Science-Based Medicine

Sep 04 2012

New AAP Policy on Circumcision

Published by Harriet Hall under Surgical Procedures
Comments: 178

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178 responses so far

178 Responses to “New AAP Policy on Circumcision”

# Ceratiuson 04 Sep 2012 at 5:11 am

I’m probably going to regret entering this debate, as it always seems to get quite heated. This latest policy seems to indicate that circumcision reduces the rates of STIs significantly enough to be a beneficial procedure (please correct me if I’m wrong in my reading). From other reading it seems to be based on studies primarily in Africa, yet I have not seen any comparisons with countries from the west such as Europe which which would, to my mind (again, please correct me if I’m wrong) be better comparisons. Have there been any studies comparing STI rates between European men and American men?

I ask as a Brit who had never heard of circumcision as anything other than a religious practice until I began reading American blogs. It is a rare thing, certainly not routine, here and I have to wonder why, if the health benefits are so pronounced, there aren’t efforts to introduce it here?
# Barefoot Intactiviston 04 Sep 2012 at 5:13 am

Actually, the AAP’s review of literature stopped at 2010, leaving out the most important scientific piece of work ever conducted on the sexual impact of circumcision (indeed, one of the only ones ever conducted) — a study of 5,000 couples by Frisch et al, published in late 2011, that found circumcised men and their partners were 3.5X more likely to have frequent orgasm problems, in addition to less sexual satisfaction and increased problems with vaginal pain.

http://ije.oxfordjournals.org/content/early/2011/06/13/ije.dyr104.short?rss=1

The KNMG, representing 40,000 Dutch doctors, cited this study in a recent symposium on circumcision, following their 2010 report condemning infant circumcision as being risky and without medical benefit.

http://knmg.artsennet.nl/Nieuws/Nieuwsarchief/Nieuwsbericht-1/Jongensbesnijdenis-wereldwijd-ter-discussie.htm
http://knmg.artsennet.nl/Publicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm

Moreover, a study was just published by Rodriguez et al that found a sample of men in Puerto Rico were more likely to have HIV if circumcised. This is in line with a 2009 USAID study that found, in 10 of 18 countries with data available, circumcised men were more likely to have HIV. This is important given several flawed studies in AFRICA were the primary basis for the AAP’s updated stance more heavily favoring circumcision. No population level data has ever shown an HIV reduction from circumcision.

http://onlinelibrary.wiley.com/doi/10.1111/j.1743-6109.2012.02871.x/abstract
http://www.measuredhs.com/pubs/pdf/CR22/CR22.pdf

I encourage you to read the AAP’s full “Technical Report” on infant circumcision, where the “Task Force” never even bothers to describe what exactly the foreskin is or the anatomy and physiology of the penis. You won’t find the word ‘frenulum’ anywhere in the report.

Taylor’s studies discussing the “Ridged Band” of nerve endings are never mentioned, and Sorrells’ findings on penile sensitivity are glossed over. The AAP admits that circumcision has been found to reduce masturbatory pleasure, but omits this from any of their conclusions.

The section on penile cancer is an absolute absurdity — penile cancer is rarer than male breast cancer. The AAP Task Force found one credible study showed that there would need to be 322,000 infant circumcisions, and 644 circumcision complications, to prevent one case of penile cancer.

Science, my friend, does not support infant circumcision. The AAP supports it because they are biased and defending their members, who are responsible for millions of infant circumcisions over the past 100 years.

Case in point: the head of the Task Force is an STD expert from the CDC. Babies aren’t even sexually active. How does this make any sense?

I notice that while criticizing Goldman’s 20 point response, you cherry pick your points, much like you accuse him of cherry picking the science. How does the foreskin being 6 square inches or 12 square inches make any difference in whether it should be amputated from a baby?

~Barefoot Intactivist
# Cymbeon 04 Sep 2012 at 8:31 am

“It doesn’t mention physician coercion and unauthorized circumcisions.”

So it requires that they get the baby’s permission? If not, the mutilation is unauthorized coercion. How absolutely revolting.

Why do people get HIV? Because they do not use protection. They can easily avoid it. This disgusting practice slightly reduces the chance that someone who does not use protection gets HIV, at the price of mutilating the genitalia of the defenseless, robbing them of dignity, bodily integrity, and in some cases, of their lives. The New York Times referred to one estimate that 117 boys in America alone die every year. Yes, that’s the spirit.

And let us not forget that this is the selfsame group that endorsed a form of illegal bloodletting from girls – also “rightfully”, Harriet: http://www.nytimes.com/2010/05/07/health/policy/07cuts.html – only to retreat after several weeks of withering criticism. If that does not demonstrate that this group is political and only political, what does?
# Catherinaon 04 Sep 2012 at 9:07 am

I have read the recommendations of the AAP and I must say, I find it downright weird that they argue (a lot) with incidence of STIs. Independent of whether those studies were poorly designed or not (and the HIV transmission studies obviously were), STIs will not be relevant for most boys until they are sexually active. Medically, these criteria do not make sense when looking at a procedure to be performed on infants. Politically, that fits with the general (European) notion that US Americans are obsessed with their children’s sexuality.

Looking in from the outside (UK/Europe), the AAP’s criteria do look like the attempt to justify a religion/culture/tradition-based practise by carefully selecting literature.
The fact that ethical and cultural considerations are carefully avoided is interesting in itself. The AAP had no such reservations when they released their statement on female “circumcision” http://pediatrics.aappublications.org/content/125/5/1088.full

To quote the AAP: “Health educators must also be prepared to explain to parents from outside North America why male genital alteration is routinely practiced here but female genital alteration is routinely condemned.”. Indeed.
# Catherinaon 04 Sep 2012 at 9:10 am

Barefoot Inactivist! Excellent point about the lack of anatomical description – the statement about female ritual genital cutting has several drawings to illustrate the practise and consequences of FGM.
# BillyJoeon 04 Sep 2012 at 9:20 am

“Although health beneﬁts are not great enough to recommend routine circumcision for all male newborns, the beneﬁts of circumcision are sufﬁcient to justify access to this procedure for families choosing it”

If the health beneﬁts, as judged by an expert panel, are not great enough to recommend circumcision (the word “routine” and the phrase “for all male newborns” seems superfluous, but I am open to challenge), then why should there be access to those choosing it against the recommendations of that expert panel, and on what basis could parents, devoid of a medical degree and the data to which the expert panel had access, decide to choose circumcision.

“Parents ultimately should decide whether circumcision is in the best interests of their male child.”

And on what basis are they to judge what is in the best interests of their child.
# Catherinaon 04 Sep 2012 at 9:26 am

Without wanting to hog the discussion, Harriet, I looked back at your previous assessment (http://www.sciencebasedmedicine.org/index.php/circumcision-what-does-science-say/) where you said

“I used to live in Spain, where you could tell girl babies from boy babies just by looking at their ears: all the baby girls had their ears pierced in the delivery room. That was a “mutilating” procedure with no conceivable medical benefit and a small risk of infection, deformity, or ingestion of earring parts. It was nowhere near as controversial as circumcision. I wonder why.”

In Germany, the Bundesverband der Kinder- und Jugendärzte (basically the AAP equivalent) clearly states that ear piercing constitutes a violation of physical integrity/a permanent physical alteration and that therefore, parents should not do it until their children have reached the age of consent. Following the recent judgement against non-medically indicated circumcision in Cologne and the judgement in another trial where a girl sustained permanent damage from her ear piercing, several papers have run polls on whether ear piercing should be expressedly forbidden. An interesting year for children’s rights.
# Cymbeon 04 Sep 2012 at 9:27 am

My comment won’t get approved. But all of you need to know that this selfsame organization, the AAP, in 2010 endorsed a form of FGM: http://www.nytimes.com/2010/05/07/health/policy/07cuts.html Supposedly because it’s in the best interests of the child. After a few weeks of criticism, they withdrew this statement – so I guess it was not in the best interests of the child after all. It’s in the best interests of the AAP.
# Joseph4GIon 04 Sep 2012 at 10:17 am

This blog should be re-named “myth based medicine.”

Firstly, I’d like to address the relevance of ACOG’s endorsement of the new AAP statement; their business is the health and well being of WOMEN. Just what do they care?

Answer; as charlatans with first dibs on babies, they perform the greater bulk of circumcisions in the US. Without endorsement from some medical organization they’re up a creek. It should otherwise be irrelevant what ACOG thinks. All circumcisers of children would like the AAP’s latest statement.

“…preventive health beneﬁts of elective circumcision of male newborns outweigh the risks of the procedure. Although health beneﬁts are not great enough to recommend routine circumcision for all male newborns, the beneﬁts of circumcision are sufﬁcient to justify access to this procedure for families choosing it … Parents ultimately should decide whether circumcision is in the best interests of their male child.”

It bears pointing out the conflicting message; the AAP believes parents should have “access to” and public coffers should pay for an elective procedure on healthy, non-consenting individuals that it cannot bring itself to endorse.

That being said, I must criticize this author for merely self-servingly repeating what the AAP has to say regarding its new statement. The AAP is highly selective on the data it chose to evaluate, and yet the author dares to say they did a “thorough evaluation of the data,” and call opponents of infant circumcision “cherry-pickers.” Circumcision advocates have an incorrigible problem with projection.

The author appears to want to the 20 points put out by the Circumcision Resource Center based on pure opinion alone, hoping readers will take the dismissal at face value. Let’s look at some of the “commentary.

“(The challenges they cite are unconvincing or based on issues outside of the studies themselves.)”

According to WHOM? What were these challenges? Or does the author hope readers will simply take her word at face value?

(They try to refute this by citing cancer incidence in two countries with different rates of circumcision.)

What is the data the AAP evaluates? Why have other medical organizations in the world not come to the same conclusions using the same data the AAP has access to?

(The report advised adequate anesthesia).

Which isn’t exactly the same as talking about the pain and it’s effects.

(False. It has a whole section about ethical issues, and it covers all reported risks.)

False. The not all ethical issues nor risks were addressed. Actually, the report comes out and says they were unable to evaluate the risks.

It doesn’t mention the functions of the foreskin. (Actually it does, and it provides evidence that foreskin removal doesn’t affect sexual pleasure or cause any significant loss of function.)

Actually, no it doesn’t, and it even says the best evidence they had was the African trials, which were basically skewed surveys. Self serving hogwash.

(There’s no credible evidence of any connection.)

Credible according to WHOM? Again, are you going to tell us, or we’re just going to have to trust you?

It doesn’t mention psychological harm. (Because there’s no evidence in the literature.)

At least not that the AAP, or any other group whose members profit from circumcision…

It lacks balance, devoting more space to benefits than to harms. (Because there is more evidence of benefits than harms.)

Or at least that’s why you and the AAP think…

“This critique is far less credible than the AAP statement. It gets some of its facts wrong, moves the goalposts, says studies are not the way to look at the problem but then cites studies… the whole thing amounts to anti-circumcision apologetics rather than a reasoned scientific critique.”

Fortunately, readers can come to their own conclusions.

“It refers to removing 12 square inches (77 square centimeters) of tissue. That’s an overestimate. According to this study the average area of the adult foreskin is more like 37 to 43 sq. cm.”

And, of course, it’s the only one that counts…

“It says some infants don’t cry during circumcision “because they go into shock.” That’s ridiculous. They are clearly not in circulatory shock, and the idea that they are in some state of emotional shock is nothing more than a fanciful speculation.”

Yes, clearly. No citation or anything.

“I would argue that it’s more likely to be because they aren’t experiencing pain.”

Yes, you would… They’re actually in a state of bliss. And the research you have to show for this is…?

“My own anecdotal observation: I’ve seen babies cry from being restrained but then calm down before anything else was done and not cry during the actual procedure, even when it was done without anesthesia.”

That’s not what other attending nurses say…

“The cutting itself would not be expected to hurt, because the tissue that is cut has already been crushed and numbed by the application of hemostats and clamps.”

And, of course, crushing flesh with clamps and hemostats doesn’t hurt at all… The shrieks we hear in videos are all imagined and/or have absolutely nothing to do with the fact a child’s most sensitive organ is have a part of it cut off… You, Harriet Hall, must think your readers are idiotic.

“They say anesthetics are injected into the penis and don’t eliminate pain. That’s misleading. For the most effective anesthesia, the dorsal penile nerve block, two injections are given adjacent to the base of the penis, and they prevent pain from the circumcision, although the injections themselves are painful.”

Actually, no, there is actually research that shows that not even all of this is effective in killing pain. Not that it matters, because 93% of circumcisers don’t even use pain relief anyway.

“They cite some poor quality cherry-picked studies.”

This.

“The AAP policy is based on a fair evaluation of the scientific evidence for and against circumcision.”

False; it is based on a highly selective group of “studies,” mostly in favor of circumcision, and mostly written by the same group of people in Africa. Respected medical boards in other parts of the world have access to the same “research” the AAP has, and they’ve reached different conclusions; I’m afraid the AAP is out of line, and stands alone defying the whole of modern medicine in claimin “the benefits outweigh the risks.”

“Ethical, religious, legal, and cultural issues are outside the sphere of science, and the AAP rightfully (conveniently?) leaves those issues for parents and society to decide.”

Note: For most other surgery, the doctor is usually the one to decide whether it is medically necessary; circumcision seems to be the only instance where parents do their own diagnosis and must evaluate the evidence (which wasn’t enough to bring the AAP or any other medical organization in the world to endorse it) and the doctor, too stupid to know better (shouldn’t evaluating the “evidence” and issuing a prognosis I be *his* job?) conveniently acquescences.

Readers are encouraged to read the AAP statement for themselves, and to evaluate the evidence presented by intactivists and come to their own conclusions as to who is more credible.

In the mean time, I challenge a publication that calls itself “evidence-based medicine” to furnish the causal link between circumcision and a reduced HIV transmission rate. So far, we hear many “theories” as to how circumcision is supposed to prevent HIV transmission, but not a single, solid scientifically demonstrable proof. Check the “gold standard trials; they are but ill-conceived statistics embellished with correlation hypothesis, why are purely based on beliefs which have been shown to be completely false. The Langerhans cells are quite effective at destroying HIV, for example. (deWitte) Also, no difference in inner skin (mucosa) nor outer skin can be visualized. (Dinh)

Without a causal link, claiming circumcision prevents HIV is about as valid as claiming garlic keeps away vampires.

Where is the evidence?

How does circumcision prevent HIV?

And why are HIV transmission rates higher in the US, where 80% of adult men have been circumcised from birth, than in Europe, where circumcision is rare?

Could you please provide a demonstrable causal link? Researchers in Africa don’t seem forthcoming…
# bakteriofagon 04 Sep 2012 at 11:16 am

Just minor point from me – I think that there is a huge amount of more or less effective treatments where at the end it all boils down to whether we can afford it. 200-600$ per procedure seem to be quite expensive for it very vogue outcome.
I also think that in this particular case the reason people mix ethics/tradition with science is understandable since that’s exactly the reason people do these procedures. We might now have enough data to say that it most likely have positive health outcome, but why is it possible? Simply because we had a huge group of people circumcised because of non-scientific reasons. And therefore this debate formed with different focus and since everybody got used to discussing it with perfect analogy of cutting the lobule they just stick with it.
Personally I must admit, being European, that it feels as a violation of a child’s body and I don’t know if I’d feel comfortable taking this decision for it. Though there is a tipping point, when data would convince me that it should be done because of health benefits.
I don’t feel like were there yet and it seems that in making this decision we’re still driven by other motivations but I’m following the discussion closely;).
# James Loewenon 04 Sep 2012 at 11:20 am

Genital cutting of infants and children is UNETHICAL.

Forced circumcision of anyone is UNETHICAL.

Surgery without need and the fully informed consent of the individual on whom its being performed is UNETHICAL.

Forced circumcision is the illness, a social illness rooted in religion.

The AAP lost all credibility when they tried to reinstitute genital cutting (nicking) of female children in 2010.

The harm from botched infant circumcision (death, penile ablation, too much sin being removed, part or all of the glans destroyed) far outweighs the specious “benefits” the AAP is currently touting.

Children’s rights demand that all unnecessary body modifications be deferred until the owner of that body can make INFORMED CHOICES for themselves.
# Lytrigianon 04 Sep 2012 at 11:28 am

I wonder: This sort of research on male circumcision is possible only because we have this huge population of men who received the procedure involuntarily. I’m certain it was involuntary in my case; at the time I was born parents were generally not even offered the choice. (I know it was possible to refuse it, but a parent had to take positive action to do so; they weren’t asked.) We can also be sure that until the past couple of decades there really was inadequate research into the benefits and risks of male circumcision. This procedure has been done routinely for over a century, and for any procedure with that long a history I’d have expected the issue to have been well-settled long before now, but clearly it is not. Anyone familiar with the history of it knows that it was introduced for totally bogus reasons, with nothing like adequate understanding of any real risks or any real benefits.

It is only because the procedure was performed on so many men for so long, and for such inadequate reasons, that we have the data available on it that we do. Why do we not institute other procedures in this way? The self-righteous horror over female genital mutilation seems oddly contrasted with the shrug over the origins of routine male circumcision. Sure, we have no evidence that the former has any benefits at all, and the risks are significant — but both were also true of routine male circumcision when it was first promoted. Surely if we were to start cutting all newborn girls’ genitals, and kept doing it for 100 years, we’d find SOMETHING within a whole range of possible conditions that seemed to make it worthwhile, no?

That, of course, seems abhorrent, and rightly so. But perhaps looking at it that way might provide some insight into why this issue provokes such strong reactions. For any man who has stepped back to examine the history of this thing, that’s exactly what it looks like.

Are there any other cases where we routinely perform prophylactic surgery to remove healthy body parts because there may be a detectable decrease in risk for one condition or another, when the patient is not particularly at risk for any of them? If not, why are we so fixated on doing it with penises?
# elmeron 04 Sep 2012 at 11:34 am

What do you think of ritual (Jewish) circumcision? I don’t remember my bris, of course, but I’d assumed it must have been pretty unpleasant.
# Catherinaon 04 Sep 2012 at 11:43 am

Elmer – Jewish ritualistic circumcision significantly increases the number of UTIs (a finding that was also not mentioned by the AAP)

http://www.ncbi.nlm.nih.gov/pubmed/12380588
http://www.ncbi.nlm.nih.gov/pubmed/1628463
http://www.ncbi.nlm.nih.gov/pubmed/18838417
http://www.ncbi.nlm.nih.gov/pubmed/20929075 (yes, inappropriate control group, but this is just one of several)
# Catherinaon 04 Sep 2012 at 11:50 am

I have a comment in moderation (4 links) detailing that Jewish ritualistic circumcision significantly increases the number of UTIs (a finding that was also not mentioned by the AAP)
# Michael Kon 04 Sep 2012 at 12:09 pm

As someone who still has all his parts I have to call BS on the “no loss in sensitivity” line that I hear over and over again.

There is a whole lot of sensation in the foreskin alone, just play a bit with it if you want to get a rise out of me. Same goes for the head. Ask any uncut teenager how it feels to suddenly get a hardon in your underwear, I can assure you that is not a pleasant experience, it stands to reason that the head is not protected at all it will reduce sensitivity over time, simple as that.

So that would address the “personal experience” part and we can probably debate this until the cows come home as those who are cut will continue to insist that they have no loss of feel (how do they know if they were cut as a baby?).

As for the science, as mentioned before, most of it seems to revolve around STIs and I would love to see a study between Europe and the US where we would probably get a much clearer picture about the risk of STIs in adults.

