Articles

653 thoughts on “The case for neonatal circumcision

  1. provaxmom says:

    “Would anyone like to discuss the actual evidence? An argument can be constructed that the benefits in a low risk population do not justify the World Health Organization recommendation for circumcision, but I haven’t seen that argument. Instead there is a lot of opinion on why other people should not circumcise their sons.”

    My opinion is based on evidence. Since the ‘beginning of AIDS/HIV’ there have been a half-million Americans reported to have it. Include the unreported cases and the confidentiality issues…and I’ll double that to 1 million. So since the early 80s, only 1 million people in this country have gotten it. We have what, 300 million people. Granted our population hasn’t always been 300 mill, but we have 4 million births, over 2 million deaths each year. I’m not the math major, so I don’t know what that 1 million figure is truly out of, 350 million perhaps?

    And out of that one million, only 35% are white, 75% are men. Over half of the cases are due to high-risk activities.

    So if you want to call it an emotional decision, so be it. I don’t have a penis, so really it was all about logical deduction for me. Just like I don’t want to be overmedicated or over prescribed antibiotics, I’m not going to subject myself or my kids to what I see as unnecessary medical procedures. Yes, I am agnostic, so the fact that over time this has largely been a religious procedure….I’d be lying if I said that wasn’t a factor. But that *is* how is started. To me, the fact that some very minor (in my son’s situation) health benefits have been found, it wasn’t enough to sway me.

    I will agree with you that yes, via scientific analysis, benefits have been found. But for someone in my situation, those benefits are too small for me to consider. My emotions have nothing to do with it.

  2. provaxmom says:

    “Would anyone like to discuss the actual evidence? An argument can be constructed that the benefits in a low risk population do not justify the World Health Organization recommendation for circumcision, but I haven’t seen that argument. Instead there is a lot of opinion on why other people should not circumcise their sons.”

    My opinion is based on evidence. Since the ‘beginning of AIDS/HIV’ there have been a half-million Americans reported to have it. Include the unreported cases and the confidentiality issues…and I’ll double that to 1 million. So since the early 80s, only 1 million people in this country have gotten it. We have what, 300 million people. Granted our population hasn’t always been 300 mill, but we have 4 million births, over 2 million deaths each year. I’m not the math major, so I don’t know what that 1 million figure is truly out of, 350 million perhaps?

    And out of that one million, only 35% are white, 75% are men. Over half of the cases are due to high-risk activities. (this was all from a UK website, avert)

    So if you want to call it an emotional decision, so be it. I don’t have a penis, so really it was all about logical deduction for me. Just like I don’t want to be overmedicated or over prescribed antibiotics, I’m not going to subject myself or my kids to what I see as unnecessary medical procedures. Yes, I am agnostic, so the fact that over time this has largely been a religious procedure….I’d be lying if I said that wasn’t a factor. But that *is* how is started. To me, the fact that some very minor (in my son’s situation) health benefits have been found, it wasn’t enough to sway me.

    I will agree with you that yes, via scientific analysis, benefits have been found. But for someone in my situation, those benefits are too small for me to consider. My emotions have nothing to do with it.

  3. provaxmom says:

    “Would anyone like to discuss the actual evidence? An argument can be constructed that the benefits in a low risk population do not justify the World Health Organization recommendation for circumcision, but I haven’t seen that argument. Instead there is a lot of opinion on why other people should not circumcise their sons.”

    My opinion is based on evidence. Since the ‘beginning of AIDS/HIV’ there have been a half-million Americans reported to have it. Include the unreported cases and the confidentiality issues…and I’ll double that to 1 million. So since the early 80s, only 1 million people in this country have gotten it. We have what, 300 million people. Granted our population hasn’t always been 300 mill, but we have 4 million births, over 2 million deaths each year. I’m not the math major, so I don’t know what that 1 million figure is truly out of, 350 million perhaps?

    And out of that one million, only 35% are white, 75% are men. Over half of the cases are due to high-risk activities. (this was all from a UK website, avert)

    So if you want to call it an emotional decision, so be it. I don’t have a penis, so really it was all about logical deduction for me. Just like I don’t want to be overmedicated or over prescribed antibiotics, I’m not going to subject myself or my kids to what I see as unnecessary medical procedures. Yes, I am agnostic, so the fact that over time this has largely been a religious procedure….I’d be lying if I said that wasn’t a factor. But that *is* how is started. The fact that some very minor (in my son’s situation) health benefits have been found, that doesn’t change the fact that the origins are based in religion. And the scientific evidence just wasn’t enough for me to change my mind.

    I will agree with you that yes, via scientific analysis, benefits have been found. But for someone in my situation, those benefits are too small for me to consider. My emotions have nothing to do with it.

  4. joep says:

    @moderation
    I don’t think anyone here is against circumcision where there is an actual need or an adult is making the decision for themselves. So the term ‘anti-circ’ is misleading.

    Quickly, I would say that in the situation you describe, we could consider offering it to mature individuals. Where that line is is open to debate. However, there is a danger in doing this in countries that you describe. Specifically, there is a strong possibility of individuals misinterpreting the level of “protection” provided and shedding the condom altogether. I suspect this phenomenon will be under reported for years but rarely does an article about this issue in Africa get written where they don’t quote a bunch of men who cheer their new ‘virtual condom’. We also have to consider that nonsocial infection is a large and underreported vector in these countries.

    As to the supposed higher risk, that is part of the individuals decision. If the benefit is worth the risk he can take it, if not he won’t. It’s up to him. The difference is not significant. Though I will say that I’ve heard of infants (in developed countries) dieing as a result of circumcision, I’ve never heard of an adult dieing of a circumcision (except perhaps in some of those African ritual circumcisions.).

  5. David Gorski says:

    Given some people’s stridency on the right to circumcise, I can only see a few justifications:

    1) cognitive dissonance – i.e. they have participated in performing it, or themselves have suffered it, and must make the case to themselves that there is nothing wrong with taking knives to any young boy’s penises;
    2) religious indoctrination;
    3) castration fantasies.

    Apparently you can only “see” what you want to “see,” then. You’ve got to be kidding on #3 and hugely exaggerating on #1. #2 may have some validity, but that’s certainly not the “only” reason.

    As for castration fantasies? Got any evidence to support that last assertion? I’ll wait, although I suspect I’ll be waiting a long time.

