’s clear that there is a double standard when it comes to the treatment of female versus male genitals in infants (previous commenters have provided descriptions of the extent and nature of both). A similar double standard exists with respect to religious traditions and infant body modification. Why is this? This has been brought up repeatedly in this thread, yet I haven’t seen anyone from the “pro-circ” camp comment on this, except to misrepresent the statements of others, or to trivialize what many of us have come to regard as institutionalized child abuse.
It’s clear that infant circumcision is an unnecessary body modification, rooted in religion and misguided attempts at sexual repression, whose potential benefits, still questionable and only secondarily realized, can wait until the child is of an age to make the decision for himself. The “pro-circ” camp has not sufficiently explained why they think circumcision cannot wait until the individual is able to consent, and seems to consistently ignore this question, despite the frequency with which it has been raised. Once again, why can’t circumcision wait? Why must it be performed on infants? Please provide justification for this.
It’s also clear that if there were no cultural precedence for infant male circumcision and it were a novel idea, very few would consider it acceptable — beneficial or not. Again, are members of the “pro-circ” camp really incapable of seeing the issue outside of the present cultural context? Attempts to downplay the severity of male genital mutilation by calling it “minor” and referring to those who use emotional language to describe their emotions as “inflammatory” are really quite distressing. Can anyone really be so unimaginative that they can’t see why some of us find this appalling? Can they not for one moment try to envision analogous procedures on toes, fingers, breasts, or other body parts, and appreciate the sense of horror that we feel? Historical precedence is not an excuse for suspending basic human rights. When you look at infant circumcision from an outsider’s perspective, it seems monstrous. The callousness with which some people write it off or try to downplay is all the more disturbing to me.
The fact is we don’t know if there are psychological effects. And to steal from an earlier poster, we don’t know that society isn’t suffering from some form of Stockholm Syndrome that leads us to trivialize and even rationalize what might otherwise be considered child abuse. It certainly seems plausible that there are negative psychological consequences. Does the “pro-circ” camp have sufficient evidence to show that it is psychologically safe? Have they done rigorous testing on the psychological and emotional well-being of males who are circumcised as infants? If not, then why? If you’re going to perform an unnecessary surgery on someone without their consent, you really need to investigate the potential side-effects, both psychological and physical.
But that is beside the point. Even if there is no psychological damage, it remains an unnecessary violation of one’s physical autonomy. How can this be justified? While merely anectdotal, I do know several circumcised men who lament their lack of choice. What would you say to these men, who had a part of their body taken from them for no good reason and can never get it back? I would say that they’ve been violated. Would you disagree? If so, then why?
And why do people keep pretending that the only possible biases are monetary? I find this very disingenuous. Other commenters have already spelled out potential cultural, psychological, and religious biases. Acknowledging and weeding out bias is a vital part of science. Cherry-picking the comments about monetary bias and then calling them conspiracy theories while ignoring the comments about other forms of bias does not resolve the issue.
Why continue to condone and even promote a violation of an individual’s “physical integrity” (to borrow a phrase from the WHO) that is neither ethically nor medically justified? These are not rhetorical questions, I want answers.
The onus is on the “pro-circ” camp to provide sufficient evidence that necessitates violating a child’s right to choose, not the other way around. Such evidence has not been provided. This is the opposite of science based medicine. I think some of you should seriously consider whether your cultural biases are not interfering with your objectivity, and I will do the same.
It would be interesting to see how medical professionals in the future will judge their predecessors.
@ Amy
Are you really comparing a legal citizenship to a religion? Seriously? Nowhere on any birth certificate or any drivers license or any passport do I see the word Jewish. Nor are there any legal proceedings a person must perform to become “un Jewish.” You are comparing apples and oranges. A person is not Jewish if they say they are not Jewish. We are not talking about a persons race, we are talking about a religion.
“Why is this so difficult to understand?”
“If your mother is a Jew, you are a Jew.”
This is true only if you consider yourself a Jew and are part of this religion, that means you must respect the rules. If you mother is Jew and you’re no longer interested in this religion, the fact you are Jew because your mother is (only according to Jewish law) doesn’t really matter anymore.