BTW, with the AAP being so obsessed with circumcision and STIs, why aren’t they advocate comprehensive SexEd?
# Janet Campon 04 Sep 2012 at 12:23 pm

I have three sons. The eldest was circumcised because the very paternalistic doctor overrode our choice to NOT do it with arguments on the order of, “he’ll surely die of some hideous infection if you don’t do it–and he won’t look like all the other little boys”.

We were only 23 and gave in, but I was ready for the next two. My objection is that a grown male would think hard before having two needle sticks into his penis for the negligible medical advantages, so why do this to a tiny baby? Also, while the issue of male sexual pleasure is covered, no one mentions the female view of this!

It’s a cultural practice for the most part, but I agree with Billy Joe that many (perhaps most) parents have insufficient information to make a reasoned “choice” and are largely guided by the personal views of their physicians in the absence of strict religious direction–a view that may or may not be strictly guided by absolute science.

I should add that my sons argue incessantly about their status–the circumcised one declaring loudly that he is glad to be rid of “that nasty bit of gristle”, while the two that are not, argue equally loudly that the women in their lives much prefer the “gristle”.
# mauson 04 Sep 2012 at 12:35 pm

” (a finding that was also not mentioned by the AAP)”

Likely because the AAP believes that intact foreskin increases the number of UTIs?
# DevoutCatalyston 04 Sep 2012 at 12:39 pm

Gristle matters.
# mousethatroaredon 04 Sep 2012 at 1:26 pm

@BillyJoe – I’m not going to get into the cultural, etc issues. I think I’ll just sit back and watch that debate.

I’ll say that when my son was younger he had an inflammation of the foreskin that was quite painful.. Our Ped noted that if it didn’t clear up quickly, she would recommend to a urologist for treatment, which might include circumcision. The inflammation did clear up quickly and didn’t return, so didn’t need further treatment.She has also mentioned that circumcision might be recommended for boys with repeat UTIs.

So those are a couple medical reasons that circumcisions might be recommended on a individual basis. Of course, I’m not a doctor, so take that info with a grain of salt.
# rmgwon 04 Sep 2012 at 1:35 pm

“What do they call that extra bit of skin on the end of the penis”?

- a man.
# windrivenon 04 Sep 2012 at 2:41 pm

This highway leads to the shadowy tip (if you’ll pardon the expression) of reality: you’re on a through route to the land of the different, the bizarre, the unexplainable … Go as far as you’d like on this road. Its limits are only those of mind itself. Ladies and Gentlemen, you’re entering the wondrous dimension of imagination … the commentary section of SBM.

With sincere apologies to Rod Serling
# Janet Campon 04 Sep 2012 at 4:31 pm

@Devout Catalyst and rmgw

Thanks for that
# Joseph4GIon 04 Sep 2012 at 4:44 pm

Mouse that roared, when we talk about a different part of the body, similar stories sound ho-hummish.

Most other surgery is performed because there was some sort of medical indication, where other forms of treatment were tried, and they failed.

It should strike people as odd that, instead of looking deeper for the root of the problem, some people are content to hear something quick and easy like “oh, it’s just the foreskin that needs to be cut off… No big deal.”

We dont cut off the toes to prevent recurring cases of toe fungus. We don’t consider removing the labia in girls if they keep getting yeast infections. We don’t remove a child’s toungue after their second bout of thrush. No. We find the root of the problem and amputate only when absolutely necessary.

Few doctors are aware that premature retraction of the foreskin can cause iatrogenic infections and problems, and yet they continue to advise parents to forcibly pull back on their child’s foreskin “for cleaning,” making “medically indicated circumcision” a self fulfilling prophecy.

Are we going to hear a more thorough explanation to UTIS than “they’re caused by the foreskin?” In women, we would never dream to attack say, they presence of the labia or clitoris.

There has got to be something inherently wrong with “science” that tries to justify, no, necessitate, no require the destruction of a normal body part, as opposed to preserving the integrity of the human body.
# pharmavixenon 04 Sep 2012 at 5:10 pm

Female genital mutilation does the equivalent of chopping off the entire head of the penis. Just saying.

The “intactivists” are an obsessive lot, no? Just Google “foreskin restoration.”
# muletonicon 04 Sep 2012 at 5:14 pm

Dr. Hall’s articles are usually pretty good, but this is sadly weak. Both the CRC and Doctors Opposed to Circumcision critiques are from wild and screechy activist groups, so it’s easy to use them as examples to knock down. There are, however, some genuinely dubious conclusions in the AAP’s report, and it would have been much more interesting to see those addressed rather than dismissed in deference to the AAP. For instance:

- The HIV prevention aspect is being judged based upon the alleged connection between HIV and adult circumcision in Africa, but there is no evidence to suggest that infant circumcision in the US will have a preventative effect. Those are totally different populations with totally different behaviors. Aside from the extremely poor quality of the studies* their recommendation is based on, I consider this extrapolation to be very bad science.

- The reduction in absolute risk for male infant UTIs is extremely low, which the AAP report admits, stating it to be at most, 1% (largely occurring among those with genetic predispositions). This is only slightly higher than the circumcision complication rate – and let’s be real, while major complications are rare, they’re extremely severe in impact to the recipient.

- Not only do they not mention condoms, but they don’t mention HPV vaccination, which is a much better way to prevent HPV transmission than infant circumcisions.

Honestly, it’s rather silly to claim that circumcision is an effective way to prevent STIs while completely neglecting the importance of far superior and cost-effective methods. This would have been a much better article if Dr. Hall had actually examined the claims of the AAP and the validity of the evidence for and against them, rather than using wacky activist groups as a foil.

* http://www.salem-news.com/fms/pdf/2011-12_JLM-Boyle-Hill.pdf
# BillyJoeon 04 Sep 2012 at 5:18 pm

Michelle: “So those are a couple medical reasons that circumcisions might be recommended on a individual basis”

But we are talking here about routine circumcision, not circumcision for medical reasons.
# BillyJoeon 04 Sep 2012 at 5:27 pm

Anyway…

The main point here is that, if the AAP can find no reason to actually promote circumcision, then why are they okay about circumcisions being done. If there is not a clear advantage then, quite simply, they should not be done and they should be advising against it.

And why do they say that it is okay for parents to make the choice without explaining why they think so. Do they really think that parents have the background and the knowledge to make a medical (as opposed to a cultural, personal, or religious) decision about circumcision?
# moderationon 04 Sep 2012 at 6:14 pm

I consider myself a fence sitter on this topic and appreciate the information coming out of this discussion. It does however seem the majority of respondents are vehemently opposed to circumcision. So to inform my own point of view, I do have a couple of questions/points:

1. Like mentioning Nazis in a discussion, in any way comparing female circumcision (clitoral removal) to male circumcision (foreskin removal) makes it hard to take anything else someone says seriously.

2. It is completely logical and consistent, if you concluded that that benefits outweigh risks to allow parents to make this decision for their children. You can argue that it is not true that benefits outweigh risks, but parents routinely consent to non-life saving medical procedures for their children, that could be deferred until they are older.

3. For Joseph4GI: Your wave of the hand dismissal of the the significance of UTI’s in infants shows a real lack of knowledge of their implications. Under 2 months old it means hospital admission for IV antibiotics after a blood draw and spinal tap and for older infants there can be issues with reflux and kidney disease and failure … not to mention the possibility of urosepsis. Like complications of circumcision, all are uncommon I will grant you, but it is not as simple as “just treating them with antibiotics”.

4. Also, the implication that there is some kind of huge profit to be made off circumcision is crazy, if it were the cash cow that some think, why are there so few health care providers willing to do them? I live in one of the 20 largest cities in the US and there are very few OB’s and almost no Pediatricians that still do the procedure, despite the fact it is mostly paid in cash since insurance does not generally cover it.

5. Finally, for opponents, what evidence would there have to be to make circumcision a viable choice for you? Is this a moral objection that no evidence would overcome?
# liladyon 04 Sep 2012 at 6:20 pm

First of all, I give Harriet Hall credit for even “tackling” the revised AAP Circumcision Policy.

I’ve read the pros and cons about non-religious circumcision and I find them somewhat bizarre when it comes to sexual satisfaction as reported by circumcised-versus-uncircumcised men. Did I miss something here? Isn’t sexual satisfaction a very subjective opinion?

The issue of the transmission of sexually transmitted diseases was thoroughly discussed in the AAP Policy. As was the issue of proper cleaning of a baby’s/young child’s uncircumcised penis, but is there a risk that parents will not follow those cleansing techniques *religiously*? Here’s a webpage about care of a baby’s “natural penis” and the natural progression of teaching young boys about penis hygiene, so that when these kids reach sexual maturity, they are well versed in penis hygiene, to virtually eliminate STDs transmission.

http://www.webmd.com/parenting/baby/tc/caring-for-your-young-sons-uncircumcised-penis-topic-overview

The nonsense on some of the anti-circumcision websites is not based on science. The question of “why the AAP Circumcision Policy does not address sex education is silly, because other AAP Policies Statements do address sex education for boys and girls.

(Anecdotal) When I had my babies, 1970 and 1976, most of the young parents had their boys circumcised before leaving the hospital. Now I read in the AAP Policy that ~ 60 % of boys are circumcised in the United States.

(Anecdotal) I’ve been to several brises. The last one was performed by a female mohel (mohelet)…better yet, she is a pediatrician. She was so competent and explained throughout the procedure, the rite of circumcision. The little guy was anesthetized with a strong “numbing” cream and pacified with a few drops of sugar water; he did cry for a few minutes and then stopped.

I’m not going to *venture there* about my own personal opinion about circumcision…suffice to state I concentrated on the parents/ grandparents faces and listened intently to what the mohelen was saying.
# Naradon 04 Sep 2012 at 6:21 pm

Note: For most other surgery, the doctor is usually the one to decide whether it is medically necessary; circumcision seems to be the only instance where parents do their own diagnosis [sic] and must evaluate the evidence

Apparently, Joseph4GI has never heard of epidermoid cysts.
# moderationon 04 Sep 2012 at 6:23 pm

Billy Joe:

I understand your point. However, if something is 90/10 it is easy to recommend one way or the other, but what if the risk-benefit falls more toward the middle of the spectrum. Shouldn’t the approach be more nuanced in that case?
# Naradon 04 Sep 2012 at 6:26 pm

Did I miss something here? Isn’t sexual satisfaction a very subjective opinion?

Venture over to MDC’s intactivist retinue if you want to see the response in its full floridness. The short version is that failure to complain bitterly is repression of psychological trauma over the horrible deed that one’s parents have inflicted upon one. In other news, circumcision causes both excessive sensation and lack of sensation, and not a male that I’ve discussed it with, circumcised or not, really seems to give a damn.
# Cymbeon 04 Sep 2012 at 6:40 pm

Pharmavixen: Female genital mutilation does the equivalent of chopping off the entire head of the penis. Just saying.

No, this comment only shows your unawareness of the fact there are many forms of FGM – all of them disgusting. It is very telling that the AAP’s policy statement on a ‘nick’ drawning a single drop a blood from girls drew more outrage than this new statement, endorsing a practice that kills 117 boys every year.

Pharmavixen: The “intactivists” are an obsessive lot, no? Just Google “foreskin restoration.”

On the contrary, they are not the ones seeking to deny people a choice when they are babies. They are merely trying to reclaim their lost bodily integrity.
# Cymbeon 04 Sep 2012 at 6:45 pm

Moderation: 1. Like mentioning Nazis in a discussion, in any way comparing female circumcision (clitoral removal) to male circumcision (foreskin removal) makes it hard to take anything else someone says seriously.

Again, you are unaware of the fact that there are multiple forms of FGM – all of them disgusting and immoral, some of them similar to the removal of skin, others less severe. Culture is the only reason drawing a drop of blood from girls draws more outrage than the practice that kills 117 boys every year in America alone. You’re opining on matters that you clearly know not very much about, and this makes it difficult to take your statements seriously.

Frankly, I do not think we should be putting knives to the genitalia of children at all – boy or girl. I know, what a completely crazy statements.

Moderation: Finally, for opponents, what evidence would there have to be to make circumcision a viable choice for you? Is this a moral objection that no evidence would overcome?

If it is such a great practice, and it has such great benefits, then why the need to inflict it on the defenseless? Of course, no one actually does that, notwithstanding the “benefits”.
# Cymbeon 04 Sep 2012 at 6:47 pm

Lillady: Isn’t sexual satisfaction a very subjective opinion?

Then are you saying that we cannot say that FGM affects sexual satisfaction, as sexual satisfaction is a very subjective opinion?
# liladyon 04 Sep 2012 at 7:06 pm

@ Narad: MDC is one of my *favorite* sites for reliable information.

Would you believe that Wikipedia has an article on male and female sexual satisfaction, comparing circumcised-vs-uncircumcised males?

Here’s everything you ever wanted to know (or not know), and were *afraid to ask* about circumcision and sexual satisfaction

http://en.wikipedia.org/wiki/Sexual_effects_of_circumcision
# Matt Romanon 04 Sep 2012 at 7:50 pm

Most of the points made to say benefits outweigh risks are poorly backed up by evidence. For example, the idea that HIV incidence is decreased is based on African studies. Extrapolating that evidence to a different population is poor science. Furthermore, all but one studies supporting that notion were only FAIR, and prone to biases and/or confounders. The one that was GOOD evidence, used information from the aforementioned studies to predict and calculate rates of HIV prevention in the US. Therefore, its a good study that used fair studies from another population to come to a conclusion in the States.

And then there’s the whole condom thing. Wear condoms vs. circumcision?? Clearly a condom would prevent STDs more than circumcision.

As for prevention of penile carcinoma, the authors throw around a lot of numbers about circumcision preventing it, and how non-circumcised have it more, and then at the end they say, “in addition these findings are likely to decrease with increased HPV vaccination.” Umm YEAHHHH. Evidence shows that penile cancer is decreased in those vaccinated and the vaccination of boys for HPV has only just been recommended last year. It is very effective in decreasing rates of such cancer in boys. So, why discuss all that pro-circumcision talk in the first place and give only one sentence to something that makes all the prior discussion irrelevant? This kind of “scientific” reporting demonstrates an inherent bias in the writing, which I have picked up throughout the whole article. The whole article is a very unprofessional smear against uncircumcised men, masquerading as evidence-based writing.

And finally, UTIs are treatable. Circumcision is not. I know for sure that I would not recommend circumcision to any family based on the scientific evidence. Even if there is a little benefit, it’s not that great. Do we, as physicians, recommend antibiotics for acute sinusitis? No. We don’t. Because the benefits are few, and the risks are few but present, so we don’t recommend it. That is true of many, many treatments/procedures in medicine. Circumcision falls wayyy to the one side of such “possibly beneficial” therapies, and if it wasn’t such a emotionally affecting procedure (especially for those w/ the tips of their penises cut off… sure guys, theres a good thing to that…. keep fooling yourself and convince the public of that), doctors would never actually support it.
# muletonicon 04 Sep 2012 at 8:04 pm

Moderation: I largely agree (except for 2) – people, shut up about FGM and argue the case on its own merits. No, they are not equivalent, yes there are similarities, yes there are different types – however, fact remains that it’s inflammatory and unhelpful to bring it up.

In regards to 5, there would really have to be an overwhelmingly clear and very significant danger posed to all infants by being uncircumcised, exceeding the complication rate many times over. In the absence of this, I don’t think it’s ethical to perform it as an elective procedure. I always find it weird that people who are otherwise very secular and scientifically minded are willing to accept a bizarre religious ritual as being normal and medically beneficial with only the flimsiest of evidence – probably just because they had it done to them. I mean seriously, humanity’s historical justifications have been terrible:

a) magic skygod told us to
b) it prevents masturbation
c) everyone else is doing it
d) “parents should decide”
e) someone said it might prevent diseases that we already have better methods for preventing

Narad: I realize that the fervency of “intactivists” often comes off as loopy (this is a source of constant frustration to me), but just because you haven’t personally encountered someone with a negative circumcision story doesn’t mean that everyone that does have one is just a crybaby or making it up. Most men who were circumcised don’t give a damn, sure – however, there really are people with excessive scar tissue, deformations, excessively tight skin that causes tears and abrasions, desensitization, etc. I’ve noticed there’s an extremely strong tendency to classify any man who’s unhappy with his circumcised penis as an unmanly whiner. Knowing some of these people personally and having seen the cringeworthy results in person, I consider it fairly insensitive to dismiss them out of hand.

I think people often look at the fact that the sexual results are subjective and go “well, there’s no scientific evidence supporting a gain or loss of sexual capacity, so let’s just go ahead and do it” – especially if the person stating this has never had a foreskin (or a penis, for that matter). But just because sexual pleasure is subjective and difficult to measure does not mean that people’s experience of it is not real or relevant, and the fact that there’s so much disagreement here seems like just another good reason to leave well enough alone.

At the end of the day, it’s really hard to engage in a debate about this kind of thing, because people inherently think that the opposing side is characterizing the their side’s penis as inferior. But for me, it’s not about that – it’s just ethically wrong to perform involuntary unnecessary surgery on someone else’s genitals, even if their parents said to.
# Cymbeon 04 Sep 2012 at 8:59 pm

Lilady: Would you believe that Wikipedia has an article on male and female sexual satisfaction, comparing circumcised-vs-uncircumcised males?

Earlier, you said that this was “very subjective” and suggested that it was not prone to measurement.
# Naradon 04 Sep 2012 at 9:22 pm

Narad: I realize that the fervency of “intactivists” often comes off as loopy (this is a source of constant frustration to me), but just because you haven’t personally encountered someone with a negative circumcision story doesn’t mean that everyone that does have one is just a crybaby or making it up.

I asserted neither.

Most men who were circumcised don’t give a damn, sure – however, there really are people with excessive scar tissue, deformations, excessively tight skin that causes tears and abrasions, desensitization, etc. I’ve noticed there’s an extremely strong tendency to classify any man who’s unhappy with his circumcised penis as an unmanly whiner. Knowing some of these people personally and having seen the cringeworthy results in person, I consider it fairly insensitive to dismiss them out of hand.

I’m not dismissing anyone out of hand. Are you actively seeking out these cases for inspection?
# mousethatroaredon 04 Sep 2012 at 10:06 pm

See, you learn something new everyday. I would have thought that male sexual satisfaction was pretty objective, binary, you might say. He is either satisfied or not satisfied.
# SkepticalHealthon 04 Sep 2012 at 10:56 pm

I have a beautiful circumcised penis.
# muletonicon 04 Sep 2012 at 11:06 pm

Narad: Apologies if I was reading too much into your comment – the sarcastic “horrible deed” seemed along the lines of mocking those that feel aggrieved by circumcision. And no, I’m not actually seeking out these cases – I just happened upon them via my social circle. It’s not a vast number of people, but it’s also probably not something people often readily volunteer, especially if badly botched.

Speaking of which, while I don’t vouch for any of the other site’s content, the gallery of circumcisions at circumstitions.org (http://goo.gl/PUHBP) and the “Complications” page it links to are worth perusing to get an idea of some of the defects circumcision can cause. Again, serious ones of these are very rare, but when we’re talking about an elective procedure with very little evidence of useful health effects and no informed consent, it should give some pause for thought.
# SkepticalHealthon 04 Sep 2012 at 11:24 pm

@BillyJoe

The main point here is that, if the AAP can find no reason to actually promote circumcision, then why are they okay about circumcisions being done. If there is not a clear advantage then, quite simply, they should not be done and they should be advising against it.

And why do they say that it is okay for parents to make the choice without explaining why they think so. Do they really think that parents have the background and the knowledge to make a medical (as opposed to a cultural, personal, or religious) decision about circumcision?