  6. Harriet Hall says:

    Amy, you said the AAP should heed the authors’ call. The AAP Policy Statement says

    “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.”

    I don’t see any reason to change this statement. It is fair and balanced. The new information about STD risks automatically becomes part of the “accurate and unbiased information” given to patients.

    I don’t think you are recommending routine neonatal circumcision, but questioning the current AAP policy makes it sound like you are. Perhaps you could clarify exactly what you think the AAP should say differently.

  7. JurijD says:

    I forgot to bookmark this review and it took a while for me to find it again:

    Can Routine Neonatal Circumcision Help Prevent Human
    Immunodeficiency Virus Transmission in the United States?

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2678848/pdf/nihms98333.pdf

    It discusses several reasons why the “African” studies on relative HIV-risk reduction with circumcision are not a decent guide for any kind of health-policy recommendation in the US (or by analogy Europe).

    To recap, there are a number of differences and confounding variables that cast serious doubt on whether the US would also benefit from a more generalized circumcision schedule.

    1. Different HIV prevalence rates (young adults):
    US 0,14 %
    Europe <0,1%
    Uganda, Kenya 6-7 %
    South Africa ~25%

    The NNT for circumcision in Europe and the US would be quite significant compared to the 3 African "study" countries in which the recent better-quality studies were performed. A cost benefit analysis should be most revealing. This NNT data must then be compared to the number of adverse effects incurred on all circumcised males.

    2. Different HIV modes of transmission:
    Africa: predominant mode high-risk heterosexual contact
    US: 49% penile-anal mode, 33% high-risk heterosexual

    If circumcision has a different protective effect for different HIV transmission modes (which is not all that unlikely) it is difficult to extrapolate from African data.

    3. Presence of concurrent STDs
    - 5% of all trial participants (young adults) in Kenya had a Chlamydia infection, which is know to increase the risk of HIV transmission
    - the US/EU prevalence for the entire population is about 1-3%

    any concurrent infection that leads to either ulceration or any kind of genital mucosal damage can obviously lead to a much greater infection risk where the advantages of circumcision might shine through. If these same diseases are not present in the US or Europe to such a degree one can reasonably expect the benefits of circumcision to also be lower – or at the very least that such benefits are not established for the western context.

    4. Differing numbers of sexual partners / sexual behavior and condom usage.

    Given these reasons it is even more clear that studies conducted in Africa cannot be a serious basis for such a drastic change in health-care policy. Advocating general circumcisions in Europe or the US would requite studies to be performed in these countries or at least in a reasonable analogue.

  8. David Gorski says:

    An argument can be constructed that the benefits in a low risk population do not justify the World Health Organization recommendation for circumcision, but I haven’t seen that argument. Instead there is a lot of opinion on why other people should not circumcise their sons.

    If you want to go that way, then I feel obligated to point out that I haven’t seen you address the question of risk versus benefit either, quite frankly. The word “risk” doesn’t even appear in your post, and your first paragraph frames circumcision as “saving lives from a dread and often fatal disease simply by performing a minor surgical procedure.” Your post came across to me as a glowing endorsement of circumcision. It’s true that the really emotional anti-circ crowd has come out in force (they always do whenever the post is about circumcision and is not an angry screed against the practice) and it’s easy to dismiss them based many of their dubious arguments, but you haven’t addressed the very point you accuse them of not addressing.

    Again, going back to Harriet’s post, the NNT to prevent one case of HIV/AIDS in Africa was estimated by a meta-analysis to be 72. It is not an unreasonable question to ask whether it is worth performing 72 circumcisions in order to prevent one case of HIV/AIDS. The NNT in the U.S. and western nations is, of course, likely to be much higher because the prevalence rate is lower, meaning that the African studies are not well-matched to the question of circumcision’s benefits in the U.S.

    In other words, I’m with Harriet on this one. Perhaps you should clarify.

  9. edgar says:

    I don’t think this issue can’t just be about medical facts. Quite frankly, I think it is a dangerous practice in most cases. We cannot seperate our health from our cultural, religious and moral beliefs…Nor should we. Health research should always ben interpreted within a cultural context. I will never say ‘circ is bad’. There are many cultures in which it is a critical rite of passage.

    Who am I to say than an intact penis is more important than a young boy being able to become a man?

  10. Annabel says:

    “Yes, and I’m waiting for the anti-circ folks to present some numbers, as opposed to personal opinions.”

    Here are some numbers. The risk of a man contracting HIV from a woman, which is the only HIV route circumcision has proven to reduce risk, is .04% or .0004 in the United States. One in every 2,500 sexual acts (http://www.aidsmap.com/en/news/E1249D29-0DDE-4CFF-9CC7-16B3FADB3E59.asp) . Exactly how many men do you think are going to be having sex 2,500 times before the age of 18 when they can make an educated decision for themselves about whether or not the risk reduction is worth it? Even the most conservative risk complication rate of circumcision is WELL above .0004.

    Like others have pointed out, there is no need to circumcise infant boys. There are many types of female circumcision, and not all of them are analogous to removing the entire penis of a boy. If girls are protected from even a ceremonial pin prick to their genitals, boys should be protected from having their foreskin removed. I doubt anyone would argue that a single needle prick to the labia of an infant girl carries less risks and is less harmful than removing foreskin from a baby boy. It is unconstitutional to make a human rights law that protects one gender and not the other.

    If scientists are correct in speculating that the reason circumcision reduces HIV risk is because of the prevalence of Langerhans Cells in the foreskin, why are they not proposing further study in female circumcision to reduce the risk of HIV since the genitals are where the majority of Langerhans Cells are for females as well? Even if studies proved that female circumcision reduced the risk of HIV and UTIs the law to protect infant girls would not change, because it is a violation of human rights and not the cultural norm.

    I really get tired of the argument that male circumcision is Ok because female circumcision is worse. How is that logical? Should raping children be legal because murdering children is worse? Laws don’t work that way. Just because something is worse doesn’t make a lesser offense right. And, as others have pointed out, removing the clitoral hood in females is analogous to removing the foreskin in males, it is not worse. If someone held a man down and cut his pinky off that would be bad. If someone held a man down and cut his entire leg off that would be worse. So should forcibly cutting a man’s pinky off be Ok? I don’t think so.

