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178 thoughts on “New AAP Policy on Circumcision

  1. Scott says:

    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…

  2. Scott says:

    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.

  3. Cymbe says:

    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.

  4. mousethatroared says:

    @ 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.

  5. Cymbe says:

    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.

  6. mousethatroared says:

    I’m heading off for a ct scan Cymbe. There is a link in my comment up thread. You can check it out.

  7. Scott says:

    @ 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.

  8. lilady says:

    @ 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.

  9. Narad says:

    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.

  10. Narad says:

    ^ Sorry, “haven’t stated one.”

  11. baldape says:

    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.

  12. lilady says:

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

    http://www.scrubnotes.com/2007/08/how-to-write-historyphysical-or-soap.html

  13. Cymbe says:

    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.

  14. mousethatroared says:

    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.

  15. lilady says:

    @ mousethatroared: Did your “objective” finding (CT scan), confirm your “subjective” pain? :-)

  16. lilady says:

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

    http://en.wikipedia.org/wiki/Masters_and_Johnson

  17. Narad says:

    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.

  18. mousethatroared says:

    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.

  19. Narad says:

    ^ Argh, failed to close the ital after “is.” I hope this doesn’t break the Internet.

  20. mousethatroared says:

    @Lilady – Masters and Johnson – pioneers, thanks for the link.

  21. lilady says:

    @ 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.

  22. Newcoaster says:

    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.

  23. mousethatroared says:

    @lilady – Thanks!

  24. Narad says:

    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.

  25. Narad says:

    ^ 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.

  26. Helga435 says:

    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!

  27. Cymbe says:

    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.

  28. Narad says:

    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.)

  29. Narad says:

    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.

  30. Cymbe says:

    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?

  31. Narad says:

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

    code code

  32. DWATC says:

    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.

  33. mousethatroared says:

    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.

  34. DWATC says:

    @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.

  35. Narad says:

    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.

  36. mousethatroared says:

    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.

  37. baldape says:

    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!

  38. lilady says:

    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.

  39. Cymbe says:

    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?

  40. Cymbe says:

    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.

  41. Narad says:

    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.

  42. Narad says:

    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.”

  43. BillyJoe says:

    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…

  44. mousethatroared says:

    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.

  45. Cymbe says:

    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.

  46. BillyJoe says:

    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.

  47. DWATC says:

    @Cymbe…

    …Okay, we’ll go with that. Have fun…

  48. Narad says:

    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.

  49. Narad says:

    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.

  50. mousethatroared says:

    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.

  51. Cymbe says:

    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.

  52. mousethatroared says:

    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.

  53. Narad says:

    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.”

  54. BillyJoe says:

    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.

  55. mousethatroared says:

    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.”

  56. mousethatroared says:

    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.

  57. BillyJoe says:

    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.

  58. mousethatroared says:

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

  59. BillyJoe says:

    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.

  60. mousethatroared says:

    “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.

  61. BillyJoe says:

    “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.

  62. mousethatroared says:

    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.

  63. mousethatroared says:

    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

  64. lilady says:

    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.

  65. Cymbe says:

    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

  66. Narad says:

    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.

  67. Narad says:

    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.

  68. jalzate says:

    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.

  69. Always Curious says:

    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.

  70. Narad says:

    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.

  71. Narad says:

    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.

  72. lilady says:

    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.

  73. Cymbe says:

    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.

  74. Cymbe says:

    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.

  75. lilady says:

    @ 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.

  76. Narad says:

    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.

  77. Narad says:

    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.

  78. Always Curious says:

    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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