You have possibly some of the worst reasoning abilities on earth. Hey, we know that giving kids french fries and coca-cola is bad for them. So why not make a law preventing parents from feeding them junk food? And we know that they possibly could be shot in school, so why not outlaw both guns and school? And then they could die in a car wreck – it’s one of the more dangerous modes of transportation – so we should probably outlaw cars. Alcohol has minor health advantages but can cause severe complications such as cirrhosis and heart failure, not to mention drunk driving (ack! cars again!) and having dangerous sex. So we should outlaw alcohol.. and extra-marital sex. And condoms, because kids could choke on condoms. And while we’re at it, what about all those pesky household chemicals that kids could consume by accident? We shouldn’t allow people to buy them, because they could be dangerous. We need to control every aspect of their lives.
# mousethatroaredon 04 Sep 2012 at 11:36 pm

@SH – you forgot teeter totters…oh wait, we don’t have teeter totters anymore.
# mousethatroaredon 04 Sep 2012 at 11:38 pm

Also SH – that was in response to your last comment, not the one before that.
# muletonicon 05 Sep 2012 at 12:13 am

SkepticalHealth: 4/10. Sadly, that’ll probably be enough.
# liladyon 05 Sep 2012 at 12:16 am

Cymbe:

Twice you twisted what I stated in my posts above. I posed two (rhetorical) questions
in my first post (about questioning circumcised men and uncircumcised men about their degree of sexual satisfaction).:

Did I miss something here? Isn’t sexual satisfaction a very subjective opinion?

You, then totally (deliberately?), misinterpreting what I stated, posed this out-of-left-field question:

“Then are you saying that we cannot say that FGM affects sexual satisfaction, as sexual satisfaction is a very subjective opinion?”

Why don’t you read the subject of this blog which is the AAP Policy about male circumcision? Did I mention anything about female circumcision?

Moving along, you “read” my post back at Narad. I stated to Narad and linked to a Wikipedia entry:

“Would you believe that Wikipedia has an article on male and female sexual satisfaction, comparing circumcised-vs-uncircumcised males?”

Here again, you totally (deliberately?) misinterpreting what I stated and have put your own spin on what you *believe* I stated:

“Earlier, you said that this was “very subjective” and suggested that it was not prone to measurement.”

It appears to me that you have some sort of personal issues and you are using this blog for your own agenda. I really don’t care to know what your issues are or what your agenda is. Just don’t assume you can work out your issues and advance your agenda, by attacking me.

Earlier, you said that this was “very subjective” and suggested that it was not prone to measurement.
# liladyon 05 Sep 2012 at 12:25 am

Disregard last sentence which is redundant; sorry I still make mistakes *proofing* my posts.
# BillyJoeon 05 Sep 2012 at 12:42 am

SH,

“You have possibly some of the worst reasoning abilities on earth.”

Back on you.
But I blame your poor comprehension skills.
Note that I said nothing about banning, or outlawing circumcision. Here are the words I used:

“If there is not a clear advantage then, quite simply, they [circumcisions] should not be done and they [the AAP] should be advising against it.”

I’m not saying that circumcision should be banned or outlawed, I’m saying that the AAP should be advising against circumcsion, and that circumcisions should not be done because there is no clear evidence of benefit.

It’s similar to the PSA debate. The evidence is that it is not a useful screening test, therefore, the colleges should be advising against it (as does the RACGP in Australia). But they (RACP) also accept that patients, driven by media publicity, will ask for the test to be done, so they also advise what should be done in this situation: explain the pros and cons and if the patient still wishes to proceed, then it is reasonable to order the test. The consequences of not doing so being the possiblity of being sued by that patient if he is later diagnosed with prostate cancer.

Based on the evidence, neither PSA nor circumcisions should not be done.
But uniformed, poorly informed, and incompletely informed decisions by patients often overrule what the evidence available to experts says should be the case. It’s a pity that these experts often do not stand by the obvious conclusions of the evidence they have considered.
# BillyJoeon 05 Sep 2012 at 12:42 am

SH,

“You have possibly some of the worst reasoning abilities on earth.”

Back at you.
But I blame your poor comprehension skills.
Note that I said nothing about banning, or outlawing circumcision. Here are the words I used:

“If there is not a clear advantage then, quite simply, they [circumcisions] should not be done and they [the AAP] should be advising against it.”

I’m not saying that circumcision should be banned or outlawed, I’m saying that the AAP should be advising against circumcsion, and that circumcisions should not be done because there is no clear evidence of benefit.

It’s similar to the PSA debate. The evidence is that it is not a useful screening test, therefore, the colleges should be advising against it (as does the RACGP in Australia). But they (RACP) also accept that patients, driven by media publicity, will ask for the test to be done, so they also advise what should be done in this situation: explain the pros and cons and if the patient still wishes to proceed, then it is reasonable to order the test. The consequences of not doing so being the possiblity of being sued by that patient if he is later diagnosed with prostate cancer.

Based on the evidence, neither PSA nor circumcisions should not be done.
But uniformed, poorly informed, and incompletely informed decisions by patients often overrule what the evidence available to experts says should be the case. It’s a pity that these experts often do not stand by the obvious conclusions of the evidence they have considered.
# SkepticalHealthon 05 Sep 2012 at 5:26 am

@BillyJoe

I’m not saying that circumcision should be banned or outlawed, I’m saying that the AAP should be advising against circumcsion, and that circumcisions should not be done because there is no clear evidence of benefit.

I’m well aware of what you are saying. What I’m saying is that every time you come here saying how doctors should practice, or how an expert panel should advise, it’s always based on a completely naive understanding of medicine.
# BillyJoeon 05 Sep 2012 at 6:54 am

SH,

“What I’m saying is that every time you come here saying how doctors should practice, or how an expert panel should advise, it’s always based on a completely naive understanding of medicine.”

That was actually not what you were saying, but anyway…

What I said was reasonable and tempered with the practicalities of actual patient encounters.
The evidence says X but patients do not have the background knowledge and the evidence at hand to understand X and doctors must deal with that fact. What I disagree with is that some doctor organisations do not make the correct decision based on the evidence in the first place before conceding the fact that patients have their own agenda (or the media’s agenda) and that these patients must be dealt with in a practical way. Instead they jumble the two together and come up with a decision at odds with the evidence.
The RACGP is a good example of doing it correctly, so I can’t be far off base.
# Helga435on 05 Sep 2012 at 10:24 am

This blog states that some studies show a small health benefit to male circumcision so the author endorses the AAP’s policy statement that the parents should decide and it should be paid for via medical insurance.

I have seen multiple times in this blog that some studies show a small health benefit to acupuncture (via the magical placebo effect) yet this blog consistently rails against acupuncturists and their desire to be covered through medical insurance.

This article states that 86 people were killed from acupuncture gone wrong over the past 45 years: http://www.guardian.co.uk/science/2010/oct/18/dozens-killed-acupuncture-needles . Multiple comments have quoted a 117 boys killed per year (I don’t know where the figure came from) from complications of male circumcision.
# DWATCon 05 Sep 2012 at 10:51 am

I’m not remotely looking to get into this philosophical debate, but have a suggestion for the anti-circumcision crowd…

Ban religion! …. Can’t do that? Well then good luck changing this social norm based on something one can’t currently ban (especially since it now has support via potential benefits).

Also have a couple questions for anyone that can answer it…

How many nociceptors and Meissner’s corpuscles are in the prepuce of the average newborn male? Can one differentiate a reaction from simply being touched and a reaction of pain?

*This is out of the scope of my practice as a lowly athletic trainer….well other than pain perception.
# DWATCon 05 Sep 2012 at 12:09 pm

The number 117 per year came from this “study”. Here’s the math they used…

“Multiplying the 772% adjustment factor for age-at-time-of-death by the 14.5 hospital-stay deaths calculated above, the result is approximately 112 circumcision-related deaths annually for the 1991–2000 decade, a 9.01/100,000 death-incidence ratio. Applying this ratio to the 1,299,000 circumcisions performed in 2007, the most recent year for which data are available (HCUP, 2007), the number of deaths is about 117. This is equivalent to one death for every 11,105 cases, which is not in substantial conflict with Patel’s observation of zero deaths in 6,753 procedures. It is more than some
other estimates (Speert, 1953; Wiswell, 1989),”

Lost Boys: An Estimate of U.S. Circumcision-Related Infant Deaths
Journal Thymos: Journal of Boyhood Studies
Publisher Men’s Studies Press
ISSN 1931-9045 (Print)
1872-4329 (Online)
Issue Volume 4, Number 1 / Spring 2010
Pages 78-90
DOI 10.3149/thy.0401.78
Online Date Monday, April 26, 2010
# DWATCon 05 Sep 2012 at 12:13 pm

“The CDC’s online searchable database, Mortality: Underlying cause of death, 2004 (CDC), lists causes by various age ranges and reveals that the percentage of deaths after release, compared with deaths before, is 772% greater. This ratio is comparable to Patel’s (1966) 700% postrelease infection rate.”

where the 772% came from…
# Cymbeon 05 Sep 2012 at 12:16 pm

SkepticalHealth: Hey, we know that giving kids french fries and coca-cola is bad for them…We need to control every aspect of their lives

Aren’t you the one granting yourself the right to control every aspect of their lives, up to what part of their genitalia you will decree to be cut off? Mutilation of children is already against the law. That’s not “control”. It’s just that bizarrely, an exception is made in the case of the genitalia of boys.

Lilady: “Then are you saying that we cannot say that FGM affects sexual satisfaction, as sexual satisfaction is a very subjective opinion?” Why don’t you read the subject of this blog which is the AAP Policy about male circumcision? Did I mention anything about female circumcision?

You didn’t, and neither did the AAP (which earlier endorsed a form of FGM), but you did say that sexual satisfaction is “very subjective” and thus implied that it is not prone to measurement. If that is true for men, it is true for women. Consequently, if one cannot measure the effect genital mutilation of boys has on sexual satisfaction, neither can one do it for girls.

Lilady: It appears to me that you have some sort of personal issues and you are using this blog for your own agenda…Just don’t assume you can work out your issues and advance your agenda, by attacking me.

Comedy, attack another personally while claiming that he is attacking you. Were you so lucky that only people with personal issues would point out the inconsistencies in your posts. Your personal attacks are not particularly impressive, they only show the weakness of your position, that you do not even bother to defend them.

Lilady: Disregard last sentence which is redundant; sorry I still make mistakes *proofing* my posts.

No problem at all, I would much prefer proofing posts for facts and logic.
# Cymbeon 05 Sep 2012 at 12:22 pm

DWATC: I’m not remotely looking to get into this philosophical debate, but have a suggestion for the anti-circumcision crowd… Ban religion! …. Can’t do that? Well then good luck changing this social norm based on something one can’t currently ban

So shall we legalize honor killing and FGM (as they are in some places) – because we can’t ban religion, which is marshaled as a defense for these practices? Or should we defend the rights of innocents?

DWATC: (especially since it now has support via potential benefits).

Well, it does give gravediggers 117 extra jobs every year, I suppose that is a benefit.

DWATC: The number 117 per year came from this “study”. Here’s the math they used…

I see no problem with the study, other than the fact that the results are unfriendly to your cause. No, putting study in scare quotes does not refute it. If you have a better study, present it. Until then, enlighten us on why we should be pleased that 117 babies have to die every year.
# DWATCon 05 Sep 2012 at 12:44 pm

@Cymbe…

This is what I find entertaining about philosophical debates. People love to assume the other positions like this …

“other than the fact that the results are unfriendly to your cause”…as in assuming you know my “cause”.

I put “scare quotes” because it’s a quote that they call it a “study”. I was only presenting where the number came from, whether it’s rational statistics or not. I’m indifferent either way. Parents do all kinds of ignorant stuff to their children including religious/political indoctrination. Circumcision is an emotional, philosophical debate, not one of science. When it’s discussed, people go on irrational rants and tell people to cite their claims or “enlighten us” to various ideologies opposing the claims when they, themselves, are doing the exact same thing as the people they’re condemning. I wish circumcision wasn’t done, but as I said, good luck changing a social norm.

I notice you tend to manipulate context of others comments. The only thing I can recommend when talking about your particular “facts and logic” is don’t forget to cite when making specific claims and be able to differentiate opinion from those “facts”.
# DWATCon 05 Sep 2012 at 12:51 pm

…and you’re right, I don’t have a better study. You’d think in the US, they’d document adverse reactions such as death from a specific procedure like circumcision, and said data would be easily accessible.

Any speculation to why it’s not……
# Cymbeon 05 Sep 2012 at 1:09 pm

DWATC: “other than the fact that the results are unfriendly to your cause”…as in assuming you know my “cause”.

It is no more an assumption than you ‘assuming’ that I am a foe of genital mutilation. It may be that you were playing devil’s advocate, or who knows what, but that would then not be immediately clear to me, and I can only respond to what I see in your comments.

DWATC: Parents do all kinds of ignorant stuff to their children including religious/political indoctrination.

And that still does not mean that people have to be OK with the ignorant things that people do, especially when it involves irreversible mutilation of the body.

DWATC: I wish circumcision wasn’t done, but as I said, good luck changing a social norm.

The same is true for any social norm, but that does not mean that opponents should do nothing. It is difficult, I will grant you that, perhaps impossible to completely end this practice, but if good people do nothing, evil will necessarily prevail.

DWATC: I notice you tend to manipulate context of others comments.

There is no basis for that statement, other than Lilady’s comment, who was displeased with the fact that I pointed out an inconsistency in her posts. But then again, she also claimed that I was ‘attacking’ her while leveling a personal attack of her very own – so her claims are not to be taken seriously. If you look at the source yourself, then you will see that I did no such thing, to her or anyone else.
# Draalon 05 Sep 2012 at 1:38 pm

Did ya’ll know that neonatal foreskin is used in deriving pluripotent cells?
http://www.nature.com/nprot/journal/v5/n2/abs/nprot.2009.241.html

About 5 years ago, I worked next door to a lab that worked on keratinocytes. A grad student would go to a local hospital and have to request foreskin tissue. I can imagine what it was like asking a help desk where to pick up the samples. In the lab, there would be jars fill with liquid and floating foreskin.
# Helga435on 05 Sep 2012 at 1:47 pm

Furthermore, if the foreskin is a superfluous piece of skin, why has evolution not gotten rid of it? Humans no longer have tails for this reason.

To me, this article (and the AAP’s endorsement) reek of a bias that reads “What the heck, it’s no big deal, just cut it off.” This ignores the fact that boys are born with a foreskin and there needs to be a demonstrable (not small) gain from removing it based on standard science rules. If not, then there are many other body parts that we should also be removing at birth because it may prevent illness later in life i.e. appendices, tonsils, adenoids, etc.
# liladyon 05 Sep 2012 at 3:35 pm

@ Cymbe: You were “caught” criticizing two of my innocuous statements from two of my posts…and I called you out on your behavior.

Now, clutching you pearls in a lame attempt to defend your unwarranted criticisms…and issuing another invective directed at me, you misinterpreted what I stated, “It appears to me that you have some sort of personal issues and you are using this blog for your own agenda…Just don’t assume you can work out your issues and advance your agenda, by attacking me.”

“Comedy, attack another personally while claiming that he is attacking you. Were you so lucky that only people with personal issues would point out the inconsistencies in your posts. Your personal attacks are not particularly impressive, they only show the weakness of your position, that you do not even bother to defend them.

Lilady: Disregard last sentence which is redundant; sorry I still make mistakes *proofing* my posts.

No problem at all, I would much prefer proofing posts for facts and logic”.

Other posters have also called you out for your pugnacious accusations and your deliberate misreading of the content of posters’ statements, in order to evoke responses to your off-topic subject of female circumcision by posting back at you, “I notice you tend to manipulate context of others’ comments”.

Your reply to this poster is another example of your deliberate misinterpreting of my innocuous comments, your animus directed at me and your inability to own up to your deliberate and consistent misinterpreting of my comments.

“There is no basis for that statement, other than Lilady’s comment, who was displeased with the fact that I pointed out an inconsistency in her posts. But then again, she also claimed that I was ‘attacking’ her while leveling a personal attack of her very own – so her claims are not to be taken seriously. If you look at the source yourself, then you will see that I did no such thing, to her or anyone else.”

My post are available upthread, I suggest you re-read them in their entirety, before you even attempt to defend your actions.

Let me reiterate, the subject of this blog is the AAP Policy on male circumcision, not female circumcision.

Let me add, that I have every right and intend to continue posting about subjects that interest me. Not having a penis is not a disqualifying factor for any female poster, nor is it a disqualifying factor for Harriet Hall to blog about the AAP male circumcision policy. If anyone has a problem with restricting bloggers and posters to subjects that pertain to bloggers’ and posters’ genders, then submit those *problems* to the Executive Editor Dr. Novella and the Managing Editor Dr. Gorski of SBM. I *suspect* that you wouldn’t find support from David Gorski, a breast cancer surgeon and researcher, who frequently blogs about female breast cancer and updates us on breast cancer research.
# DWATCon 05 Sep 2012 at 3:35 pm

@Cymbe…

I’ll gladly admit when I’m assuming your position, even though I made no comment of your position beyond the context comment. I can say I assume your position based on previous comments such as repeated use of the term “mutilation” and various terms of personal moral stance on the subject. I wouldn’t say I’m playing devil’s advocate. I’m just for the choice of the parent, regardless of how ignorant or what the perceived ethics are thought to be.
It will get weeded out, if it truly becomes an issue of concern. I would say if 117 per year is an accurate estimate as a direct result of circumcision, it would classify as “of concern”. The anti-circumcision crowd rarely look at anything with skepticism if it supports their side as shown in many comments here. I’m circumcised (irrelevant), and hold no resentment to my parents for it, and my opinion on such things would be to question ones psychological state if they hold resentment, as there are apparent emotional insecurities. Male sexual pleasure is subjective as it requires recruitment of touch receptors which are highly adaptive. I’m not sure why the various female circumcision types are brought up when talking about this particular topic. It’s not a social norm based on religion anymore. It’s based on aesthetics now. I would say that makes it much harder to change.

Its similar to talking about abortion. It’s a philosophical debate in the “interest” of the adults’ view of the child’s interest, not the child themself or the impact on the population. Children only understand what is relayed to them via the environment they’re brought up in. If the parent finds circumcision to be disgusting and immoral, and it’s relayed in a manner thats displayed to the child, the child will feel the same. The problem with this topic I’m seeing, is it often falls in the conspiracy realm of profiteering doctors and coersion. Websites are built on these ideologies, then they’re propagated by those thinking they’re doing good by spreading it. My view is that patient education and compliance are severely lacking in our system. Omission of circumcision info and parents disinterest in it play a huge role.

I’m interested in finding out who here is male or female. Anecdotally, I often see an uproar among the females about circumcision but indifference among males.
# liladyon 05 Sep 2012 at 4:07 pm

@ Dwatch: I’m a female…but I suppose you already surmised that by completely reading my first post, especially the last few paragraphs:

“(Anecdotal) When I had my babies, 1970 and 1976, most of the young parents had their boys circumcised before leaving the hospital. Now I read in the AAP Policy that ~ 60 % of boys are circumcised in the United States.”

For you Dwatch, I’ll expand on that first anecdote. Neither I nor my husband, when I was pregnant, ever contemplated having our soon-to-be-born child(ren) circumcised. My second child was a boy. We specifically declined circumcision at the time of his birth. BTW, he was born with a second degree hypospadias penis, amongst other birth defects and the surgical repair would have required tissue from his intact partial foreskin.

(Anecdotal) I’ve been to several brises. The last one was performed by a female mohel (mohelet)…better yet, she is a pediatrician. She was so competent and explained throughout the procedure, the rite of circumcision. The little guy was anesthetized with a strong “numbing” cream and pacified with a few drops of sugar water; he did cry for a few minutes and then stopped.