  11. Diverdi says:

    I’ve only got a few minutes before I leave work to post this.

    Having a quick look at the article quoted, this is a review article, mixing data from some RCTs and a meta-analysis.

    It’s not clear if there is some crossover between the meta-analysis and the RCTs. The 2 of the 3 RCTs use rates per 100 person years (a dubious concept) and the quoted 60% reduction is a reduction from 1.33 cases per 100 persons years to 0.66. (Not significant enough for me to consider operating on my sons).

    Not to mention this is data is from adult males aged 18-24 in high risk countries and should not be extrapolated to infants in low risk countries.

    I thought SBM was better than this…

  12. windriven says:

    Dr. Tuteur, you sure know how to bring them out of the woodwork.

    It seems to me that what is missing from most of the posts (including my own I’m ashamed to say) is any citation of studies or meaningful critical examination of the facts. Instead, we have rants steeped in personal and cultural prejudices.

    I would like to understand if the reduction in sexually transmitted diseases in circumsized males has been noted in first world countries as well as in societies with less robust hygienic infrastructures. Do the reduced rates relate to reduced need to carefully clean the genitals? Is there literature to demonstrate this one way or the other?

  13. JurijD says:

    “I would like to understand if the reduction in sexually transmitted diseases in circumsized males has been noted in first world countries ”

    there has been a few studies in this regard and they are mostly negative. – that is they show that in those populations most at risk for HIV infection in developed countries, circumcision does not decrease HIV infection risk.

    A recent review of these studies that asses high-risk populations and circumcision (homosexual, bisexual men)

    http://jama.ama-assn.org/cgi/content/short/300/14/1674

    The problem is that, to my knowledge, there are no good RTCs of circumcision as a preventative measure against HIV infection in developed countries. The observational studies are quite mixed, some report a decrease in risk, some even an increase in risk, but they are difficult to interpret.

  14. Annabel says:

    “It seems to me that what is missing from most of the posts (including my own I’m ashamed to say) is any citation of studies or meaningful critical examination of the facts. Instead, we have rants steeped in personal and cultural prejudices.
    I would like to understand if the reduction in sexually transmitted diseases in circumsized males has been noted in first world countries as well as in societies with less robust hygienic infrastructures. Do the reduced rates relate to reduced need to carefully clean the genitals? Is there literature to demonstrate this one way or the other?”

    Here is a site with links to countries and the prevalence of HIV in each of them. (http://hivinsite.ucsf.edu/global?page=cr-00-02)

    Of all the western countries including the UK, Australia, New Zealand and Canada, the United States has by far the highest rate of HIV and the highest rate of circumcision. Circumcision rates in those countries are under 20 percent. Also note that the primary means of transmission is the same in all of these countries : Homosexual male intercourse, which circumcision has shown to have no effect in reducing transmission in. In stark contrast is Africa, whose primary means of transmission is male to female sex, which is among the rarest form of transmission in the United States and all western countries.

  15. Scott says:

    Yes, and I’m waiting for the anti-circ folks to present some numbers, as opposed to personal opinions.

    And multiple commenters who cannot reasonably be termed “anti-circ” are still waiting for you to provide ANY BASIS WHATSOEVER for a central point you are advocating. You haven’t even gotten to the point of presenting personal opinion!

    So yet again. In light of the ethical issues of permanent modification of an individual’s body without their consent, from where does the urgency arise to justify neonatal circumcision as opposed to recommending it to the individual when they are old enough to express an opinion, but before they become sexually active?

  16. “Amy, you said the AAP should heed the authors’ call.”

    Yes, the authors call on the AAP to revise its policy in light of the latest evidence. I take that to mean advising parents of the benefits of circumcision in preventing transmission of HIV and STDs.

  17. Annabel says:

    “In stark contrast is Africa, whose primary means of transmission is male to female sex, which is among the rarest form of transmission in the United States and all western countries.”

    Sorry I meant to say female to male is the primary means of transmission in Africa, not male to female.

  18. edgar says:

    Does the fact than a Kenyan man is in the circumcised arm somehow change his behavior? Did they control for this?

  19. Bitey says:

    Amy, you know damn well these African studies are flawed in many different ways and not applicable to those living in first-world countries. Studies about cir done in European or American contexts have had very mixed and informative results.

    Anyway, it was interesting that those women that answered that sex with their husband was more satisfying post-cir cited “cleanliness” as the reason. Then the authors go on to claim that as a universal applicability. How about if these folks had access to washing everyday and using soap, “cleanliness” either way would not be a problem. We aren’t living in 1st century Israeli or Uganda. This cleanliness issue is no longer a problem.

    Dr. Dean Edell has a really good segment on this issue. Look it up on itunes, folks.

  20. Sid Offit says:

    Because the male analogue of female “circumcision” is amputation of the penis. Why do anti-circ activists disingenuously equate male circumcision with clitoridectomy?

    —————-

    Can you reproduce without a clitoris? Can you reproduce without a penis? Bad analogy.

  21. JurijD says:

    ” Yes, the authors call on the AAP to revise its policy in light of the latest evidence. I take that to mean advising parents of the benefits of circumcision in preventing transmission of HIV and STDs.”
    ———————

    but the point we’ve been trying to get you to recognize this whole time is that, the “new” evidence is only a small piece of the puzzle and not in line with some other evidence. Especially when one looks at the bigger picture and asks if it is reasonable to extrapolate from Africa to Europe or the US.

    To my knowledge there is no decent evidence to support the contention that generalized circumcision will help reduce HIV infection rates in the US or Europe. Furthermore I have yet to see rigorous analysis of NNT for the US/EU case and a comparison with relevant adverse effects.

    On top of that there are review papers published for the case of Europe and US (liked one in my previous post) that conclude that circumcision does not decrease HIV infections for high-risk groups (MSM).

    In light of these facts, that you consistently dodge, I cannot see how one can reasonably conclude that recommending routine circumcisions is a good idea and will lead to the desired effect in the US or Europe.

  22. Nick says:

    If you want real information on HIV/circumcision :

    http://www.youtube.com/watch?v=OlsUg0sdAtE

    instead of losing your time with novice doctors from Science-Biased Medecine with all sorts of incomprehensible statistics that come from nowhere : “NNT to prevent one case of HIV/AIDS in Africa was estimated by a meta-analysis to be 72″.