But someone isn’t a Jew until someone announces they’re a Jew, what don’t YOU understand? In the Jewish tradition, uncircumcised men can’t get into heaven so it’s questionable if one’s truly a Jew if not circumcised (or a Catholic if not baptized, these are rituals of faith that are necessary to belong). If a Jewish woman had a baby, left it at a Catholic church and it was baptized and raised Catholic, is that child still a Jew if it hasn’t been proclaimed one? Your argument is specious and ultimately has nothing to do with circumcision as a medical procedure outside of religion. Particularly since the very origins of the more extreme form of circumcision was used as a means of making sure that Jews and didn’t wander off and stop being Jewish (it was to prevent Jews from trying to pass as gentiles). Really, it’s no different than branding people so they can’t escape their masters (in this case, the Rabbi).
The hierarchal tradition of circumcision was challenged when Alexander the Great conquered Jewish lands between 334 B.C. and 331 B.C., and as a result, Greek culture swept through Jewish communities. It was counter to Greek beliefs to violate the natural human form, and this caused young Jewish men to try to appear to be uncircumcised, which greatly annoyed Jewish rabbis. In response, Jewish rabbis argued that the foreskin was an imperfection that needed to be cut off in order to reveal the correct human male form.
Like I said, I’m against unnecessary surgery for babies but I have no preference for an circumcised or uncircumcised penis. Nor, unlike you, do I have a desire to impose or promote one or the other. There’s science that can be presented for and against – particularly by those who want to cherry pick the evidence – though most seems to lean towards allowing the person to make an adult choice (since safer sex isn’t a consideration for a child so that’s a specious argument on many levels, unless you’re advocating sex with children). Still, I’m much more tempted to side with the Ancient Greeks and modern nations that have universal healthcare (and actually practice real preventative medicine) on this one. Particularly since the roots of circumcision in Christian culture are so wacky and come from the same source as so much weird and anti-science new agey woo, and are distinctly based on the idea that masturbation is evil and creates sickness and circumcision is the cure. There really don’t seem to be any real benefits for babies or children and there are potential dangers – the risks do seem to outweigh the benefits. Adults can make up their own minds about body modification, whatever form it takes, and their sexual health.
Yes, I do think it was quite clear what his purpose was: To construct a straw man and tear it down. He knew what Amy was talking about, but instead decided to try to make it sound as though she were making an argument that Jewishness is some sort of biological trait passed through the mother. It was pointless and served no useful purpose in the discussion.
And this doesn’t even get into the dichotomy between cultural Jews and religious Jews. In fact there are quite a few atheists who consider themselves Jewish by culture because they were born to a Jewish mother into a Jewish family. There are secular Jews who take part in the religious rituals to varying degrees from not at all to just some extent. This whole argument about whether being Jewish is more religious or cultural is not a new argument. The bottom line is that, to the Jewish religion, a person is considered Jewish if his mother is Jewish. That person may choose to accept or reject Judaism, but even if that person rejects it the Jewish religion will still consider him Jewish and take him back if he ever changes his mind.
But what does any of this have to do with the scientific evidence for and against circumcision? It’s acknowledged that to Jews circumcision is a religious obligation and not done for any health purposes. Let’s put it this way yet again. I’ve taken Amy to task in this thread for some things she’s said, but I really don’t see why in this discussion of Judaism it’s even an issue whether having a Jewish mother makes a person Jewish by birth. That is indisputable, because it’s part of the Jewish religion.
I apologize. It was Annabel who first said “A baby cannot say whether or not he is Jewish. There is no way of knowing whether or not he will want to be a part of the Jewish religion as an adult, therefore it is unethical.”
Dr. Tuteur then responded to this with “You really need to learn a lot more about Judaism before you make claims about it.” Akheloios then took up the thread of that discussion, and I mistakingly attributed the original idea to Akheloios. However my point stands. The semantics of religious inclusion does not address Annabel’s original point.