I’m not going to *venture there* about my own personal opinion about circumcision…suffice to state I concentrated on the parents/ grandparents faces and listened intently to what the mohelen was saying.

To add to this anecdote and the other comment, the grandparents are my closest friends. This bris ceremony was a celebration of their long-awaited only grandchild that they would ever have. It was a continuation of the family lineage and a reaffirmation of life, because grandpa was an only child of survivors of the holocaust.

Here’s an additional “anecdote”. Years ago while in University in a nursing program, I declined to watch a circumcision while doing a clinical rotation in pediatrics.
# Cymbeon 05 Sep 2012 at 4:22 pm

Lilady: You were “caught” criticizing two of my innocuous statements from two of my posts…

I did not criticize them, I pointed out the inconsistency between the two, innocuous or not. There’s a difference. You responded, not by laying the question of the inconsistency to rest, but by attacking me personally, which speaks volumes.

Lilady: Now, clutching you pearls in a lame attempt to defend your unwarranted criticisms…and issuing another invective directed at me, you misinterpreted what I stated,

No invective can be found in any of my posts. On the other hand, baselessly accusing another skeptic of having “personal issues” – now that is invective. No misinterpretation.

Lilady: Other posters have also called you out for your pugnacious accusations and your deliberate misreading of the content of posters’ statements

Another poster took your word for it. As a good skeptic, you undoubtedly know that two sources count as one source, when one of the two sources can be traced back to the other. And the only one being pugnacious is the one baselessly accusing another of having “personal issues”.

Lilady: My post are available upthread, I suggest you re-read them in their entirety, before you even attempt to defend your actions.

You have not pointed out any way in which me pointing out that your two statements were inconsistent was in error.

Lilady: Let me reiterate, the subject of this blog is the AAP Policy on male circumcision, not female circumcision.

True, but for the questions of the ethics, it is worthy to inquire into the nature of this organization. It turns out that it has in the past endorsed a form of FGM. Its disregard for the sanctity of the bodies of children is a relevant issue. As is your claim that sexual satisfaction is very subjective – which, if true, applies to women as well as men. Hence, my question was an entirely appropriate one.

Lilady: Let me add, that I have every right and intend to continue posting about subjects that interest me. Not having a penis is not a disqualifying factor for any female poster

Then tell me, who questioned your ‘every right’ to post about subjects that interest you? And who mentioned the fact that you are female? There is absolutely no need to play the victim, when you are in fact the one leveling the personal attacks, and I have patiently and civilly responded to your comments, not responding in kind.
# Cymbeon 05 Sep 2012 at 4:31 pm

DWATC: I’m just for the choice of the parent, regardless of how ignorant or what the perceived ethics are thought to be.

How far are you willing to extend this principle? After all, you are advocating a parent’s choice to deny choice, which seems to me to be the very negation of the concept. It’s akin to having the freedom to deny another person freedom. Would you, for example, advocate a parent’s right to inflict FGM on his daughter?

DWATC: I’m circumcised (irrelevant), and hold no resentment to my parents for it, and my opinion on such things would be to question ones psychological state if they hold resentment, as there are apparent emotional insecurities.

Not true. If this were a practice unknown, it would be universally criminalized – as cutting into any other part of a child’s body currently is a crime. And all people would respond with horror at the idea of pulling down the pants of a child and putting a knife to his genitalia, at the whims of a parent.

DWATC: I’m not sure why the various female circumcision types are brought up when talking about this particular topic.

If one is unwilling to respect the bodily integrity of a child, why restrict the practice to boys? Remember, there are multiple forms of FGM, some of them more ‘innocuous’ than mutilating boys. And yet they are criminalized, because, as you as, it is a cultural norm.

DWATC: The problem with this topic I’m seeing, is it often falls in the conspiracy realm of profiteering doctors and coersion.

Well, I am not a conspiracy theorist. But I will tell you this, why is it ‘coercion’ when a child’s genitalia are mutilated against a parent’s will, but not coercion when they are mutilated against a child’s will? It is not the parent who is coerced, it’s the child, with or without the permission of the parent.

DWATC: I’m interested in finding out who here is male or female.

Cymbe = Cymbeline
# liladyon 05 Sep 2012 at 5:00 pm

You still wont acknowledge, will you Cymbe, that there were NO inconsistencies in my remarks? The only inconsistencies are with you and your conjuring up in your own fertile imagination that I ever made a comment about female circumcision.

Again I don’t care what your issues are and what your agenda is. I care that you are criticizing my comments, based on your inability to read my basic comments posted in easy-to-understand language.
# Naradon 05 Sep 2012 at 6:08 pm

I see no problem with the study, other than the fact that the results are unfriendly to your cause. No, putting study in scare quotes does not refute it.

It’s not clear that there’s really much of anything to refute in the first place. I can’t see the original, but it appears to be prestidigitation somewhat akin to Lazarou et al. (putting it generously). If there’s more here than pure inference plus extrapolation, I’d be curious to see the relevant parts. There’s nothing obvious in HCUP Statistical Brief 56 or Statistics on Hospital-based Care in the United States, 2007, which are apparently being relied on. Bollinger certainly doesn’t seem to have any revelant training whatever.
# Cymbeon 05 Sep 2012 at 6:26 pm

Lilady: You still wont acknowledge, will you Cymbe, that there were NO inconsistencies in my remarks?

Any fair-minded person can see whether there are:

“Isn’t sexual satisfaction a very subjective opinion?”

“Would you believe that Wikipedia has an article on male and female sexual satisfaction, comparing circumcised-vs-uncircumcised males? Here’s everything you ever wanted to know (or not know)”

Either it is subjective, or it is not. Reality does not change with your mind.

Lilady: The only inconsistencies are with you and your conjuring up in your own fertile imagination that I ever made a comment about female circumcision.

I didn’t, I asked a very simple question, which you have refused to answer in your multiple posts: whether your statement that sexual satisfaction is “a very subjective opinion” also applies to FGM. It mystifies me why a simple question would make you behave in this manner.

Lilady: Again I don’t care what your issues are and what your agenda is. I care that you are criticizing my comments, based on your inability to read my basic comments posted in easy-to-understand language.

Your greatest ability appears to be making baseless personal attacks. Three in your latest four sentence post alone. Again, it speaks volumes that you think personal attacks are a defense of your position.
# Cymbeon 05 Sep 2012 at 6:28 pm

Narad: If there’s more here than pure inference plus extrapolation, I’d be curious to see the relevant parts.

And if not, I would like you to present a better study, because until then, inference plus extrapolation is the best we’ve got.
# Naradon 05 Sep 2012 at 6:45 pm

And if not, I would like you to present a better study, because until then, inference plus extrapolation is the best we’ve got.

I don’t know how that is supposed to represent an answer. In fact, I’m not sure it even really parses. If you have the original, I’d like to know the methodology. If you don’t, there’s no particular reason to describe it as “the best” of anything.
# liladyon 05 Sep 2012 at 6:54 pm

Give it up Cymbe. Everyone knows your game here. You are persistently and consistently drawing wrong conclusions, based on your inability to read English and YOUR interpretation of what I and other posters have stated.

Don’t like the pushback for your insulting criticism, eh? Too bad.
# Cymbeon 05 Sep 2012 at 7:22 pm

Narad: I don’t know how that is supposed to represent an answer. In fact, I’m not sure it even really parses. If you have the original, I’d like to know the methodology. If you don’t, there’s no particular reason to describe it as “the best” of anything.

Enough to be cited in the New York Times. In the absence of actual reporting of deaths, an estimate is the best we will have, and considering the gravity of the matter, dismissing out of hand any inconvenience for your position is not what I would recommend.

Lilady: Give it up Cymbe. Everyone knows your game here.

Pointing out the inconsistencies in your comments, which you have given up on even tepidly defending.

Lilady: Don’t like the pushback for your insulting criticism, eh?

Pointing out your inconsistency is not “insulting”. Stop playing the victim, like you did when you asserted your “right” to voice your opinion (which no one had disputed). The only person insulting others here is you. Go ahead. I will continue to uphold decency and civility, while you continue in your own manner. You give yourself way too much credit, if you think I care about what venom and hatred you send my way. I point it out because it shows that you have no arguments, or else you’d be making them.
# Naradon 05 Sep 2012 at 7:38 pm

Enough to be cited in the New York Times. In the absence of actual reporting of deaths, an estimate is the best we will have, and considering the gravity of the matter, dismissing out of hand any inconvenience for your position is not what I would recommend.

“Enough”? Enough what? What am I “dismissing out of hand”? What is “my position”? Can you read?

Anyway, as Cymbe seems to be of no help whatever on the “gravediggers” front, the work of refrigerator-magnet magnate Bollinger is here. It’s the rambling mess that I suspected. Basically, he assumes that all-cause deaths while hospitalized after birth in which circumcision occurred are candidates for being due to circumcision, times 0.4 because “males have a 40.4% higher death rate than females from causes that are associated with male circumcision complications, such as infection and hemorrhage,[4] during the period of one hour after birth to hospital release (day 2.4).”
# mousethatroaredon 05 Sep 2012 at 8:14 pm

heheh – damn lies and statistics
# Cymbeon 05 Sep 2012 at 8:57 pm

Narad: Basically, he assumes that all-cause deaths while hospitalized after birth in which circumcision occurred are candidates for being due to circumcision

Uh… no. You have posited no reason why boys should suffer more deaths from infection and hemmorhage than girls, and yet they die at a 40.4% higher rate than girls. It is entirely reasonable to conclude that what is inflicted on boys and not girls, and which is known to cause infection and hemmorhage, is at least in large part responsible for these deaths. Is this unreasonable? You are completely silent on Gairdner’s even higher estimate – presumably also a “rambling mess”. Of course, both are estimates and no more than that, but in the absence of any better information, one cannot escape the conclusion that many babies die because of genital mutilation.

You’ve made it abundantly clear on what side of this debate you are, and it is natural that you would attempt to dismiss an estimate that implicates this practice in so many deaths as a “rambling mess”. But of course, attacking someone is not an actual argument.
# Naradon 05 Sep 2012 at 9:26 pm

Uh… no. You have posited no reason why boys should suffer more deaths from infection and hemmorhage than girls, and yet they die at a 40.4% higher rate than girls. It is entirely reasonable to conclude that what is inflicted on boys and not girls, and which is known to cause infection and hemmorhage, is at least in large part responsible for these deaths. Is this unreasonable?

Why yes, it is unreasonable. In fact, it’s completely without basis. The further extrapolation (the “adjustment factor”) is simply idiotic.

You’ve made it abundantly clear on what side of this debate you are

Go ahead and tell me, just so I know.
# mousethatroaredon 05 Sep 2012 at 10:02 pm

Joseph4GI Sorry, I missed that a comment was addressed to me.

you said “Few doctors are aware that premature retraction of the foreskin can cause iatrogenic infections and problems, and yet they continue to advise parents to forcibly pull back on their child’s foreskin “for cleaning,” making “medically indicated circumcision” a self fulfilling prophecy.”

That’s strange because our Ped instructed us NOT to forcibly pull back the foreskin at least a year before our son experienced the inflammation. We followed her instructions. On what do you base your comment that few doctors know that? Does the AAP state that parent should “clean” this way?
# mousethatroaredon 05 Sep 2012 at 10:07 pm

@Cymbe

You know, my son is not circumcised (Due to information we received from our Ped) and I’d actually kinda like the percentage of uncircumcised guys to be relatively high, so that he doesn’t have to deal with being different in the locker room and bedroom.

But I really feel like you are undermining my cause with your poor arguments. There are people here who you could learn from, if you listen. If you are open to learning you could build a better argument, but instead you are focused on alienating the people who are trying to show you how your evidence is lacking.
# SkepticalHealthon 05 Sep 2012 at 11:08 pm

I love that when an expert consensus agrees with someones world views, that they are “legitimate, science-minded practitioners.” But when the same expert consensus disagrees with someones world views, they are “biased people with an agenda.”

People are stupid. The world is f-ed
# baldapeon 05 Sep 2012 at 11:39 pm

Lilady,

You did enter into this forray with the following comment:

I’ve read the pros and cons about non-religious circumcision and I find them somewhat bizarre when it comes to sexual satisfaction as reported by circumcised-versus-uncircumcised men. Did I miss something here? Isn’t sexual satisfaction a very subjective opinion?

This is semantically equivalent to “Because “sexual satisfaction” is a very subjective opinion, it makes no sense to me to compare reports of sexual satisfaction reported by circumcised and uncircumcised men when evalutating pros and cons of circumcision.”
First of all – is that what you meant? If not, I think you need to work on your communication skills a bit. This is no different than:
“I find it bizzare that she would order the hamburger. Did I miss something? Isn’t she a vegetarian?”
being (obviously) equivalent to:
“Because she is is a vegetarian, it makes no sense to me that she would order the hamburger.”

Assuming that the paraphrased comment above was what you intended to say, Cymbe was simply pointing out that the reduced sexual satisfaction associated with FGM is CERTAINLY a sensible (one of many) “con” to point out in discussing pros and cons of FGM.

Logic dictates that either:
1) You disagree, and think reduced sexual satisifaction reported by women who’ve been subjected to FGM, relative to those who haven’t, is a bizarre reason to denounce the procedure.
2) You believe that reports comparing relative rates of sexual satisfaction is relavent to the issue of FGM, but somehow “bizarre” in the context of circumcision.
3) You meant something other than what I paraphrased above (in which case, I can hardly find fault in Cymbe’s follow-ups, because either #1 or #2 are pretty untenable positions to hold).
# antiskepticalhealthon 06 Sep 2012 at 12:05 am

# SkepticalHealthon 04 Sep 2012 at 10:56 pm
says “I have a beautiful circumcised penis”.

You forgot to insert ” teeny”
# BillyJoeon 06 Sep 2012 at 12:33 am

SH:

“I love that when an expert consensus agrees with someones world views, that they are “legitimate, science-minded practitioners.” But when the same expert consensus disagrees with someones world views, they are “biased people with an agenda.” ”

False characterisation of my post, but…

When all their reasoning adds up to “no”, but they instead conclude “yes”, I think we have a problem that is as obvious as the foreskin on your penis. Oh wait…
# liladyon 06 Sep 2012 at 1:13 am

@ baldape: What you stated in your first paragraph as what I meant, is correct. Odd, that you were able to interpret my meaning which somehow eluded another poster.

Now re-read the posts from me and show me where I ever went off-topic from the subject of this thread, which is the AAP Male Circumcision Policy. Show me where, in my original two posts, I ever mentioned female circumcision.
# Mrs. N.on 06 Sep 2012 at 1:32 am

Ah, the intactivist harangue– same tropes, same ideologically-motivated extremism. It’s funny, too, how many of them cry “parental rights” when it comes to things like refusing vaccination and subjecting their children to CAM quackery, but when it comes to circumcision, a procedure which for thousands of years remains despite the apocalyptic consequences purported by the anti-circ crowd, they have no problem forcing the rest of us to conform to their point of view. Perhaps if intactivists could convince more “normal” circumcised MEN that their circumcision isn’t something they want to pass on to their sons, they wouldn’t have to be so nutty. As it is, they’re mostly convincing crunchy-inclined extreme-parenting mothers and some men who need to externalize blame for their life’s problems.

And, no, no variant of FGM is comparable because there aren’t any benefits to the procedure, not even hygiene, only significant risks. One of the primary purposes is to reduce “illicit” sexual behavior (something no one who circumcises males in the 21st century west would even find rational, let alone licit). Additionally, something like a clitoridectomy can be said to OBJECTIVELY cause harm sexually because you cannot have clitoral stimulation or a clitoral orgasm without a damn clitoris! Circumcised males, on the other hand, are (easily) sexually stimulated and do have successful orgasms so the subtleties of “satisfaction” are subjective and nuanced.

I’m happy to admit that I am a very satisfied customer of a circumcised penis. And, frankly, that’s my preference… but the more important thing is the MAN attached to the penis. That’s why all this focus on an appendage who’s lifetime utility is consumed mostly by urine elimination is so mind boggling! IT’S A PENIS. NOT THE ARC OF THE COVENANT! (And, yes, I’d say the same thing if there were an equivalent procedure– generally benign with some hygiene and some potential minor benefits– for females.)
# SkepticalHealthon 06 Sep 2012 at 5:21 am

@BillyJoe,

YOU LEAVE MY PENIS ALONE!!
# mousethatroaredon 06 Sep 2012 at 6:22 am

BillyJoe “When all their reasoning adds up to “no”, but they instead conclude “yes”, I think we have a problem that is as obvious.”

Have you read the actual statement? Because I was just reading it and I don’t think your statement is a fair summary. In my reading, the reasoning adds up to a very slight inclination to “yes” there appears to be a slight health advantage to circumsicion, although not to the point that’s it’s considered a necessity and the conclusion is the medical community should give the parent the information they need to decide within the context of their culture, family, religion…
# mousethatroaredon 06 Sep 2012 at 6:32 am

It’s actually kind of interesting to compare the 1982 statement with the recent statement. Gives you a good sense for what new information has been incorporated as well as a little lesson in how bureaucratic language has changed over time.

http://www.cirp.org/library/general/king1982/

Yes, I’m spending my time reading archived AAP circumscisions statements. How twisted is that? In my defense, I’m still having the side pain that the doctors think is kidney stones, seems to hurt much less laying down and I’ve run out of new Doctor Who episodes.
# mousethatroaredon 06 Sep 2012 at 7:03 am

Oh and by the way, the 1982 statement says that records tracking circumsicisions preformed by qualified surgeons in NY showed 500,000 circumsicisions with no deaths. Figures for annual number of circumcisions in the U.S. was 1.2 million. If we are doing projects on data, how many annual deaths from circumcisions does that make?

Not 117, I think.
# baldapeon 06 Sep 2012 at 7:07 am

Hi Lilady,

I’m glad that we are in agreement; that I did properly misrepresent your original statement. So, are we agreed that the basic flow of conversation (paraphrased) was:

L1: Because sexual satisfaction is subjective, it makes no sense to consider lower reported rates of sexual satisfaction in circumcised vs uncircumsices men as having any bearing on the question of male circumsion.

C1: Wouldn’t that rationale imply ‘Because sexual satisfaction is subjective, it makes no sense to consider lower reported rates of sexual satisfaction in mutilated vs unmutilated women as having any bearing on the question of FGM.’?

L2: Stop putting words in my mouth; I never said anything about FGM. This conversation is about male circumcision.

If not, please tell me what I’m misinterpretting. Because if that /was/ the basic flow of conversation, I have to say your “L2″ retort is either incredibly obtuse or deliberately disengenuous. Cymbe was merely pointing out that your rationale, if applied consistently, leads to statements about FGM which most people would consider false, and heinously so. This is a very common way to show somebody that their reasoning is flawed. Consider a Jack/Jill conversation:

Jack: Because cars are red, they can drive on the highway.
Jill: Are you saying that “since barns are red, barns can drive on the highway”?
Jack: Stop putting words in my mouth, I never said anything about barns. This conversation is about cars!

In that Jack/Jill conversation, would you say “Jill was derailing by mentioning barns” or that “Jack was arguing in bad faith”?
# BillyJoeon 06 Sep 2012 at 7:31 am

Michelle,

Sorry, but this post is going to be repetitively repetitive.

There has to be a clear benefit over risks, not a possibly very slight benefit over risks, in order to accept a medical/surgical procedure. Think of all the money, time and manpower that would otherwise be wasted on something of marginal benefit at best. And the decision should be a medical one, not based on or influenced by cultural, personal, or religious considerations.