  23. Sid Offit says:

    “David Gorski”

    She mentioned that the NNT for sexually transmitted diseases is 72.

    That’s African data. Let’s bring it back to America where most of us live

  24. Geekoid says:

    If the anti-circ crowds argument is ‘the infant newborn should ahve a say in anything that isn’t immediate medical need” then you must be against the following or you are hypocrite:

    ‘brushing gums’, later teeth.

    Cleaning behind the ears.

    Fixing damaged clefts

    removing unusable extra limbs (Polydactyly)

    separating Siamese twins (some case are immediately medically necessary, but many aren’t)

    and so on.

    the fact of the matter is circumcision reduce the chance of catching some deadly STDs.
    It can be very difficult to have a boy entering puberty ti do proper cleaning.
    The study looking at sensitivity showed no los, and the people taking the position thet they have or don’t have more sensitivity aren’t really qualified for the judgment because they have no way to compare, and they will be rife will personal bias. This is logically no different then saying my son got a vaccine, and then was diagnosed with autism and since it happened to me, I must be right.

    Not get your child circumcised means you have chose to let your child have a hire risk of dying from STDs. That’s the bottom line no matter how you like to paint it.

    On a personal note: as a man I would appreciate less stimulation during intercourse. well, until I turned 45, now I need all I can get~

  25. Zoe237 says:

    Windriven:

    “It seems to me that what is missing from most of the posts (including my own I’m ashamed to say) is any citation of studies or meaningful critical examination of the facts. Instead, we have rants steeped in personal and cultural prejudices.”

    Might it be because this is, at it’s core, an ethical/religious/philosophical debate, at least in the U.S.?

    The AAP and most medical organizations in the world (including the WHO, for developed countries, contrary to Dr. Tuteur’s “facts”) do NOT recommend routine infant circumcision. The medical benefits DO NOT justify American neonates being routinely circumcised. A study of the relevant medical literature as a whole don’t present compelling arguments for RIC. If a parent wishes to have a surgical procedure for their infant, that’s fine. The risks are minimal, most likely. But don’t pretend there aren’t cultural issues (on either side). And stop using medicine and science (as was done for the first 90 years of the 20th century) to justify your (general) religious beliefs. A fringe few in the 21st are still at it.

    Thus, it’s not a medical issue for most boys born in this country. It’s a cultural/religious one, and people on either side are going to go nuts about it.

  26. Scott says:

    @ Geekoid:

    Surely you must see the difference between a permanent modification of the body and your cited examples.

    As for dismissing anybody who questions what the proper timing for the decision is as “anti-circ” – well, there’s simply zero justification for that.

    And in particular:

    Not get your child circumcised means you have chose to let your child have a hire risk of dying from STDs. That’s the bottom line no matter how you like to paint it.

    Unless you have some evidence to support a claim that neonatal circumcision is more effective in this regard than teenage circumcision, this claim is completely false.

  27. Sid Offit says:

    Wouldn’t MNTBA be a better metric, as in members needed to be amputated

  28. Geekoid says:

    Lets not for get about female risk as well:

    “Among female partners of circumcised men, bacterial vaginosis was reduced by 40%, and Trichomonas vaginalis infection was reduced by 48%. “

  29. JurijD says:

    Geekoid:
    “the fact of the matter is circumcision reduce the chance of catching some deadly STDs.”

    This is in fact NOT the whole story. This is likely the case for Africa where the recent 3 good RCTs were done. It is far from certain in the US or European context (see the review I linked previously)

    Geekoid:
    “It can be very difficult to have a boy entering puberty ti do proper cleaning.”

    Really? How difficult can it be to get a boy entering puberty to “play” with himself in the shower ? You must be from some kind of a bizzaro-universe because this is certainly not the case where I’m from ;)

    Geekoid:
    “Not get your child circumcised means you have chose to let your child have a hire risk of dying from STDs. That’s the bottom line no matter how you like to paint it.”

    This is not established in the European or US context at all. Some studies show a decrease in risk but others even an increase in risk. A large review for the MSM group shows no benefit in (mostly) developed countries.

    Apart from that you are only looking at one side of the coin. Even if it were established that circumcision does significantly reduce the risk of say HIV infection in the US or European context this would only be ONE side of the decision-equation. You would also have to weight this benefit against the side effects of circumcision especially since the NNT in the US/EU would be huge.

    It is therefore not just a choice between exposing your child to an increased risk for STDs or not (even if that were established). You must weight that benefit against other circumcision related operational side effects.

  30. Nick says:

    @Geekoid :

    You are talking about birth defects or some medical conditions.
    The foreskin is neither of them.
    FORESKIN ISN’T A BIRTH DEFECT
    It’s supposed to be there, there’s no need to remove it despite false claims of non-cleanliness. How the rest of the world has done just fine without lobbing off baby peni, I don’t know. Maybe their kids can clean themselves?

  31. windriven says:

    Zoe-
    I generally agree though Dr. Tuteur’s post – at least as I read it – was nothing more than an introduction of the study, presumably as a springboard for this sort of discussion. I think there are interesting and legitimate scientific areas of exploration:

    - Is the noted decrease in STD transmission fundamentally one of hygiene?

    - Is there or was there an evolutionary benefit to having a foreskin and if so, what is/was it?

    - Does presence or absence of a foreskin correlate with sexual satisfaction of either partner?

    - What are the ethical issues of performing an irreversible (for the most part) surgical procedure on an infant and where and how is that line drawn. This last of course transcends the circumcision discussion but is still, I think, appropriate.

    Personally, I don’t have a dog in this fight and I am amused by the level of emotion evident in many of the posts. I had my son circumcised as it was the thing to do at the time. I frankly didn’t give it any thought. If I were making the decision today I would likely leave the decision to be made by him. But as a circumcised male I certainly don’t feel psychologically scarred, maimed, deprived of sexual satisfaction or otherwise hard done by. Much of the heat of this thread seems a tempest in a teapot to me.

  32. Scott says:

    Surely you must see the difference between a permanent modification of the body and your cited examples.

    I call editing fail on myself, sorry. That should have read “first two cited examples”, and been followed by

    The others have real and clear benefits to acting swiftly; unless you can provide evidence of urgency for circumcision they fail as well.