There should be a clear statement from the AAP that circumcision is not a medically justified procedure because of lack of clear benefit above risks. Having made that clear, then consideration should (and I do mean ‘should’) be given to the practicalities of dealing with individual patients who come with their own media-driven, cultural, personal, or religious baggage (and I do mean ‘baggage’), at the same time as making it clear that the procedure is not medically justified becasue of no clear benefit above risks.

To be clear, if the evidence was otherwise, I would have no hesitation accepting circumcision as a valid procedure. In other words, I do not have an agenda other than defending science, reason and logic.
# baldapeon 06 Sep 2012 at 7:41 am

D’oh, morning post before coffee = bad idea That should read, “I’m glad that we are in agreement; that I did properly represent your original statement. “
# BillyJoeon 06 Sep 2012 at 7:44 am

Michelle: “the 1982 statement says that records tracking circumsicisions preformed by qualified surgeons in NY showed 500,000 circumsicisions with no deaths.”

http://www.aafp.org/online/en/home/clinical/clinicalrecs/guidelines/Circumcison.html

“An estimated 1 million circumcisions are performed each year in the United States.”
“Death is rare, and mortality risk has been estimated to be 1/500,000 procedures.”

That makes 2 deaths per year on average.
(They don’t say if these deaths are at the hands of unqualified surgeons)
# mousethatroaredon 06 Sep 2012 at 8:41 am

Thanks BillyJoe
# Cymbeon 06 Sep 2012 at 9:06 am

Narad: Why yes, it is unreasonable. In fact, it’s completely without basis. The further extrapolation (the “adjustment factor”) is simply idiotic.

Then you can demonstrate what causes the 40.4% greater deaths in boys than girls due to infection and hemmorhage, or else it is not unreasonable.

Narad: Go ahead and tell me, just so I know.

Don’t play games.

Lilady: What you stated in your first paragraph as what I meant, is correct. Odd, that you were able to interpret my meaning which somehow eluded another poster.

And that was exactly the way I interpreted it. So now what is the problem?
# mousethatroaredon 06 Sep 2012 at 9:08 am

BillyJoe – medical procedures are not always based on medical need, for instance cochlear implants, many plastic surgery procedures and dental procedures.

It is not medically nesscessary for a person with profound hearing loss to hear, but, a deaf person can experience a substantial cultural disadvantage. Many people in the deaf community argue that that cultural disadvantage should not exist, but it currently does. Is it the AAP job to set up guidelines that deny the present cultural reality?

Similar realities exist for certain birthmarks, congenital differences, accidental injuries and dental differences. Many procedures are carried out on children (and adult) that do not have a clear medical benefit but do have the clear cultural benefit of allowing the individual to more easily fit in with the people around them.

If you think the culture is wrong in this case, fine. I suggest you do what you can to change the culture or create a viable alternative-culture, as the deaf community has. But I don’t find the argument that the AAP should be blind to human’s emotional need to easily integrate with society, convincing.
# Scotton 06 Sep 2012 at 9:10 am

Then you can demonstrate what causes the 40.4% greater deaths in boys than girls due to infection and hemmorhage, or else it is not unreasonable.

IOW your claim is that it’s circumcision unless proven otherwise? Seriously? Do you not see how utterly ludicrous that is? As if there were only that one difference between baby boys and baby girls…
# Scotton 06 Sep 2012 at 9:12 am

Oh, and for the record…

I am opposed to circumcision on ethical grounds. General agreement with a conclusion, however, does not protect one against being called out on one’s faulty reasoning.
# Cymbeon 06 Sep 2012 at 9:13 am

Mrs. N: It’s funny, too, how many of them cry “parental rights” when it comes to things like refusing vaccination and subjecting their children to CAM quackery

Not me. I am concerned with the rights of children.

Mrs. N: but when it comes to circumcision,a procedure which for thousands of years remains despite the apocalyptic consequences purported by the anti-circ crowd,

Same for bloodletting. Same for all forms of quackery. Same for FGM. No apocalyptic consequences from these either, but I would not favor the “right” of people to inflict these on children, either.

Mrs. N: they have no problem forcing the rest of us to conform to their point of view.

What, do they oppose you cutting any part of your body that you dislike? No, they oppose you forcing it on defenseless babies.

Mrs. N: Perhaps if intactivists could convince more “normal” circumcised MEN that their circumcision isn’t something they want to pass on to their sons

The exact same argument can be made for FGM in countries where it is common. Feminists activists can’t convince “normal” (mutilated) women not to inflict it on their children.

Mrs. N: I’m happy to admit that I am a very satisfied customer of a circumcised penis. And, frankly, that’s my preference…

I thank you for laying your cards on the table, that you make no pretense of objectivity.
# mousethatroaredon 06 Sep 2012 at 9:21 am

@ BillyJoe, maybe it’s not obvious. I usual read comments from bottom up. My first response to you was to your most recent response, the second was to the previous comment.
# Cymbeon 06 Sep 2012 at 9:22 am

Mouse: Oh and by the way, the 1982 statement says that records tracking circumsicisions preformed by qualified surgeons in NY showed 500,000 circumsicisions with no deaths.

What did they track? On the spot deaths?

Scott: IOW your claim is that it’s circumcision unless proven otherwise? Seriously? Do you not see how utterly ludicrous that is? As if there were only that one difference between baby boys and baby girls…

I didn’t say that it is the only difference – and that is why I asked the person to point to another cause of the 40.4% increase in deaths for boys. Obviously, a study comparing boys on which this is inflicted to other boys would be far superior. But you have to work with the data you have, not with the data you’d wish you had. This is an estimate, I think it is a cause for great concern, and I do not think it should be callously dismissed, as some people wish to do.
# mousethatroaredon 06 Sep 2012 at 9:42 am

I’m heading off for a ct scan Cymbe. There is a link in my comment up thread. You can check it out.
# Scotton 06 Sep 2012 at 9:51 am

@ Cymbe:

Your argument assumes that is the only difference, by claiming that those deaths may be attributed to circumcision. That is just wrong. Barring actual evidence that they were in fact related to circumcision, that ratio has exactly zero relevance to this discussion.
# liladyon 06 Sep 2012 at 10:48 am

@ baldape: I’m not going to further explain how I properly used the word “subjective”. See Mrs. N.’s post up thread and her use of “subjective” and “objective”.

Better yet, see mousethatroared’s posts about the pain she is experiencing. How she describes pain is “subjective”. Now she is off to have a CT scan. The radiologist will look at the CT scan to SEE if there is a renal stone. or other anomalies and provide a written report for her chart. The CT scan is an “objective” finding. BTW anything a group of patients describes about pain, “feeling” feverish, etc. are all “subjective” statements and are each individualized “subjective findings”, not subject to comparison. The results of individual CT scans or their body temperatures measured by a thermometer are “objective findings” and could be used by a researcher who is writing up a study to be published.
# Naradon 06 Sep 2012 at 11:42 am

Then you can demonstrate what causes the 40.4% greater deaths in boys than girls due to infection and hemmorhage, or else it is not unreasonable.

No, all that is necessary is to demonstrate that girls have a lower rate of infant mortality than boys regardless of underlying circumcision rate. Done.

Don’t play games.

I’m not playing any “games,” you’re being coy. You asserted that my position is “abundantly clear.” Well, I have stated one, so pony up the goods.
# Naradon 06 Sep 2012 at 11:49 am

^ Sorry, “haven’t stated one.”
# baldapeon 06 Sep 2012 at 1:59 pm

Hi Lilady,

Better yet, see mousethatroared’s posts about the pain she is experiencing. How she describes pain is “subjective”. Now she is off to have a CT scan. The radiologist will look at the CT scan to SEE if there is a renal stone. or other anomalies and provide a written report for her chart. The CT scan is an “objective” finding. BTW anything a group of patients describes about pain, “feeling” feverish, etc. are all “subjective” statements and are each individualized “subjective findings”, not subject to comparison. The results of individual CT scans or their body temperatures measured by a thermometer are “objective findings” and could be used by a researcher who is writing up a study to be published.

And so you demonstrate, point blank, that your logic does in fact lead to absurd conclusions. Say we have 100 people complaining of a headache. 50 take Aspirin, 50 take placebo (distributed via DBRC protocol). The asprin group reports relief in an average of 30 min (stdev = 5 min). The placebo group reports headache relief in an average of 2.5 hours, std=20 min. Since headache pain is subjective, you claim that it’d be bizarre to conclude anything from these results. Which is absurd. (Assuming you want to double-down on this rationale: how would YOU go about evalutaing whether aspirin was more effective than placebo for headache relief?)

Anyway, I’ll circle back to the main point – you posted faulty logic, Cymbe pointed it out, and you then spent an inordinant amount of time trying to make it out that Cymbe was the confused / malicious / dishonest party in that exchange. Though I think Cymbe has been way off the mark on many other things in this thread, I just wanted to let you know to at least this bystander that you seemed WAY off base in your initial comment, and way out of line in how you responded to Cymbe pointing that out.
# liladyon 06 Sep 2012 at 3:35 pm

baldape: Differences between “subjective” and “objective”.

http://www.scrubnotes.com/2007/08/how-to-write-historyphysical-or-soap.html
# Cymbeon 06 Sep 2012 at 3:50 pm

Scott: Your argument assumes that is the only difference, by claiming that those deaths may be attributed to circumcision. That is just wrong. Barring actual evidence that they were in fact related to circumcision, that ratio has exactly zero relevance to this discussion.

By no means have I made the claim that it is the only difference that matters. But it’s a difference that matters. Unless one can determine other causes that cause boys to die of infections and hemmorhages at a greater rate, and I have invited people to provide them, it is reasonable to think that a lot of these deaths can be attributed to this practice. Could it potentially be that boys are, for other reasons, more likely to die of these two causes? Of course. Equally well, it could be that boys are less likely to die of these two causes, but that this practice makes them exceed girls. Mere speculation in both cases. Nonetheless, it is an estimate still, and I would very much like to see a solid study.

Narad: No, all that is necessary is to demonstrate that girls have a lower rate of infant mortality than boys regardless of underlying circumcision rate. Done.

But your study focuses on all infant mortality, not just on these two causes. And if you take a look at your own study’s page 5018, you’ll see that deaths due to infections are an extremely small part of the deaths that have been studied (leading to about 1/4 of the next most important cause), hardly enough to meaningfully affect the total number. So one can’t conclude that rates of death due to infection are uniformly higher for boys than for girls (fallacy of division), and that they are higher to the extent that they are in the United States.

Narad: I’m not playing any “games,” you’re being coy. You asserted that my position is “abundantly clear.” Well, I have stated one, so pony up the goods.

It seems to me that you are very clearly in favor of this practice. But perhaps you’re just being skeptical.
# mousethatroaredon 06 Sep 2012 at 3:51 pm

Baldape – I don’t think you are getting what lilady is saying. This is what I think she is saying. Comparing subjective reports is ineffective because people report them too differently. If you have a group of people with the flu who report that their pain is an average of a 5 on a scale of 10 and compare it to a group of cancer patients who report their pain is a 5 on a scale of 10, do you think that is a reliable indicator of the comparison between flu and cancer? No, maybe some objective measures would help. Also subjective measures can be influenced by many things, such as cultural, personal expectations, economic statis, region, etc. This is another reason researcher’s look for objective measures, they are trying to separate out the influences that are not relavant to their study.

So in your aspirin analogy it’s likely that the researcher would not only look at self reporting for pain, but other more objective measures. With the question of circumscisions there are subjective measures that are going to be influenced by many factors and then there are objective measures. What are the objective measures? I am speculating here…because I am not a medical person or researcher. Complications, sexual and urinary function, anything else?

Stating the weakness of relying on subjective measures is not arguing for circumsicion, it is merely saying objective measures need to be considered to get the whole picture.
# liladyon 06 Sep 2012 at 4:01 pm

@ mousethatroared: Did your “objective” finding (CT scan), confirm your “subjective” pain?
# liladyon 06 Sep 2012 at 4:08 pm

@ mousethatroared: This team of researchers measured “objective” sexual function:

http://en.wikipedia.org/wiki/Masters_and_Johnson
# Naradon 06 Sep 2012 at 4:15 pm

But your study focuses on all infant mortality, not just on these two causes. And if you take a look at your own study’s page 5018, you’ll see that deaths due to infections are an extremely small part of the deaths that have been studied (leading to about 1/4 of the next most important cause), hardly enough to meaningfully affect the total number. So one can’t conclude that rates of death due to infection are uniformly higher for boys than for girls (fallacy of division), and that they are higher to the extent that they are in the United States.

One also can’t assume that anything that one thinks could be due to circumcision is due to circumcision. Bollinger failed to make the relevant comparison and instead went bounding over the lea.

It seems to me that you are very clearly in favor of this practice. But perhaps you’re just being skeptical.

Wrong on both counts.
# mousethatroaredon 06 Sep 2012 at 4:19 pm

Lilady – Don’t know yet. The ct scan technician said my doctor will call in two days.

I hope they see something (self limiting or easily treatable) because I’ve learned that subjective symptoms with little or no objective findings are kinda a drag.
# Naradon 06 Sep 2012 at 4:19 pm

^ Argh, failed to close the ital after “is.” I hope this doesn’t break the Internet.
# mousethatroaredon 06 Sep 2012 at 4:21 pm

@Lilady – Masters and Johnson – pioneers, thanks for the link.
# liladyon 06 Sep 2012 at 4:52 pm

@ mousethatroared:

Here’s hoping that the pain you are experiencing resolves…or…the CT scan finds “something” that is VERY easily treatable

I read one or the other books that Masters and Johnson authored and I certain they are available at your local library.
# Newcoasteron 06 Sep 2012 at 5:01 pm

I will acknowledge my bias as an non-mutilated male physician up front, but have to say I am unimpressed with the evidence presented by the AAP. I’m also Canadian, where historically, circs have never really been very common or popular outside the traditional groups (muslims, jews, and for some reason, Filipinos) Most (?all) provincial health plans in Canada do not cover infant circumcision as it is considered a cosmetic and elective procedure.

Americans for cultural (?fashion) reasons have a higher rate of circs than the rest of the industrialized world and the AAP statement seems to want to justify this by looking for any evidence that lends scientific credence. However cultural and ethical views cannot be separated out from what is essentially (mostly) surgery for the majority of men who get it. It violates the 4 fundamental prinicipals of medical ethics.

Bladder infections are rare in males, about 1/10th that of females, and are easily treated.
Penile cancer is extremely rare. I’ve never even heard of a case in 20 years of practice.

Neither of these are convincing reasons to circumcise huge numbers of infant males.

There maybe are better indications in certain high risk populations, for example HIV prevention in African populations where hygeine, education, and access to condoms is an issue. But that is not a good enough reason to recommend it for all men everywhere.
# mousethatroaredon 06 Sep 2012 at 5:13 pm

@lilady – Thanks!
# Naradon 06 Sep 2012 at 5:50 pm

By the way, what is with Bollinger’s choice of “circumcision-related” ICD-10 codes? Here we go:

P21.9 Birth asphyxia, unspecified
P22.0 Respiratory distress syndrome of newborn
P22.1 Transient tachypnoea of newborn
P22.8 Other respiratory distress of newborn
P22.9 Respiratory distress of newborn, unspecified
P29.0 Neonatal cardiac failure
P29.1 Neonatal cardiac dysrhythmia
P29.2 Neonatal hypertension
P29.8 Other cardiovascular disorders originating in the perinatal period
P29.9 Cardiovascular disorder originating in the perinatal period, unspecified
P36.0 Sepsis of newborn due to streptococcus, group B
P36.1 Sepsis of newborn due to other and unspecified streptococci
P36.2 Sepsis of newborn due to Staphylococcus aureus
P36.3 Sepsis of newborn due to other and unspecified staphylococci
P36.4 Sepsis of newborn due to Escherichia coli
P36.5 Sepsis of newborn due to anaerobes
P36.8 Other bacterial sepsis of newborn
P36.9 Bacterial sepsis of newborn, unspecified
P37.5 Neonatal candidiasis
P39.8 Other specified infections specific to the perinatal period
P39.9 Infection specific to the perinatal period, unspecified
P50.9 Fetal blood loss, unspecified
P52.3 Unspecified intraventricular (nontraumatic) haemorrhage of fetus and newborn
P54.3 Other neonatal gastrointestinal haemorrhage
P54.8 Other specified neonatal haemorrhages
P54.9 Neonatal haemorrhage, unspecified
P55.9 Haemolytic disease of fetus and newborn, unspecified
P96.8 Other specified conditions originating in the perinatal period
P96.9 Condition originating in the perinatal period, unspecified (Incl.: Congenital debility NOS)

Now, my training is not in the medical sciences, and I understand that he was mainly trying to pick anything vague enough to support his case, but some of these have an indiscriminate feel to them.
# Naradon 06 Sep 2012 at 5:55 pm

^ P29.2 is included erroneously above, my error. I also note that one range given in the copy that I can see is “39.8-38.9″; whether this is an OCR oddity or some such, I don’t know. I put it down as P39.8 and P39.9.
# Helga435on 06 Sep 2012 at 5:58 pm

Newcoaster- Thank you for posting something relevant to the actual article rather than the perpetual back and forth name calling of the last 40ish comments!
# Cymbeon 06 Sep 2012 at 6:53 pm

Narad: One also can’t assume that anything that one thinks could be due to circumcision is due to circumcision. Bollinger failed to make the relevant comparison and instead went bounding over the lea.

One can’t, but since these deaths are not being tracked, it would be impossible to determine on an individual which ones were actually caused by the practice, and which ones were not. Comparing boys to girls is an imperfect but legitimate way of getting at the percentage, though of course, it is possible that there are other variables that cause the higher death rate in boys. Hence it remains an estimate. Think of it this way: BMI is not reliable for individuals, but it a roughly reliable for the populations at large.

Narad: Wrong on both counts.

You are not a supporter, nor are you putting a rightfully skeptical eye to claims made by people. Then what?

Narad: Now, my training is not in the medical sciences, and I understand that he was mainly trying to pick anything vague enough to support his case, but some of these have an indiscriminate feel to them.

Most of them look legitimate, even to my untrained eye, but you are correct that Bollinger is is an opponent of this practice. I’m frankly surprised that no one has explicitly pointed this out. As long-time supporters like the AAP will attempt to downplay any harms, an opponent like Bollinger will likely play up the harms of the practice.
# Naradon 06 Sep 2012 at 7:08 pm

And if you take a look at your own study’s page 5018, you’ll see that deaths due to infections are an extremely small part of the deaths that have been studied (leading to about 1/4 of the next most important cause), hardly enough to meaningfully affect the total number. So one can’t conclude that rates of death due to infection are uniformly higher for boys than for girls (fallacy of division), and that they are higher to the extent that they are in the United States.

Perhaps it’s just been a long day, but I’m not exactly seeing the point of this observation unless it’s to suggest that general excess male infant mortality for some reason disappears in one of the very categories that is being pointed at.

Anyway, here (JPG) are the 1999–2009 CDC compressed mortality numbers by ICD subchapter and sex for ages 0–27 days. Bollinger seems to have selected 2004 despite having written in 2009, for reasons that aren’t apparent to me. (One might note as well, with respect to Drevenstedt et al.’s Fig. 3, that he is also fishing in the “perinatal conditions” bucket.)
# Naradon 06 Sep 2012 at 7:25 pm

You are not a supporter, nor are you putting a rightfully skeptical eye to claims made by people. Then what?

I am largely indifferent to circumcision (and have tremendous respect for my Orthodox friends), think the potential health benefits advanced are just that, suspect that the practice is likely to continue to decrease in popularity in the U.S. over time, doubt that this policy statement is going to have much effect on people’s decisions anyway, and consider this Bollinger effort to be precisely the sort of thing one might expect from a guy whose credentials are a B.A. in industrial design and deep bitterness over all the foreskins in Heaven.
# Cymbeon 07 Sep 2012 at 11:09 am

Narad: Perhaps it’s just been a long day, but I’m not exactly seeing the point of this observation unless it’s to suggest that general excess male infant mortality for some reason disappears in one of the very categories that is being pointed at.

That’s the fallacy of division, assuming that what is true for the whole is true of the part. Now, if the ‘part’ you were talking about were 75% of the total number of deaths, you would have a case, but in this study, the number of deaths due to infection are about 5% (though it is difficult to read the graph exactly).

Narad: Anyway, here (JPG) are the 1999–2009 CDC compressed mortality numbers by ICD subchapter and sex for ages 0–27 days. Bollinger seems to have selected 2004 despite having written in 2009, for reasons that aren’t apparent to me. (One might note as well, with respect to Drevenstedt et al.’s Fig. 3, that he is also fishing in the “perinatal conditions” bucket.)

Thanks for the link. It’s interesting how many conditions kill more girls than boys.

Narad: and consider this Bollinger effort to be precisely the sort of thing one might expect from a guy whose credentials are a B.A. in industrial design and deep bitterness over all the foreskins in Heaven.

It’s interesting, you are one of several people to level personal attacks at opponents. Do you believe that there is no reasonable explanation for why people would oppose the forcible mutilation of children, except ‘bitterness’? Do you suppose Ayaan Hirsi Ali is bitter, and that she can therefore be dismissed?
# Naradon 07 Sep 2012 at 1:14 pm

Test to see whether either <tt> or <code> works: tt tt

code code
# DWATCon 07 Sep 2012 at 2:12 pm

Again this is why I find philosophical debates entertaining… 130+ comments, nothing resolved. Personal attacks, references to topics not related to the initial post, neither side considering the other’s point, etc. It’s a social norm originally based on religious dogma that is now a norm based on aesthetics. Female circumcision (or mutilation, depending on one’s preference) keeps getting brought up in a discussion about infant male circumcision, which seems to be a primary argument of some. Any suggested resolutions?

In a society where hissy fits are made because a party doesn’t make reference to god in their platform, at what point will a social norm based on religion and aesthetics going to get banned? In a country where many women have an aversion to an uncircumcized penis (due to it being a common practice, and aesthetic change is considered odd), is the practice going to be discontinued? How much effort is being put in by the intactivists to present the research against the perceived necessity of the practice? Much like alternative medicine, until the effort is put into the claims, it’s all semantics. What’s the difference in this particular topic and the anti-vaccine movement? (I see differences but I’d like to hear others’ take on it.)

Like I said before, I WISH the practice wasn’t done beyond medical necessity simply because it’s not necessary on large scale in a developed, generally hygienic country (I’m indifferent, as it appears many men are, about the proclaimed detrimental effects of the procedure on infants), but instead of pissing and moaning back and forth to each other over semantics, what possible resolutions are being brought up? My wishes are irrelevant, especially as a circumcised man that, although biased, likes it better that way mainly for aesthetic reasons. What are YOU doing yourself to present your case beyond bickering on a forum? Who is putting effort in presenting legitimate data for these proclaimed deaths that are occurring each year? Who is putting in effort to be objective about the procedure and not let emotion get involved, which creates immense bias and skewed unreliable research? Why does it seem to be the most vocal intactivists are women?

I ask with sincerity, that if this bickering does continue, stick with a single topic. This blog piece is about male infant circumcision, not “FGM”(varying types) or adult circumcision.
# mousethatroaredon 07 Sep 2012 at 2:42 pm

Okay, I hear this time and time again, but I still don’t get it. Why do we need to strickly stay on topic?

If a side track is obvious, such as how a philosophy of only providing “medically nescasary” procedures may effect people with a congenital difference, why shouldn’t it be brought up?

People are always talking about “reality”, But reality doesn’t come in tight little hermetically sealed containers – marked – Vaccination, Circumsicison, Oncology, Psychology. Our opinions on one topic should be informed by how that opinion may effect other topics.

Insert trite phrase about forest and trees here.
# DWATCon 07 Sep 2012 at 3:24 pm

@mousethatroared…

I agree, if it’s related to male circumcision. Bringing up sexual sensation as a result of female circumcision or even adult male circumcision in a discussion about infant male circumcision doesn’t seem to apply. People can go off on rants about other topics all they want but I don’t see a reason to use those as an argument that doesn’t effect the initial topic. Everything is a spectrum. If we are talking about “should all forms of circumcision not be done” then we can go indepth on all aspects of circumcision. I only recommend staying on that topic, because it makes it difficult for the commenters to understand context. One person may be arguing about the effects of male circumcision while another makes reference to female circumcision, which is repeatedly being done. I just see it cluttering up the discussion with unnecessary rhetoric and increasing division without resolution. I’m not trying to be argumentative in this point, just seeing the discussion burning it’s tires, not going anywhere. Of course, this is common with ALL philosophical debates.
# Naradon 07 Sep 2012 at 3:26 pm

That’s the fallacy of division, assuming that what is true for the whole is true of the part. Now, if the ‘part’ you were talking about were 75% of the total number of deaths, you would have a case, but in this study, the number of deaths due to infection are about 5% (though it is difficult to read the graph exactly).

First of all, your sudden desire to focus on infections in Figure 3 of Drevenstedt et al. fails on two counts: Bollinger didn’t just focus on infections, and it’s not immediately clear which bundle of ICD-10 codes is underneath the label in that figure. Now, the basic assertion is that, in Bollinger’s categories, all excess male mortality is due to circumcision. This collapses if the excess persists in the face of widely discrepant circumcision rates.

There are two preliminary things that need to be done here. The first is to redo Bollinger without the bogus categories. The second is to repeat this for countries with lower circumcision rates. Then one can get to his magic 772% inflation factor.
# mousethatroaredon 07 Sep 2012 at 4:57 pm

DWATC – Okay – I think I understand you better now. It seems similar to a moving the goal post protest. Which is certainly valid in many situations.

By the way, I should have said before, although I haven’t had the opportunity to read many of your comments, The ones I have read have been very well thought out and expressed. Thanks.
# baldapeon 08 Sep 2012 at 11:29 am

Hi Lilady, happy weekend.

I followed your link, which absolutely backs up your definition of “subjective” (in addition to teaching me a few interesting mnemonic devices should I enter the medical field). But I don’t understand why you linked it – I had no problem with your definition of subjective, nor your differentiation of subjective vs. objective.

My confusion with your stance is simple. You claim that comparing reports of subjective experiences between groups is bizarre/nonsensical. This claim implies that comparing reports of pain intensity is a bizarre way to evaluate the efficacy of pain medication. Is that your stance? Do you think it would be bizarre to test headache medication vs placebo by asking the experimental and control group, “How much time passed before you felt pain relief after taking the pill?”. If you DO think that would be a bizarre means to figure out whether a headache medicine works, then what would you propose (perhaps an objective headache measurement test, like hht http://www.nbc.com/saturday-night-live/video/hht/1354906)? If you feel I am misrepresenting or not understanding your assertion that “Subjective experiences are not subject to comparison”, please tell me where I’m going astray.

Thanks!
# liladyon 08 Sep 2012 at 12:52 pm

A better measure of subjective pain is to use a pain scale on an individual patient:

http://painconsortium.nih.gov/pain_scales/NumericRatingScale.pdf

I think you would agree that the Numerical Rating Scale serves a real purpose with an individual patient…to diagnose lessening or worsening pain from baseline or to evaluate if an individual might require pain-relieving medication.

There is also a wide variation among individuals for their individual pain thresholds, so comparing one individual’s pain Numerical Rating Scale to another individual’s pain Numerical Rating Scale doesn’t yield accurate results.
# Cymbeon 08 Sep 2012 at 4:03 pm

DWATC: Female circumcision (or mutilation, depending on one’s preference) keeps getting brought up in a discussion about infant male circumcision

It’s hard to avoid, when this topic deals with the AAP’s recent advocacy. It was about two years ago when this esteemed organization endorsed mutilation for girls. And it might as well. If you won’t respect the bodily integrity of boys, why not girls as well. Culture is the only reason. Had they lived in Egypt – where the president recently said that FGM should be a ‘family decision’ – we’d see them advocate mutilation for girls, too

DWATC: Much like alternative medicine, until the effort is put into the claims, it’s all semantics.

There is no substantive ethical case to be made against conventional medicine. There is a very good ethical case against exempting the genitalia of boys from generally applicable mutilation laws.

DWATC: Who is putting in effort to be objective about the procedure and not let emotion get involved

Not the AAP, nor opponents.

DWATC: Why does it seem to be the most vocal intactivists are women?

Probably because they will not have to accept the fact that they have been mutilated, which is very difficult. When it is difficult for women who have had their genitalia mutilated, why should it be any less so for men?
# Cymbeon 08 Sep 2012 at 4:18 pm

Narad: First of all, your sudden desire to focus on infections in Figure 3 of Drevenstedt et al. fails on two counts: Bollinger didn’t just focus on infections, and it’s not immediately clear which bundle of ICD-10 codes is underneath the label in that figure.

Bollinger focused mostly on infections and hemmorhages. As you state, it is not entirely clear what your study includes under infections. But whatever is included, the number is rather small, compared to the other fatal causes and one cannot draw the broad conclusion that you seem to draw.

Narad: Now, the basic assertion is that, in Bollinger’s categories, all excess male mortality is due to circumcision. This collapses if the excess persists in the face of widely discrepant circumcision rates.

Not an assertion, an assumption, barring better data. It could go either way. As your CDC-link has shown, there are notable categories that have more deaths among girls than boys. To take one large data set, and assume that the same proportions apply to the smaller data sets (very small in the case of infection) is division. Hence, I do not think one can conclude that deaths due to infection (and the other categories) are similar in these countries.

I think we’re arguing over trifling matters. I completely agree with what I think is the kernel of your point. This is but an estimate. I would very much like a solid study, so we can precisely pin-point how many babies are killed every year by this practice.

And DWATC, one more thing. It seems like you count any time FGM is brought up as ‘comparing this to FGM’. For example, I could point out that people in countries where FGM is common have a revulsion against women with a clitoris. And that is the exact argument that you are making, on behalf of women, even as you note that women are the most vocal opponents of mutilation of their sons. Note that this argument is not saying that these two practices are exactly the same, it is simply pointing out that your argument could also be made in favor of FGM. Since your argument can be made in favor of FGM, I am inclined to dismiss it. Again, I do not suggest, nor have I suggested, that the effects are entirely identical. But they are largely similar, won’t you agree? One is cutting off healthy tissue from the bodies of children, and the other one is… the same thing. It’s foolishness not to see the similarity.
# Naradon 08 Sep 2012 at 4:41 pm

I think we’re arguing over trifling matters. I completely agree with what I think is the kernel of your point. This is but an estimate.

No, my point is that Bollinger isn’t even an estimate. It’s 100%, Grade AAA, methodological garbage. It has a signal-to-noise ratio of zero. If it’s going to be trotted out repeatedly with remarks such as your “endorsing a practice that kills 117 boys every year,” hand-waving about the flaws being “trifling” doesn’t improve the situation.
# Naradon 08 Sep 2012 at 4:52 pm

Oh, and…

I would very much like a solid study, so we can precisely pin-point how many babies are killed every year by this practice.

You mean like this? You are in fact echoing Bollinger, who includes this gem:

Inexplicably, no deaths at all were reported from any cause in a population of 100,157 circumcised, neonatal boys in a survey of U.S. Army hospital records (Wiswell & Geschke, 1989). However, the national male neonatal death rate from just two causes—hemorrhage and sepsis—is 30.2 per 100,000 (NCHS, 2004), leaving us unsure what to make of this discrepancy.

Here’s a thought, Dan: maybe there isn’t any “discrepancy.”
# BillyJoeon 09 Sep 2012 at 9:10 am

Michelle,

“@ BillyJoe, maybe it’s not obvious. I usual read comments from bottom up. My first response to you was to your most recent response, the second was to the previous comment.”

It was obvious.

But, let me guess: this is so you don’t have to scan slowly down the commnets till you find the first unread post? Unless the thread is dead, you can be sure to have not read the last post and you can work up form there till you read something familar and that will be the last read post.

“BillyJoe – medical procedures are not always based on medical need”

Which is why I added – and repeated it so that you would not miss it…

“There should be a clear statement from the AAP that circumcision is not a medically justified procedure because of lack of clear benefit above risks. Having made that clear, then consideration should (and I do mean ‘should’) be given to the practicalities of dealing with individual patients who come with their own media-driven, cultural, personal, or religious baggage (and I do mean ‘baggage’), at the same time as making it clear that the procedure is not medically justified becasue of no clear benefit above risks.”

Oh well…
# mousethatroaredon 09 Sep 2012 at 10:39 am

Actually, I click on the latest comment in a thread I’m interested in then read the comments from people who are entertaining until I get bored. If I have addressed someone, I try to look for their response.

Here’s two questions for you. How many surgeries did your children require to basically fit in the norm? Are your children in the ethnic majority in your area?

Perhaps we are looking at this issue from different perspectives.
# Cymbeon 09 Sep 2012 at 4:30 pm

Narad: No, my point is that Bollinger isn’t even an estimate. It’s 100%, Grade AAA, methodological garbage. It has a signal-to-noise ratio of zero. If it’s going to be trotted out repeatedly with remarks such as your “endorsing a practice that kills 117 boys every year,” hand-waving about the flaws being “trifling” doesn’t improve the situation.

Are there other variables that can reasonably explain the 40.4%? At first, you said that there is an approximately equal, regardless of genital mutilation rates, but your evidence did not support that (nor did it refute the idea). Bollinger assumes that excess male deaths due to infection or hemmorhage are likely to be due to this practice. A possible error could go three ways:

1. boys are less likely to die of these two factors, without this practice (as is true of some causes mentioned in your CDC-link).
2. boys are more likely to die of these two factors, without this practice.

If the first case is true, then Bollinger is underestimating the number of deaths. If the second one is true, then he is overestimating the number.

Narad: You mean like this?

I do not see how you can think of that as a “serious study”, as it says that the aim is “summarize the literature”. It also agrees with me that “there are relatively few data on the safety of the procedure”. also includes the following: “Among 750 child circumcisions, there were 12 cases reported of excessive bleeding, 6 infections, 2 cases of tetanus and one death. The authors report that, although they include the death, there was insufficient information to be certain it was caused by circumcision.”

Narad: Here’s a thought, Dan: maybe there isn’t any “discrepancy.”

I’d suggest that you read it again. He is not claiming that any of these deaths were caused by this practice. He is merely noting that it is odd for that study to note zero deaths, of any cause, when singular causes are responsible for significant numbers of deaths.
# BillyJoeon 09 Sep 2012 at 5:22 pm

Michelle:

” How many surgeries did your children require to basically fit in the norm?”

My son had a thyroglossal cyst removed. There was no choice because the cyst had become infected and would continue to do so unless it was removed.

My daughter is about to have ablation surgery to an ectopic focus in her heart which is causing 35% of her heart beats to be ectopics. It is an elective preocedure, but the ectopics keep her awake at night causing chronic fatigue. Also, greater than 10,000 ectopics a day (she has 30,000) can eventually lead to cardiomyopathy which can result in heart failure.The alternative is life long flecainide which she is not even considering.

My other son and daughter have had no surgery.

Interestingly, on the question of circumcision, none of my extended family which now includes the sons of nephews and nieces have had circumcisions. It is just not an issue here. I have a bother, though, who was born without a foreskin (an apprently very rare occurence)

“Are your children in the ethnic majority in your area?”

Yes.
# DWATCon 10 Sep 2012 at 10:01 am

@Cymbe…

…Okay, we’ll go with that. Have fun…
# Naradon 10 Sep 2012 at 2:35 pm

Are there other variables that can reasonably explain the 40.4%? At first, you said that there is an approximately equal, regardless of genital mutilation rates, but your evidence did not support that (nor did it refute the idea).

Beg pardon? I stated that excess male mortality persists in countries where circumcision rates are much lower. You then started babbling about the fallacy of division rather than actually drilling down into the data. Bollinger doesn’t even have his own 40.4% figure, as a result of the pollution in the ICD-10 code selection. At the outset, toss P21, P22, P29, P37, P52, P54.3, and P55. Then examine P36 for relevant infections. You have not even left the starting gate yet.

I do not see how you can think of that as a “serious study”, as it says that the aim is “summarize the literature”.

It is a systematic review of the literature. It’s a hell of a lot more informative than Bollinger’s belly-flop.

It also agrees with me that “there are relatively few data on the safety of the procedure”. also includes the following: “Among 750 child circumcisions, there were 12 cases reported of excessive bleeding, 6 infections, 2 cases of tetanus and one death. The authors report that, although they include the death, there was insufficient information to be certain it was caused by circumcision.”

Yes. In Nigeria.

He is merely noting that it is odd for that study to note zero deaths, of any cause, when singular causes are responsible for significant numbers of deaths.

He isn’t “merely noting” anything, he is claiming that it is “inexplicable” that no deaths were reported among 100,000 circumcised neonates. Why? Because circumcision kills, that’s why. This is the alpha and the omega.
# Naradon 10 Sep 2012 at 3:19 pm

I should also note that Bollinger doesn’t seem to have ponied up the Marketscan data that he’s relying on to get the 35.9 that is the launching pad, and given his general data slovenliness, I’m disinclined to simply take his word for it.
# mousethatroaredon 10 Sep 2012 at 9:49 pm

BillyJoe – drat! I typed up a whole response, then mrs iPad powered down and I lost it. Sorry about the delay in response, but too frustrating this evening, respond tommorrow.
# Cymbeon 11 Sep 2012 at 7:30 pm

Narad: I stated that excess male mortality persists in countries where circumcision rates are much lower.

Not for infection and hemorrhage, just male mortality in general. You cannot jump to conclusions on the basis of all infant male mortality, as there are categories that claim more female than male lives, as the CDC showed.

Narad: It is a systematic review of the literature. It’s a hell of a lot more informative than Bollinger’s belly-flop.

It is a review of whatever literature exists, not a serious study on its own, and it also states that there has been very little research on the health effects of this practice. Hence, the need for a serious study that will clear things up.

Narad: Yes. In Nigeria.

Yes, in Nigeria, but it’s part of what relatively little data there is, enough to be noted by a systematic review.

Narad: He isn’t “merely noting” anything, he is claiming that it is “inexplicable” that no deaths were reported among 100,000 circumcised neonates. Why? Because circumcision kills, that’s why. This is the alpha and the omega.

You really should have read the part again, before you doubled down on your claim. I misread it the same way you did, before I read it again. The discrepancy is that in the second study, no deaths were reported for causes even unrelated to genital mutilation.
# mousethatroaredon 11 Sep 2012 at 7:53 pm

BillyJoe – I doubt we will see eye to eye, but here goes.

If you check out wiki, you’ll see that circumscisions rates in Austraila are quite low. So your families’ decision placed the boys in the majority. Perhaps it’s a little easier to talk about ignoring the media driven, cultural, religious baggage (or something similar) when you are conforming with them. It could feel a little different when your child is an ethnic minority (one of two or three at their school) and the majority of children are circumsiced. To me worrying that my son would feel even more set apart or odd seemed like a valid concern, not “baggage”.