  33. edgar says:

    Wind,

    I would add cultural significance in there too.

  34. joep says:

    @Geekoid

    Last time I checked brushing gums and teeth are an issue of hygiene; if not done, the usual consequence ensues such as tooth decay and gum disease. While not cleaning behind the ears might not lead to the same problems, such a minimally invasive intervention doesn’t seem to raise the same ethical questions.

    A damaged cleft, extra limbs and Siamese twins represent birth defects. In the case of a cleft, it might lead to problems with feeding, ear disease, and speech to name a few that springs to mind.

    It seems disingenuous to compare necessary hygiene practices and birth defects, which have immediate impacts on the child, to a practice that involves none of these things. And circumcision is significantly different from vaccinations in just about every conceivable way.

  35. Nick says:

    There is definitely with Amy Tuteur hen I read her articles.
    She obviously hates nature and feels the compulsive need to destroy it using the excuse to protect it :
    she is against homebirth
    she is against natural birth (preference for c-section)
    she is against breastfeeding
    she is against natural penis

  36. Nick says:

    There is definitely something wrong with Amy Tuteur when I read her articles.
    She obviously hates nature and feels the compulsive need to destroy it using the excuse to protect it :
    she is against homebirth
    she is against natural birth (preference for c-section)
    she is against breastfeeding
    she is against natural penis

  37. Annabel says:

    “‘brushing gums’, later teeth.”

    - does this remove any healthy tissue from an infant or child? Does this change the function of the teeth or gums of the child? Does brushing teeth cause any permanent change that cannot be undone? Is brushing your child’s teeth legal for one gender and illegal for another?

    “Cleaning behind the ears.”

    -does this remove any healthy tissue from an infant or child? Does this change the function of the ears of the child? Does cleaning behind the ears cause any permanent change that cannot be undone? Does cleaning the ears permanently change the appearance of the ears?Is cleaning your child’s ears legal for one gender and illegal for another?

    “Fixing damaged clefts”

    - Are children normally born with damages clefts, or is it a birth defect? Are foreskins a birth defect? Can you fix a damaged cleft for a boy and not for a girl?

    “removing unusable extra limbs (Polydactyly)”

    - Are children normally born with unusable extra limbs, or is it a birth defect? Are foreskins a birth defect? Can you remove the extra limb from a boy but not from a girl?

    “separating Siamese twins (some case are immediately medically necessary, but many aren’t)”

    - Are children normally born attached to another human being, or is it a birth defect? Are foreskins a birth defect? Can you separate siamese boys but not siamese girls? Also note that unless there is immediate medical need, siamese twins are not usually separated until much older when they can voice whether or not they want to remain that way. The risk of surgery to separate twins is not worth it if there is no immediate life threatening risk to the twins, and you would be hard pressed to find a doctor that would perform such a surgery if both infants were completely healthy and weren’t at any such risk.

    “This is logically no different then saying my son got a vaccine, and then was diagnosed with autism and since it happened to me, I must be right.”

    Actually it is very different. Studies have not shown a definitive link to autism and vaccines. Diseases that children are vaccinated against such as polio, smallpox, and measles are not sexually transmitted. They are contracted by such unforeseeable circumstances are unknowingly breathing the same air as someone who is infected. You can’t get sneezed on and contract HIV or herpes or genital warts. Vaccines are also the most effective, least invasive and usually ONLY way of achieving the desired effect, and they show the same risk reduction for everyone. These vaccines are responsible for eradicating the diseases for which they provide immunity for on a global scale. You would never see 4 out of 5 vaccinated people getting polio. Or even 5 out of 10. Circumcision is a risk reduction, vaccination is an immunity. Also, vaccination does not remove healthy functioning tissue, or alter the appearance or function of their body parts, thus their imposition on human rights is minimal at best.

  38. JurijD says:

    Nick,

    you just went off the rails :D

  39. Zoe237 says:

    “Amy, you said the AAP should heed the authors’ call.”

    “Yes, the authors call on the AAP to revise its policy in light of the latest evidence. I take that to mean advising parents of the benefits of circumcision in preventing transmission of HIV and STDs.”..

    My baloney meter is going off. Here’s what the AAP policy says about HIV and benefits ALREADY:

    “In addition, there is a substantial body of evidence that links noncircumcision in men with risk for HIV infection.19112-114 Genital ulcers related to STD may increase susceptibility to HIV in both circumcised and uncircumcised men, but uncircumcised status is independently associated with the risk for HIV infection in several studies.115-117 There does appear to be a plausible biologic explanation for this association in that the mucous surface of the uncircumcised penis allows for viral attachment to lymphoid cells at or near the surface of the mucous membrane, as well as an increased likelihood of minor abrasions resulting in increased HIV access to target tissues. However, behavioral factors appear to be far more important risk factors in the acquisition of HIV infection than circumcision status. ..

    http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686

    And with the following quotes from the blog, and the title, pretending that you aren’t arguing for neonate circumcision is… disengenous at best.

    “Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure. ”

    “In this month’s edition of the Archives of Pediatrics and Adolescent Medicine, Tobian, Gray and Quinn present a compelling case for neonatal circumcision.”

    “But the benefits of circumcision are real and clinically important.”..

  40. Nick says:

    The so called reason why circumcision prevent AIDS is because of Langerhans cells found in the foreskin. Hoever some other studies show that these Langerhans PROTECT against HIV :

    http://www.circumcisionandhiv.com/files/de_Witte_2007.pdf

  41. Nick says:

    The so called reason why circumcision prevent AIDS is because of Langerhans cells found in the foreskin. However some other studies show that these Langerhans PROTECT against HIV :

    http://www.circumcisionandhiv.com/files/de_Witte_2007.pdf

  42. Zetetic says:

    I think we’ve had this debate here a few too many times. The polarization is astounding, it’s almost as strange as with vax vs. anti-vax!

  43. David Gorski says:

    There is definitely something wrong with Amy Tuteur when I read her articles.
    She obviously hates nature and feels the compulsive need to destroy it using the excuse to protect it:

    she is against homebirth
    she is against natural birth (preference for c-section)
    she is against breastfeeding
    she is against natural penis

    What a load of horse hockey!