I hope your daughter’s surgery goes well and that she makes a speedy recovery.
# Naradon 11 Sep 2012 at 8:55 pm

Not for infection and hemorrhage, just male mortality in general. You cannot jump to conclusions on the basis of all infant male mortality, as there are categories that claim more female than male lives, as the CDC showed.

I note that you skipped right over Bollinger’s grab-bag of ICD-10 codes.

It is a review of whatever literature exists, not a serious study on its own, and it also states that there has been very little research on the health effects of this practice. Hence, the need for a serious study that will clear things up.

And so one should merely assert that Bollinger’s figure is correct in the meantime?

Yes, in Nigeria, but it’s part of what relatively little data there is, enough to be noted by a systematic review.

Which, of course, is not a serious study in your view. Of course, it also has bugger all to do with Bollinger’s assertion.

You really should have read the part again, before you doubled down on your claim. I misread it the same way you did, before I read it again. The discrepancy is that in the second study, no deaths were reported for causes even unrelated to genital mutilation.

There was one operative death related to circumcision reported between 1939 and 1951, and so, none found in a sample of 100,000 from 1980 to 1985 is “inexplicable”? That’s your explanation? Bollinger says nothing whatever about causes “unrelated to genital mutilation.”
# BillyJoeon 12 Sep 2012 at 8:25 am

Michelle,

“If you check out wiki, you’ll see that circumscisions rates in Austraila are quite low.”
Yes, as I said, it is not an issue around here.

“So your families’ decision placed the boys in the majority.”
Actually there was no decision, it just didn’t happen.

“Perhaps it’s a little easier to talk about ignoring the media driven, cultural, religious baggage (or something similar) when you are conforming with them.”

I specifically stated at least a couple of times that the medical organisations are correct in addressing these non-medical issues that impact on medical decision making and to advise on how doctors should handle these situations.
I called it “baggage”, because that’s how I see non science-based, cultural and religious imperatives. Science should trump these, but I recognise that people carry this “baggage”, and that has to be taken into account by doctors in their handling of patients.

“To me worrying that my son would feel even more set apart or odd seemed like a valid concern, not “baggage””.

Perhaps we are using different meanings of the word “baggage”. I simply mean anything that causes you to make non science based decisions. I’m not sure what I would decide if I was in your situation.

“I hope your daughter’s surgery goes well and that she makes a speedy recovery.”

Thank you. It’s actually quite minor surgery. They pass a catheter into a blood vessel in her groin and up to the heart to ablate the aberrant nerve triggering off the ectopics. The fact she has so many ectopics is actually a bonus, because in many cases, where the ectopics are much less frequent, the anesthetic reduces them to zero and then it’s impossible to locate the focus.
# mousethatroaredon 12 Sep 2012 at 9:05 am

BillyJoe – “Perhaps we are using different meanings of the word “baggage”. I simply mean anything that causes you to make non science based decisions. I’m not sure what I would decide if I was in your situation.”

The how people react and intergrate within a particular culture is not outside of science, there is just less solid data to determine cause and effect. If a kid is bullied and ostracized because of a difference, that is a real event with real consequences, that can be studied by science, but it is harder to arrive at solid conclusions due to the number of variable.

You are not taking into account the variable of social risk. Just because it is unknown and there is not sufficient data to track it doesn’t mean that it is scientific to ignore it.

William Bruce Cameron – 1963 “Informal Sociology: A Casual Introduction to Sociological Thinking”

“It would be nice if all of the data which sociologists require could be enumerated because then we could run them through IBM machines and draw charts as the economists do. However, not everything that can be counted counts, and not everything that counts can be counted.”
# mousethatroaredon 12 Sep 2012 at 9:35 am

also @BillyJoe, I mentioned it way up thread. But I won’t put you through trying to find it. When we adopted my son at age 2 he was uncircumcised. For his first Ped visit our doctor explained that research had found no advantage to circumsicion and it wasn’t done routinely anymore. That probably around 60% of boys were circumsiced. She also said that if we did want to the procedure it could be arranged to be done at the same time as his cleft repair under anesthia. She also explained proper hygiene.

My husband (who is circumsised* like every other man I have seen naked in my age range**) was for the procedure, I was pretty much undecided. His first surgery was arranged too quickly to coordinate an additional procedure. His second and third, ear tubes, were outpatient ENT clinic so we couldn’t have it done there. During that time, I talked to another adoptive mom who’s son had been circumsiced during a club foot and Cleft repair. She said she regretted the additional recovery pain.

I estimated the social risk of being uncircumcised now as much lower than it was when I was a kid/young adult. The risk of long term effects from the procedure – minimal, the risk of short term pain, high.

So I decided against adding the procedure to any of my son’s other surgeries. Since I am the person in the family who make the medical appointments, my decision to not pursue the procedure and my husbands decision not to press me, solidified the decision. Now my son is too old to consider it. So procrastination wins the day.

To make a short story long.

* I’m sure my husband would be thrilled with me sharing the state of his penis online.
**Not to suggest that my research has a large sample size, but I did grow up near several lakes, so skinny dipping, etc do account for some of my anecdotal evidence.
# BillyJoeon 12 Sep 2012 at 9:57 am

Michelle,

Let me put it this way:

Science has a lot to say about religion, religious texts and the religious.
But religion is not itself science based and therefore I call religion “baggage” if adherence to (non science-based) religion causes you to make non science-based decisions. But, yes, the application of science based protocols should take into account these non science-based influences on the decisions that patients make.

Also I am not sure that it is a good tactic to try to ameliorate bullying by making sure you are not “different”.
In some cases you cannot help but be different. If you are homosexual, you can’t fix things by cutting something off. But should you hide the fact to avoid bullying?

” Just because it is unknown and there is not sufficient data to track it doesn’t mean that it is scientific to ignore it.”

I don’t know what more I can say to convince you that I am not saying to ignore it, except to repeat once again that I am not saying that it should be ignored, but that, on the contrary, I am saying that it should be taken into account.
# mousethatroaredon 12 Sep 2012 at 10:03 am

But Billy Joe, when the AAP said to take it into account, you said they were wrong.
# BillyJoeon 12 Sep 2012 at 10:13 am

Ah, skinny dipping!

As a teenager I chanced upon a couple of girls skinny dipping in a rock pool in the local river. Actually, one was lying face up on the rocky edge and the other was thigh deep in the pool repeatedly diving over and into the water. The sun was shining and there was a gentle breeze blowing on the sleeping girls hair. Ever since, despite the..um…inconvenience, I have preferred women who are unshaven.
Such are the vagaries of life.
# mousethatroaredon 12 Sep 2012 at 10:16 am

“Also I am not sure that it is a good tactic to try to ameliorate bullying by making sure you are not “different”.
In some cases you cannot help but be different. If you are homosexual, you can’t fix things by cutting something off. But should you hide the fact to avoid bullying?”

Yes of course, it’s perfectly acceptable to cut off a piece of an infants face or body so that they won’t be different, in fact it would be considered cruel not to provide access to those surgeries, but to cut off a foreskin is a terrible thing.

As far as I can see the AAP has handled things well over the past 30 years. There’s a good chance that their efforts are part of the reason for the decline in circumsicions. This decline has given folks even more room to make the decision not to circumcise when they weigh the available evidence.
# BillyJoeon 12 Sep 2012 at 10:25 am

“But Billy Joe, when the AAP said to take it into account, you said they were wrong.”

You might have to read back.
I said they should make a science-based medical decision about circumcision. And then they should advise what a doctor should do in real world situations where the doctor is faced with a patient who wants a circumcision based on cultural, religious, or personal reasons.
I suggested that they should not mash the two together, otherwise the science-based conclusion gets lost.
They should keep separate the science based pros and cons of circumcision from the non science-based vagaries of religion, culture and personal preference.
# mousethatroaredon 12 Sep 2012 at 11:05 am

I did actually read back before commenting…but my reading came up with a different meaning than your intended meaning.

In my reading of the AAP policy they ARE keeping the two separate, mostly. But the question of HIV risk factor, that seems to have shifted their position on risk/benefit slightly. They can’t NOT tell the parents about the finding. If they tell them, they have to emphasis the situation the higher risks are seen in for accuracy…which is dependent upon culture. If your son lives in one area and socio-economic situation, his risk may be different than if he lives in another area/socio-economic situation. So at that point the two separate considerations – medical and cultural become blended. It seems to me.

That’s a hard one, unless you have crystal ball and can see the living conditions of your son in 20 years.
# mousethatroaredon 12 Sep 2012 at 11:09 am

reply skinny dipping – In my experience* a bunch of skinny teen-age boys, swimming in a cold gravel pit, slightly anxious about the little fish with a surprisingly sharp nip, are not near so compelling.

*the three most dangerous words in science
# liladyon 12 Sep 2012 at 2:43 pm

Warning…I’m going O/T here!

Billy Joe: I’m wishing that you and your daughter had this simple ablation procedure behind you.

Dear hubby had a right atrial ablation June 2005 and a left atrial ablation September 2008; he was a lot older than your daughter. He was fortunate that his age was not a bar to the procedure…because of his excellent cardiac and general health. Otherwise, he would have required lifelong anti-arrhythmia drugs, which have serious risks for a small group of cardiac patients.

His recovery from both procedures was swift, aside from the irksome errant beats he experienced for a short period of time, due to the “irritation” of having catheters ablating the walls of his atria.

The most *challenging* part of his recovery was figuring out how to wire our phone system to send his continuous EEG via an event monitor that he used for two weeks, post procedures. Oh, and shaving his hairy chest for the placement of electrodes wasn’t my idea of fun, either.
# Cymbeon 13 Sep 2012 at 7:21 pm

Narad: I note that you skipped right over Bollinger’s grab-bag of ICD-10 codes.

What of it? Was your point related to the infant mortality article you cited?

Narad: And so one should merely assert that Bollinger’s figure is correct in the meantime?

No, but neither can one assert that his figure is incorrect in the meantime. The error can go both ways.

Narad: Which, of course, is not a serious study in your view. Of course, it also has bugger all to do with Bollinger’s assertion.

I have no problem with systematic reviews, but what I meant by serious study was solid, original research – a definitive study. I do not think that authors of this systematic review would disagree, as they commented on the dearth of data.

Narad: There was one operative death related to circumcision reported between 1939 and 1951,

By whom, and what deaths were counted? The ones who died on the spot? Also, this is inconsistent with the British study in about the same period, that reported many more deaths – and in fact, a higher per capita death rate than Bollinger’s estimate.

Narad: and so, none found in a sample of 100,000 from 1980 to 1985 is “inexplicable”? That’s your explanation? Bollinger says nothing whatever about causes “unrelated to genital mutilation.”

Right here: “Inexplicably, no deaths at all were reported from any cause…However, the national male neonatal death rate from just two causes—hemorrhage and sepsis—is 30.2 per 100,000″. Nowhere does he state that any of these deaths are necessarily related to genital mutilation. So how did they land on the figure of zero deaths, period.

In the meantime, let’s look at the depths to which humanity can sink: http://www.nytimes.com/2012/09/13/nyregion/regulation-of-circumcision-method-divides-some-jews-in-new-york.html
# Naradon 13 Sep 2012 at 8:05 pm

No, but neither can one assert that his figure is incorrect in the meantime. The error can go both ways.

Prima facie, then, it’s utterly worthless. Unfortunately, there’s also the throughly slipshod methodology and general working backward from a conclusion to take into account.
# Naradon 14 Sep 2012 at 12:08 am

Right here: “Inexplicably, no deaths at all were reported from any cause…However, the national male neonatal death rate from just two causes—hemorrhage and sepsis—is 30.2 per 100,000″.

Apparently, somebody can’t read.

The records of 136,086 boys born in US Army hospitals from 1980 to 1985 were reviewed for indexed complications related to circumcision status during the first month of life. For 100,157 circumcised boys, there were 193 complications (0.19%). These included 62 local infections, eight cases of bacteremia, 83 incidences of hemorrhage (31 requiring ligature and three requiring transfusion), 25 instances of surgical trauma, and 20 urinary tract infections. There were no deaths or reported losses of the glans or entire penis. By contrast, the complications in the 35,929 uncircumcised infants were all related to urinary tract infections. Of the 88 boys with such infections (0.24%), 32 had concomitant bacteremia, three had meningitis, two had renal failure, and two died.

Oh, wait, that can’t be right.
# jalzateon 14 Sep 2012 at 1:08 pm

Mrs. Hall,

You left your readers the task to spot the fallacies in the rest of the 20 points. Did you forget to leave the exercise to spot your own fallacies?

Let me start by saying that you acknowledged that there are 2 extreme sides to this discussion, one where circumcision of male infants could be seen as child abuse and a human rights issue, and one where it can be seen as a preventive and prophylactic medical procedure. A Task Force evaluating a policy on circumcision should be able to discuss rationally both extremes, because the conclusions should come from this discussion.

Let me also state that medicine is not just science, but also needs to be humane as it deals with the well being of human beings. For example, when a person suffers certain conditions, scientifically it may make more sense to let her die or to help her die, but from the humane point of view a doctor cannot take such a decision. A doctor should provide good treatment in the measure that the person is willing to accept that treatment.

On point 1 you said: “they say all that is needed is feelings and common sense”. While the point was poorly explained, your simplification was worse, so let me put it in perspective.

There is no denying that circumcision is an amputation. Most amputations are only done on a need basis, i.e. when the organ to be removed is so diseased or damage as to represent an immediate threat to the health of the person. This is in order to provide a conservative treatment that respects the dignity of the person. Amputations are rarely done in as prevention, and in those cases, it’s usually when the risk is immediate for that person, for example a woman who has cancer in one breast and undergoes mastectomy, might choose to have the other breast removed if there is significant risk of developing cancer on it as well.

When considering an amputation, it’s always good to consider if there are alternatives of treatment, since any part of the body that is removed will have some effect and won’t be replaceable.

However, circumcision of babies is not performed because there is an immediate risk from the foreskin, as the foreskin is healthy. And quite often, any potential benefits can be also attained through different procedures. Some benefits would only exist if the person was to later develop a condition, for example preventing phimosis only makes sense if that person is one of the few that will develop phimosis. Routinely removing tissue to prevent such a condition equates to treating what has not happened, because circumcision is not an immunization for those conditions, but a last resource treatment for those conditions.

Removing any organ removes the functions of that organ.

That’s why circumcision is seeing as harmful genital surgery.

On point 2, you again oversimplified it by summarizing to say that members of the committee (task force) were biased because they were circumcised or had performed circumcisions. Conveniently you didn’t mention religious or cultural bias. Let’s see:

Susan Blanks, Jewish, has helped mediate between the city of NY and the Jewish community in the case of the babies that contracted Herpes due to a Mohel performing the oral suction on babies, which caused at least two deaths and one case of brain damage. It would be hard to not see that she has a religious bias to a faith that considers circumcision central to its practices and identity.

Andrew Freedman, Jewish. Circumcised his own son (which on its own is ethically troublesome per the AAP), acknowledges that he didn’t do it for any medical benefit but to keep his tradition alive. He also acknowledges that a 20% of his patients will see him for reasons related to their circumcisions. Definitively biased.

Doug Diekema, of Calvinist background. Posts jobs openings for bioethicists on Jewish websites. Twice advocated for a “ritual nick” that would be performed by pediatricians on female minors as an alternative for families from places where FGM is prevalent even though such a procedure is prohibited by Federal Law. Not only a person with religious bias, but also a person who in an interview in another controversial case (the Ashley case) stated: “There are always people who will claim we’re playing god. We — we can’t help but play god in this world and in medicine. Every time we intervene in the course of patient’s care, we’re playing god. ”

So these are 3 out of the 8 members of the Task Force. They seem pretty biased to me. Remember how I said that a Task Force should be willing to evaluate both sides of the argument, that circumcision could be a violation of human rights or medicine? Well, do you think that this 3 people would be fit to discuss circumcision as a violation of human rights and as a form of genital mutilation? I don’t.

3. Other countries recommend against circumcision. This is indeed important. They have access to the same studies, the same science. Why haven’t they reached the same conclusions? Why do they discourage the practice, or completely ban it? That would surely deserve some research. Or is it that after 150 years of practicing “medical” circumcision, we are so desensitized to it that we just need to justify the perpetuation of the practice rather than evaluate if it really doesn’t make sense anymore?

4. This point is fascinating and deserves extended notes. For one, along with the 3 randomized trials from Uganda, Kenia and South Africa which showed the relative reduction of 60% (meaning real reduction of just a bit over 1%), studies from other African countries in the same time showed different results, including more prevalence among circumcised people and lack of prevalence. However, the WHO, UNAIDS and the AAP have preferred to blindly follow the 3 randomized trials. The WHO and UNAIDS make more sense as they promote an intervention in the studied territories. But those results are not necessarily applicable to the U.S. (and the technical report recognizes it) but yet they still promote it as the new big benefit of circumcision. Perhaps the disparity in studies (including a recent one from Puerto Rico and another from the NAVY, the first one showed more prevalence of HIV among circumcised men and the one from the NAVY didn’t show correlation), comes from the fact that the practice or not of circumcision is not the controlling variable, but the customs, cultural and religious practices of people.

5. The report doesn’t say the word condom. Which is true. Consider that many of the benefits have to do with preventing STDs especially the infection of HIV. As I mentioned earlier, before performing an amputation you should consider the alternatives of treatment. An uncircumcised man, as part of safe sex, should use condoms. A circumcised man still has to use condoms. So, wouldn’t it be clear that it is more important to educate the kids to practice safe sex, rather than amputate tissue from them and expect that they will learn to practice safe sex on their own?

6. You criticize the statement about penile cancer by indicating that they compare data from two different countries with different rates of circumcision. Isn’t that the same that the AAP does when they compare the 3 randomized trials of Uganda, Kenya and South Africa, with the United States, to come up with this new benefit of HIV prevention?

More important, the factors of risk of penile cancer include phimosis during adulthood, HPV, smoking, UV light treatment of psoriasis, age over 68 and weak immune system. In general, circumcision only takes care of phimosis, and it is said that it reduces the risk of HPV. Phimosis however, when present in adulthood, can be treated in less invasive ways, and HPV can also be prevented with the use of vaccines in both males and females. So those two things combined will eliminate the need to perform an amputation as prevention for penile cancer.

Penile cancer is also a very low risk. 1 in 100,000. However, the AAFP estimates the rate of deaths from circumcision to be 1 in 500,000. Which means that in order to legitimately prevent 5 cases of penile cancer in old age, one baby may have died.

The Cancer Society states that most experts agree that circumcision should not be recommended solely as a way of preventing penile cancer.

7. The decrease in UTIs is minimal and they can be treated with antibiotics. Again, this is where we should consider alternatives of treatments before performing an amputation. Not every baby will develop UTIs. In general, girls have more risks of UTIs than boys. The preventive effect of circumcision on UTIs is considered to be during the first year of life.

So, to prevent something that may or may not happen during the first year of life and that can be easily treated, we are instead promoting an irreversible amputation.

8. Preventive benefits are not actual health benefits. Well, you have to balance the supposed benefits compared to the risks, to the damage, and to the loss from the procedure. If you get sick and a treatment heals you, that is a benefit. If you get an immunization and as a result you don’t contract a disease, that is a benefit. If you get an amputation to partially prevent some diseases, you are also losing something and you are also receiving a harm. So the equation is not as clear that the “potential benefits” are such real benefits.

9. Pain. Yes the report mentions anesthesia. While there has not been a formal study, there are some indications that circumcision and the pain from it cause changes in the patterns of the brain, based on an informal MIR of a baby during his circumcision. Again, unfortunately no further studies have been performed in this area. This point also states that some babies don’t cry because they go in shock. This does not refer to circulatory shock as you said, but to neurogenic shock from the psychological trauma.

10. Yes the technical report mentions ethics, but does a weak job of it, never discussing whether circumcision of minors is a human rights issue at all. The big question that the technical report fails to answer is whether it is ethical to amputate healthy tissue that is not suffering a disease or posing an immediate threat to a person, as perhaps a preventive or prophylactic intervention, authorized only by parental consent, when such a procedure also exposes the child to certain risks and certain harms and the loss of certain functions. You won’t find an answer to this question in the technical report.

The section about ethical issues of the technical reports states that “In most situations, parents are granted
wide latitude in terms of the decisions they make on behalf of their children, and the law has respected those decisions except where they are clearly contrary to the best interests of the child or place the child’s health, well-being, or life at significant risk of serious harm.10″. This already implies that the technical report should consider whether circumcision is contrary to the best interest of the child or places the child at significant risk of serious harm. This should be clearly elaborated.

It continues: “Reasonable people may disagree, however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other.”. This equation is already out of balance. You don’t only have potential benefits and potential harms (risks), but you have real harms (the damage that always occurs, i.e., keratinization of the glans, loss of the functions of the foreskin), and potential benefits of not being circumcised. Those two last items are not even considered in the report.

The report follows: “This situation is further complicated by the fact that there are social, cultural, religious, and familial benefits and harms to be considered as well.12 It is reasonable to take these nonmedical benefits and harms for an individual into consideration when making a decision about circumcision.13″ These exact words could be used to justify another practice that is indeed federally prohibited in our country: Female Genital Mutilation, which is part of some social, religious and cultural groups and provides some non-medical benefits (such as eligibility to marry within the cultural group, a religious “honor” as stated by a mother in Malaysia, etc).

The following paragraph, in a parenthesis, mentions the cases “where the procedure is not essential to the child’s immediate well-being”. This point is most enlightening. Non-therapeutic circumcision is not essential to the child’s immediate well being.

It continues: “In the pluralistic society of the United States, where parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account their own cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice”. Again, this argument could also be used to justify FGM, which is not surprising given Dr. Diekema’s previous attempts at justifying the “ritual nick”.

Another paragraph states that “Parents may wish to consider whether the benefits of the procedure can be attained in equal measure if the procedure is delayed until the child is of sufficient age to provide his own informed consent.” This has been my point so far, not only the potential benefits can be attained waiting, they can also be attained through alternative procedures. They however follow: “Newborn males who are not circumcised at birth are much less likely to elect circumcision in adolescence or early adulthood.” This statement alone should be considered an important indication that most men, on their own, would not choose to be circumcised. So why would the parents force this upon them?

I found funny, but just another display of the religious bias, this statement: “The Task Force advises against the practice of mouth-to-penis contact during circumcision”. In ANY OTHER context, an adult men placing his or her mouth on a baby’s penis would be committing sexual abuse on a minor. However, because this happens in the context of a religious practice, it is tolerated. This practice should be denounced. Religious freedom cannot justify harming any person. NY Mayor Bloomberg said in reference to this practice: “religious liberty does not simply extend to injuring others or putting children at risk”. But this practice not only puts children at risk, but makes them victims of a sexual abuse, whether they remember it or not. As an analogy, rape is rape whether the victim is conscious or unconscious.

But to round this argument, all these paragraphs never answered the real ethical question, whether it is ethical to amputate healthy tissue that is not suffering a disease or posing an immediate threat to a person, as perhaps a preventive or prophylactic intervention, authorized only by parental consent, when such a procedure also exposes the child to certain risks and certain harms and the loss of certain functions.

Point 11 on coercion and unauthorized circumcisions is actually important. In September 2010 the Delgado Family in Miami had their son circumcised against their expressed intentions. The hospital said it was a mistake. The baby was in intensive care (so we can speculate that his health was not great), the family had expressed that they didn’t want circumcision, and yet he was taken to circumcise in the absence of the mother. The mother sued for battery. William Stowell in 2000 sued the hospital that circumcised him at birth arguing that his mother was under the effects of anesthesia when she signed the consent form. The lawsuit was settled for an undisclosed amount.

Point 12, hygiene. There is no discussion on this issue, except to state that the report’s description of the care of the uncircumcised penis is vague and improper. The “adhesions” (synechia or balano-preputial membrane, two names absent from the report) do not necessarily resolve in the first 4 months of life, some times taking until after puberty. Suggesting that “When these adhesions disappear physiologically (which occurs at an individual pace), the foreskin can be easily retracted” sounds too much like an invitation for parents to probe whether the foreskin is retractable or not after the 4 months, which is very likely to result in wounding and bleeding in the synechia, development of scar and infections, and finally development of acquired phimosis which is likely to require medical circumcision. Nobody should retract the kids foreskin, not the parents, not the doctor. The parents should wash the penis as if it was a finger, only the outside. Only the kid should retract the foreskin and only when he can do it comfortably.

Point 13, actually it does not mention the functions of the foreskin. After reading your argument I read the technical report one more time. Nada. And even though Sorrell’s study on Fine-Touch Pressure Thresholds in the Adult Penis is referenced in the technical report, they dismiss the conclusions of this study which is that the most sensible parts of the penis are removed by circumcision. Interesting enough, that part is called “rigged band” and is not mentioned in the report at all. The “frenulum” is not mentioned either. The report never refers to circumcision as an “amputation”, reserving the word “amputation” to cases of amputation of the penis or the glans. It does refer to circumcision as “excision”. Oh and the document “Neonatal Male circumcision global review” of UNAIDS mentions Sexual dysfunction as one of the risks of circumcision.

Point 14, if you do some searches you will find that since 2010 the question of whether circumcision is related to ED has been in the internet. In 2011, Dan Bollinger presented a study that found a 4.5 greater chance of ED in circumcised men. This study however falls out of the 2010 cut out range for literature covered by this policy. Anticipating point 17, this is one issue that deserves more research.

Point 15, psychological harm. I would invite you to visit the existing forum on foreskin restoration to find many men who report psychological and physical harm from circumcision. Apparently these men have not attracted the attention of researchers. In your previous article you wrote: “if some men are psychologically damaged by circumcision and mourn their lost foreskin, their mental health must be pathologically fragile. Get over it guys!”. Not only you acknowledge that there might be men who are psychologically damaged by circumcision, but you proceeded to insult and patronize those men. Would you think that women who mourn a lost breast to mastectomy have pathologically fragile mental health? Or women who suffer the trauma of being raped? Well, why do you think that men should get over it?

Let me explain you something. When you steal something from a child, the child may grow into an adult, but it’s the inner child who will always remember that something was taken from him. Not all men who are circumcised go through this, but it is undeniable that many men do. And this won’t go away just because you say “get over it” with an exclamation sign.

This is a real issue. I’ve seen terrible anger, sadness, depression. They were the patients of 20 and 30 and 40 years ago, who are suffering the consequences of their procedure. A procedure that they DID NOT ELECT, in spite of being an elective procedure. It is the ethical and moral duty of the AAP to study this, to pay attention to this phenomenon. Men have been quiet for too long, but thanks to the internet they managed to leave the shame and speak out and realize that they were not alone in suffering. This is valuable.

If the AAP does not correct this path, we are going to see more men psychologically damaged in 20 and 30 years from now. Those are the kids that the AAP is failing to protect, and that you patronized carelessly.

I don’t understand why the medical community does not realize that they have been creating a problem. Honestly, this deserves a serious study NOW. I even get agitated writing this, because I have seen those strong emotions, I’ve seen those terrible depressions.

I often visit another page, Yahoo Answers, and find teenagers as young as 13 years of age, inquiring about the methods for foreskin restoration. Why do you think that teenagers are willing to subject themselves to the discomfort of years of restoration? Is this not a valid question?

Is the psychological damage or psychological trauma not part of the scientific domain? Really, I need to know. It boggles my mind the carelessness of the medical community in this regard.

You even tried to shame men by mentioning that the foreskin is necessary for the homosexual practice of docking. Sorry, that won’t work. The foreskin is useful for many sexual practices, from masturbation to intercourse to oral sex to docking. J. H. Kellogg knew it and that’s why he promoted circumcision to curb down masturbation. It didn’t curb it down, but it made it less pleasant, even if the AAP now states that there is no difference. I have asked intact men, I have compared experiences. I have no doubt that the foreskin is the perfect complement to stimulate the glans, something that circumcised men like the doctors in the Task Force or like me, wouldn’t know about normally. And something that most uncircumcised men will take for granted. Anyway, my point here was not to go back into the pleasure issue, but to say that the medical community owes respect to those men who perceive themselves as mutilated, and ought at least to investigate this issue in order to take any corrective measures to prevent this. That is their ethic duty.

I am going to stop here, but I just realize something. The point 10 is not the ethical issues. It’s ethical objections. Basically it speaks of doctors and nurses who refuse to perform or assist circumcisions because of ethical considerations. This is something that is not mentioned in the report, and at this point I say that you didn’t read properly point 10 and oversimplified it to turn it into another fallacy. Shame on you.

You say that the intactivists cherry-picked studies. Intactivists say that the AAP cherry-picked studies by ignoring, dismissing conclusions of some, ignoring contradictions between some. All of this in regards to the studies included as references in the Technical Report.

Just one thing. Every time that you are going to perform a treatment and that treatment may cause a harm, you really need to study those harms. Exhaustively. Beyond doubt. Otherwise, you are opening yourself to tremendous ethical and legal risks. Not calling for studies on the real damage and risks of circumcision puts the AAP in that position. Evidence of that attitude is given by the words of the AAP: “Financial costs of care, emotional tolls, or the need for future corrective surgery (with the attendant anesthetic risks, family stress, and expense) are unknown.”. If it’s unknown, shouldn’t it be studied? That’s what they were supposed to be doing.

It also says: “The majority of severe or even catastrophic injuries are so infrequent as to be reported as case reports (and were therefore excluded from this literature review).” How infrequent are they? Case reports need to be studied, or studies have to be based on them. When you don’t know something and you need to form an opinion, well you need to study it, don’t you?

Death is acknowledged as one of the more severe complications, but no attempts are done to present numbers or rate of mortality. The word “death” in that context is mentioned just one time in the report. Again, this is something that surely deserves further study. Nobody takes a baby to a prophylactic or preventive intervention expecting that their baby may die, especially when there was no urgent condition for that medical intervention.

Please reconsider the humane aspects of this issue, the human rights aspect of this issue. The world will be grateful to you if you do.
# Always Curiouson 14 Sep 2012 at 6:53 pm

I’m sorry, but I can’t seem to figure out the 40.4% difference in death rate yet. The link to the data is broken, but regenerating the search for gender-based death rates (all other options default; http://wonder.cdc.gov/), I find that:

female death rate: 6.1 deaths/1000 births
male death rate: 7.4 deaths/1000 births

and only looking at first 0 hours -> 28 days after birth (as Bollinger does):

female death rate: 4.09 deaths/1000 births
male death rate: 4.93 deaths/1000 births

A real difference? Sure, but hardly 40.4%. Given that this seems to be the springboard to the rest of that article, I find myself very distrustful of the remainder of his works. Incidentally, I noticed that accidental deaths are 50%-100% more common in females of this age. By the Bollinger’s logic, we need to stop”accidental” killing of female babies immediately!! Certainly this could be ascribed to Freudian mother-daughter envy. You won’t convince me otherwise until I see some studies!

On a more serious note, the fuller article behind the graph linked earlier was more helpful to me:
http://www.pnas.org/content/105/13/5016.full

In the bulk of the article, it mentions such factors as: males inexplicably cause greater rates of complications during pregnancy and males tend to have lower birth weights. Most of the article actually describes how the difference in death rates has dramatically equalized over the last thirty years, not “why” it exists in the first place. But given the male disadvantage is most largely caused by problems existing prior to birth, and given that differing circumcision rates between foreign countries fail to explain anything about the inter-country death rate variation, it seems fair to accept that circumcision risks FAIL to be a major problem confronting newborns.

Is it a justifiable risk? Medically, the data Dr. Hall links to is on the par with antioxidants raising my energy levels and cleansing my toxins. But its safe enough, in the US anyways, that people should be able to take part in it if their cultural identity demands it.
# Naradon 14 Sep 2012 at 8:57 pm

I’m sorry, but I can’t seem to figure out the 40.4% difference in death rate yet.

You’re going to have to do it over for Bollinger’s ICD choices (and, presumably, for 2004 only) and somehow massage the <1 day and 1–6 day data together into a "2.4 day" estimate.
# Naradon 14 Sep 2012 at 9:27 pm

Nobody takes a baby to a prophylactic or preventive intervention expecting that their baby may die, especially when there was no urgent condition for that medical intervention.

Here’s the thing: Few people takes babby anywhere expecting that babby will die. But they do it all the time, and thus one is stuck with the likes of Bollinger to gin up numbers to make circumcision more deathy.
# liladyon 15 Sep 2012 at 1:57 am

I think one of the major factors, for the slight increase in male infant mortality over female infant mortality during the last 25-30 years is because we are “saving” very premature babies (less than 29 weeks gestation) and extremely low birth weight babies (less than 1000 g)

This study checked infant clinical records to determine the incidence of Respiratory Distress Syndrome a.k.a. Hyaline Membrane Disease, of very premature males and females with a subset analysis of extremely low birth weight males and females.

http://www.ncbi.nlm.nih.gov/sites/entrez/15188982?dopt=Abstract&holding=f1000,f1000m,isrctn

RESULTS:

At 6 postnatal h, 60.8% of the male infants needed mechanical ventilation versus 46.2% of the females (p = 0.026). Chronic lung disease (CLD) developed in 36.2% of males versus 9.8% of female infants (p = 0.004). Inotrope support with dopamine was used in more than 50% of the infants; additional inotrope support to dopamine was needed by 19.4% of male and 9.7% of female infants (p = 0.041). The gender-related difference in need for inotrope support was more evident among the ELBW infants; 67.1% of male infants needed inotrope support versus 50.6% of females (p = 0.028). At 12-24 h, male ELBW infants had lower minimum mean arterial blood pressure (mean (SD) 25(4) mmHg vs 28(6) mmHg, p = 0.004)) and lower minimum PaCO2 than females infants (4.3 (1.1) kPa vs 4.7 (0.9) kPa, p = 0.043).

CONCLUSIONS:

There are early gender-related differences in need for ventilatory and circulatory support that may contribute to the worse long-term outcome in prematurely born male infants.
# Cymbeon 16 Sep 2012 at 4:37 pm

Narad: Prima facie, then, it’s utterly worthless. Unfortunately, there’s also the throughly slipshod methodology and general working backward from a conclusion to take into account.

Not really, as you no doubt know that any study has a margin of error. And I am merely pointing out that your own statistics show that some ailments claim more girls than boys. It could also be that barring this procedure, more girls than boys would die of infections and hemorrhages, and that this practice gives boys an advantage of 40.4%.

There is no working backward from a conclusion, an assumption is made with which you disagree, but the correctness of which you haven’t yet refuted (not that I would say that it is definitely a correct assumption, unless you refute it).

Narad: Apparently, somebody can’t read. Oh, wait, that can’t be right.

Is this a bait and switch or an honest mistake? You complained about the ‘discrepancy’-part, and now you cite something completely different.
# Cymbeon 16 Sep 2012 at 4:39 pm

Lilady: I think one of the major factors, for the slight increase in male infant mortality over female infant mortality during the last 25-30 years is because we are “saving” very premature babies (less than 29 weeks gestation) and extremely low birth weight babies (less than 1000 g)

That may very well be, but we’re discussing deaths due to infection and hemorrhage, which the part you quoted does not seem to touch on.
# liladyon 16 Sep 2012 at 5:04 pm

@ Cymbe: I think that the study you keep referring to, has already been debunked, repeatedly.

“Always Curious” Up thread has already joined in the analysis of the Bollinger study as well…and added this excellent analysis of the reasons, in the distant past, that no doubt accounted for higher mortality and morbidity of male infants…

“On a more serious note, the fuller article behind the graph linked earlier was more helpful to me:
http://www.pnas.org/content/105/13/5016.full

In the bulk of the article, it mentions such factors as: males inexplicably cause greater rates of complications during pregnancy and males tend to have lower birth weights. Most of the article actually describes how the difference in death rates has dramatically equalized over the last thirty years, not “why” it exists in the first place. But given the male disadvantage is most largely caused by problems existing prior to birth, and given that differing circumcision rates between foreign countries fail to explain anything about the inter-country death rate variation, it seems fair to accept that circumcision risks FAIL to be a major problem confronting newborns.

Is it a justifiable risk? Medically, the data Dr. Hall links to is on the par with antioxidants raising my energy levels and cleansing my toxins. But its safe enough, in the US anyways, that people should be able to take part in it if their cultural identity demands it.”

My comment and the link I provided, only built on what “Always Curious” stated. So your assumption that I went off topic, is unwarranted and is incorrect.

BTW Cymbe: The discussion that you are having with other posters here about the Bollinger report is still not settled, so don’t even try to discuss neonatal RDS with me, as a diversionary tactic. I promise you I’ll wipe the floor with you.
# Naradon 16 Sep 2012 at 10:26 pm

Not really, as you no doubt know that any study has a margin of error.

Funny, I seem to have missed Bollinger’s estimates of uncertainty. I repeat, the choice of ICD-10 codes is inexplicable, and even the possibly relevant ones were not defended as being associated with circumcision. I tell you what: Explain why birth hypoxia is in there. I’ve got a strong suspicion, but explain it for me.

And I am merely pointing out that your own statistics show that some ailments claim more girls than boys. It could also be that barring this procedure, more girls than boys would die of infections and hemorrhages, and that this practice gives boys an advantage of 40.4%.

Do you mean disadvantage? In any event, as I’ve stated already, there is no 40.4%. Nothing has been established by this exercise. The best that it ever could have hoped to be was an upper limit, but instead it is merely a number pulled out of a hat that has no bearing on anything.

There is no working backward from a conclusion, an assumption is made with which you disagree, but the correctness of which you haven’t yet refuted (not that I would say that it is definitely a correct assumption, unless you refute it).

There is plainly working from a conclusion. A study fails to find circumcision deaths, and this is “inexplicable.” Ergo, Bollinger is going to “find” them.

Is this a bait and switch or an honest mistake? You complained about the ‘discrepancy’-part, and now you cite something completely different.

I’m citing the exact same Wiswell & Geschke study that Bollinger complains failed to find deaths. However, they did: just not in the population where he has decided that they’re supposed to be. Even more unacceptable, the deaths (indeed, all of the complications) in the uncircumcised population were due to UTIs.
# Naradon 16 Sep 2012 at 11:06 pm

I might as well also note that this remains just the start. Bollinger miscalculates the base number that he arrives at from the unestablished 40.4% more deaths among males than among females (for what he has decided without any justification are circumcision-related causes), applying it to tally of just males, before gaily proceeding to his 772% multiplier.
# Always Curiouson 18 Sep 2012 at 12:29 pm

Cymbe: You’re missing the point. I sarcastically alluded to the point that gender differences in death rates for specific causes aren’t all on the male side; but after all is said & done, males do have a disadvantage. However, this disadvantage can largely be explained by factors that have nothing remotely to do with circumcision–factors that existed PRIOR to birth, but did not happen to prove fatal until AFTER birth. You are arguing with people who agree with your conclusion, but cannot agree with your the line of reasoning for getting you there. There is reasonable data out there, but it’s not EXTREME and it only hurts your cause to cite garbage like Bollinger’s to try to bolster your position.

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New AAP Policy on Circumcision

178 Responses to “New AAP Policy on Circumcision”

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