    I’ve sparred with Amy from time to time in the comments, but what you’re saying is just plain ridiculous. Please, show us where Amy has ever said that she prefers C-sections or that she is against breast feeding or a natural penis. True, she does appear to take a dim view of home birth, but I don’t know that you can characterize her as being totally against it.

  44. Plonit says:

    A dim view indeed! Have you read homebirthdebate.blogspot.com ?

  45. Harriet Hall says:

    Amy,

    You said “Yes, the authors call on the AAP to revise its policy in light of the latest evidence. I take that to mean advising parents of the benefits of circumcision in preventing transmission of HIV and STDs.”

    The AAP policy already says
    “To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision.” I think that covers advising parents about the HIV/STD information. Do you disagree?

  46. windriven says:

    edgar,

    I absolutely agree that cultural bias is a huge component.

    That doesn’t necessarily make it right are wrong; I would argue that some scientific truths trump cultural/religious beliefs. But I certainly don’t think this one rises to anything close to that level.

    BTW, hope you enjoyed a pleasant holiday season.

  47. windriven says:

    @Zetetic

    I’m with you. I wonder if the editors might not set up a separate area where the ranters might amuse themselves. There they might while away the hours engaging each other in ad hominem attacks, puerile arguments and hagiographies of their favorite deities, cults, fads, fashions and woo.

  48. windriven says:

    @Nick

    The link to the de Witte in Nature is interesting but only tangentially related to the issue at hand. De Witte argues that Langevin disrupts the transmission of HIV by Langerhans Cells. Very interesting indeed. But in and of itself, that only means that we know one pathway whereby HIV is NOT transmitted. That is rather different from the epidemiologically noted differential rate of transmission in circumcised v. uncircumcised males.

  49. As Dr Hall points out, the current AAP reccomendation includes the statement, “To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision.”

    I’m with Dr Hall: I really don’t see anything that needs changing in that recommendation.

    For an informed choice, we would need to know:
    1) NNT for the country the boy is born into.
    2) NNH (number needed to harm) for infant circumcision.
    3) NNH for adult circumcision.

    Do you know any of those? Can you guess? Can you explain how you know or don’t know, or why you can or cannot guess? Can you talk about the difficulty in discussing the facts with parents when we don’t know all the facts? That would be Science-Based Medicine at its finest!

    According to Dr Hall, the NNT in Uganda seems to be about 72. There are differences between Uganda and the US, the country for which the AAP is making recommendations.

    One is prevalence of HIV/AIDS. Prevalence in the US is lower, which means the NNT would be higher in the US. How much higher? Can you estimate it based on relative prevalence rates? (I can’t, by the way. I wouldn’t know what the relevant numbers are. This means I can’t make any assumptions or guesses about whether the US NNT would be extremely reasonably or ridiculously small. But if you could, that would be really interesting, and it would shed some light on what exactly you think should be presented to American parents that is not already.)

    Another is patterns of sexual relationships. Serial monogamy is the most frequent pattern in the US. (No, I have no data to say by what degree and I don’t know enough about sexual anthropology to name all the different patterns and discuss them intelligently.) In African countries with a high HIV/AIDS prevalence, serial monogamy is less frequent. (I don’t know how much less frequent. I heard this analysis from a CBC radio inerview with one of the doctors doing one of the Ugandan studies — he did have the data to back up what he was saying — and this assertion made sense to me based on personal anecdotal evidence, so I did not question it. Maybe the statement could be challenged, but I think “less frequent” is a reasonable assessment that makes no claims to degree.) Though the number of lifetime partners may be the same, people tend to return to the same partners over the course of a lifetime. This affects transmission rates. If I have five lifetime partners but never return to an old partner once we have split up, then I can only retransmit any STI I contract to future partners. My exes are safe, and I am only exposed to a partner’s STIs for the time we are together.

    If I have five lifetime partners and I reconnect with one of them when I return to my hometown and contract the STI they contracted after splitting up with me, I will then retransmit it to my spouse.

    So prevalence of HIV/AIDS is higher in Uganda (greater chance that any given partner will be infected) and likelihood of retransmission is also higher (even with a similar number of lifetime partners to an American, more of one’s lifetime partners are at risk of contracting an STI.)

    Given these two differences — one of which is more easily quantifiable (prevalence rates) and one of which is less easily quantifiable (patterns of sexual relationships) — the NNT for the US is not going to be the same; but without a gross estimate of NNT and NNH in the US, we can’t make informed choices.

    IN this light, an argument for waiting until adulthood for circumcision would be that the individual would have a better understanding of what their risk factors would be. On average, a gay man’s sexual partners will be taken from a pool with a higher HIV/AIDS prevalence rate. That might affect his decision. And if he knows that serial monogamy is not appealing to him, that might also have an impact. The NNT for a moderately promiscuous gay man in the US might be similar to the NNT for a moderately promiscuous Ugandan of any sexuality.

    All these are really interesting numbers to me — even if I don’t know what the numbers are, I know they are out there.

    How do doctors use science to decide which ones are relevant to communicate to parents? That would be a really interesting post.

  50. snfraser says:

    This isn’t physics or chemistry. Medical science is messy.

    I am still waiting for a mention of the risks associated with this procedure. No mention of NNH (number needed to harm).

    Finally, the 3 commonly cited RCTs were in men. Is there any evidence that this procedure translates into the same benefits (small as they are, and certainly exaggerated by some) when performed on infants or children. (I may have missed it in this long list of posts, if someone has already provided the evidence)

  51. EricG says:

    this is a wholly absurd debate.

    there appear to be benefits. up to you (your penis and your choice for your children) as to how encouraging those benefits are.

    only in the most far fetched of circumstances, will the decision to circ or not impact others.

    I do not recall, loath, regret, notice or in anyway consider my own circ. my guess is that if you sampled the population, that sentiment would remain pretty consistent.

    the docs are accountable to present the evidence as it is appears. do with it what you will.

    always use a condom

    sex is just as much mental is it is physical

    but, im sure there is some fantastic reason to get all bent out of shape about all of this…carry on

  52. Eric G,
    “the docs are accountable to present the evidence as it is appears. do with it what you will.”

    Actually, doctors are accountable for interpreting the science for us, not just list PubMed references. This is hard to do. (If it weren’t, the AAP reccomendations would be trivial because everyone would be coming to the same undeniably correct conclusions simultaneously and independently.)

    If there are risks and benefits to balance — and there always are — then I need my doctor to explain them to me.

    What’s frustrating about Amy is that she doesn’t explain things. She makes a statement without nuance or clarity (vague but not nuanced… , asserts that anyone who disagrees with her is an irrational extremist ninny (without actually quoting anyone who disagrees with her stated opinion and explaining why they are wrong), and sits back and waits for the complaints.

    She thinks that lots of complaints about lack of nuance is a sign of an effective educator.

    I disagree.

  53. Eric G,
    “the docs are accountable to present the evidence as it is appears. do with it what you will.”

    Actually, doctors are accountable for interpreting the science for us, not just list PubMed references. This is hard to do. (If it weren’t, the AAP reccomendations would be trivial because everyone would be coming to the same undeniably correct conclusions simultaneously and independently.)

    If there are risks and benefits to balance — and there always are — then I need my doctor to explain them to me.

    What’s frustrating about Amy is that she doesn’t explain things. She makes a statement without nuance or clarity (vague but not nuanced… , asserts that anyone who disagrees with her is an irrational extremist ninny (without actually quoting anyone who disagrees with her stated opinion and explaining why they are wrong), and sits back and waits for the complaints.

    She thinks that lots of complaints about lack of nuance is a sign of an effective educator.

    I disagree.

  54. Archangl508 says:

    Having read most of the comments posted here I have to say, this discussion would make an interesting sociological experiment. It is quite interesting to note that individuals who would probably discuss vaccination or homeopathy in a quite dispassionate manner seem to devolve into ranting and raving when discussing the aspects and choice of circumcision, especially when the author of this article never calls for an end to parental choice. It does appear to me that the only people arguing against choice are those against circumcision, but I could be wrong.

    I think some of Dr. Tuteur’s statements are a little too strongly worded for the data, but certainly agree that parents should be presented with all of the facts, including the information showing a reduction in STD risk. But, if Dr. Hall is correct and the AAP guidelines already make such a statement, then no change in policy is required and this information should simply be added to the information that would be given to parents.

    It is also interesting how some parent’s consider their children to be at a lower risk group for STD’s simply because they think they would be. As the child of parents who didn’t know I was gay until I came out to them, I would say that you probably do not understand your own children’s risks as accurately as you may think you do. I certainly never talked to my parents regularly about my sexual experiences (either before or after coming out).

    As a “mutilated” male myself I have to say that I am not at all unhappy with my parent’s decision. As a matter of fact I do not even give it any thought whatsoever, nor do I have any sort of memory of the event (but I have not gone for hypnotic memory regression therapy lately, so maybe its there and I’m not sure about it). I am quite happy (sometimes too happy) with my sexual pleasurability (not sure if thats a word). Also, as a gay man I have seen both types in action and, personally, I prefer mine…but that’s just me. I’m glad my parents made the choice they did, when they did. I would rather not have to deal with the pain that I would certainly remember were I to do it now.

  55. Jason says:

    Tuteur undermines her credibility completely by lying about the AAP’s position statements. Nowhere in the organization’s history has it recommended newborn circumcision. In reverse chron order:

    1999 Position Statement: “data are not sufficient to recommend routine neonatal circumcision”

    1989 Addendum to 1975 Statement (did not alter 1975 position): “circumcision… may result in a decreased incidence of urinary tract infection. However, in the absence of well-designed prospective studies, conclusions regarding the relationship of urinary tract infection to circumcision are tentative.”

    1975 Position Statement: “There is no absolute medical indication for routine circumcision of the newborn.”

    1971 Position Statement: “There are no valid medical indications for circumcision in the neonatal period.”

    Tuteur’s bold claim: “The AAP had long recommended male circumcision”

    Please disregard anything else she writes.

  56. erric says:

    Well, this is a very interesting case.

    let’s start with a sentence like “it is time for the AAP policy to fully reflect these current data.”
    is quite a ugly mix up!

    let’s replace those “data” with : “removing all boys hands reduce drastically the death rate by gun shot.” (which, you might accept for the sake of the demonstration).

    And, thus, start again : “AAP should encourage, hands cut off.”

    Sounds ridiculous, isn’t it ?

    Be careful to always separate facts (evidence) goals, and means.

    “Circumcision reduces STD transmission rate”. It’s a fact.
    “Everybody’s goal is to be healthy at any cost ?” it’s a goal, and implicit here.
    “We should perform chirurgical procedure to achieve this goal” It’s the mean.

    When, someone go and visit doctors, they share the goal (getting better), and doctors propose a mean (or even several ones). But when it comes IRL, there is a trade off between life and health. Do not forget that.

    Evidence based “sciences” should never discuss goals, rather discuss (means,goals) couples.

    “Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure. People would hail this simple victory and rush to adopt it”

    No. Simply because, you have forgotten that not everybody share this goal. You are falling on false assumptions.

    You should try evidence-based politics. ;-)

  57. mjrobbins says:

    Alison: “What’s frustrating about Amy is that she doesn’t explain things. She … asserts that anyone who disagrees with her is an irrational extremist ninny.”

    Well indeed. The biggest issue I have with this article is that she clearly endorses *neonatal* circumcision, yet has provided zero evidence to back (circumcision in general, but not neonatal circumcision).

    The presentation of evidence is also completely one-sided. Ethical considerations like the right of an individual to choose are completely ignored, as are the medical side-effects of circumcision (aside from sexual performance), as are any recent studies reaching different conclusions.

    Anyway, I have written a detailed response here:

    Circumcision: A Response to Amy Tuteur
    http://layscience.net/node/878

  58. Let’s take a closer look at the scientific issues:

    1. There is copious scientific evidence that circumcision lowers the risk of transmission of HIV and a variety of sexually transmitted diseases including herpes and HPV. There is some evidence that circumcision of protective against cervical cancer and penile cancer, both associated with HPV.

    There’s really not much doubt about the protective effect of circumcision. So the next issue is whether the impact of circumcision would justify recommending it.

    2. What is the estimated benefit of instituting routine circumcision in a high prevalence population?

    As mentioned above, the NNT for is 72 circumcision to prevent one case of HIV.

    According to Weiss et al (Male circumcision for HIV prevention: from evidence to action?):

    “assuming full coverage, male circumcision could avert 2.0 (95% CI 1.1–3.8) million new HIV infections and 0.3 (95% CI 0.1–0.5) million deaths over the next 10 years in sub-Saharan Africa, and 3.7 million (95% CI 1.9–7.5) new HIV infections and 2.7 (95% CI 1.5–5.3) million deaths in the following 10 years.”

    Those are not trivial numbers. They would have a major impact on the spread of HIV.

    3. What about a low prevalence population?

    The answer to that question is not as straightforward as anti-circ activists claim. That’s because countries with low prevalence of HIV tend to have high rates of circumcision already. Such high rates of circumcision may be contributing to the low prevalence.

    As Weiss et al. explain:

    “Countries with very high or universal coverage of male circumcision have, without exception, relatively low and stable HIV prevalence which has never exceeded approximately 6%. The importance of male circumcision in ‘containing’ the HIV epidemic was highlighted in the Four Cities’ Study [43], which found higher levels of reported risk-taking behaviour in Yaounde,the capital city of Cameroon, where prevalence has been fairly stable at below 7% for many decades, compared with Kisumu, Kenya and Ndola, Zambia where HIV is more prevalent. The authors concluded that biological cofactors
    for HIV transmission, notably male circumcision and herpes simplex virus type 2 infection,were likely to be key factors in the HIVepidemic in sub-Saharan Africa and this has been confirmed in subsequent modelling of the data.”

    So it far from clear that circumcision does not have the same impact in low prevalence countries. The low prevalence may be a result of high circumcision rates.

    4. What are the harms of circumcision, and how do they compare to the benefits?

    A Trade-off Analysis of Routine Newborn Circumcision, a study done before the latest data was obtained from Africa reviewed circumcision over over 100,00 male neonates in the US reported:

    “Overall 287 (.2%) of circumcised children and 33 (.01%) of uncircumcised children had complications potentially associated with circumcision coded as a discharge diagnosis. Based on our findings, a complication can be expected in 1 out every 476 circumcisions. Six urinary tract infections can be prevented for every complication endured and almost 2 complications can be expected for every case of penile cancer prevented.”

    5. Do these data mean that we should recommend routine neonatal circumcision in low risk countries?

    In my judgment, at the moment there is no enough data to recommend routine neonatal circumcision in populations with low prevalence of HIV. However, if decreasing rates of circumcision lead to increased prevalence of HIV, that issue would need to be revisited.

    In summary, the benefits of neonatal circumcision are real, definitely make a difference in populations with high prevalence of HIV, and may make a significant difference in populations with low prevalence of HIV. That doesn’t even address the benefits that may accrue from decreasing transmission rates of other STDs, particularly HPV, known to be associated with cervical cancer and penile cancer.

  59. Lawrence C. says:

    snfraser notes: “This isn’t physics or chemistry. Medical science is messy.”

    Perhaps, but medical science writing needn’t be messy as this article and the majority of comments are. Kind editorial assistance for the former and some more minutes of thought before the latter hits “submit comment” would do the world a world of good.

    Alison Cummins later notes: “What’s frustrating about Amy is that she doesn’t explain things…and sits back and waits for the complaints.”

    Some people’s style resembles that of the provocateur. For subjects without so many footnotes available and studies to cite, this is often an effective way to draw attention to something. However, in medical science matters, it’s most often used by those without a firm grasp of their subject matter. I don’t think this is the case with Dr. Tuteur but rather a problem of style not being well suited to the substance. If the intent is to educate then the most effective means should be used. If the intent is to get page hits and “controversy” going then anything goes but goes away quickly without much beneficial long-term impact.

  60. “Having read most of the comments posted here I have to say, this discussion would make an interesting sociological experiment. It is quite interesting to note that individuals who would probably discuss vaccination or homeopathy in a quite dispassionate manner seem to devolve into ranting and raving when discussing the aspects and choice of circumcision, especially when the author of this article never calls for an end to parental choice.”

    I agree (not surprisingly).

    I was never particularly supportive of routine neonatal circumcision for health reasons, but new data has challenged my old assumptions. The issue is whether we are willing to go where the scientific evidence takes us.

  61. Robert Samson says:

    Oh, lord not yet another forum where American medical industry personnel are trying to convince people that there are any scientifically credible benefits for circumcision–I thought this was debunked at another forum by Harriet Hall.

    There, as well, as here, some think merely having a study deems it scientifically credible. Also that OPINIONS by organizations profiting from this unnecessary procedure can hardly be considered EVIDENCE.

    Notice also, that the questions of ethics of inflicting an unnecessary procedure on unconsenting infants are not being addressed..nor the proven harm and proven risks of this unnecessary FORCED procedure.

    If people here wish to actually defend this practice, they better start with trying to justify it with PROVEN facts and evidence.

    Perhaps people might wish to see what REAL science has to say on the subject..

    http://mysite.verizon.net/dortfay/science.html

  62. Harriet Hall says:

    I think Jason is right – I don’t think the AAP ever recommended routine neonatal circumcision.

    Amy, when you said “The AAP had long recommended male circumcision for prevention of urinary tract infections in young boys,” did you mean to say they had long acknowledged that it was effective in preventing UTIs?

  63. Robert Samson says:

    “I was never particularly supportive of routine neonatal circumcision for health reasons, but new data has challenged my old assumptions. The issue is whether we are willing to go where the scientific evidence takes us.”

    What is this SCIENTIFIC EVIDENCE? Specifically evidence that satisfy the criteria for being scientifically credible–merely having flawed and questionable studies does not automatically confer credibility.

    PLEASE provide even ONE single scientifically credible benefits for circumcision..scientific, not just medical evidence…they are not the same!

    http://mysite.verizon.net/dortfay/science.html

  64. joep says:

    Amy said: “3. What about a low prevalence population?

    The answer to that question is not as straightforward as anti-circ activists claim. That’s because countries with low prevalence of HIV tend to have high rates of circumcision already. Such high rates of circumcision may be contributing to the low prevalence.”

    Well to start off this is certainly not true. Circumcision outside of the US (and perhaps Canada to an extent too) is practically unheard of. So Amy, which European country, for example, where rates of circumcision in the population are easily below 5%, has higher HIV prevalence than the US?

  65. Plonit says:

    That’s because countries with low prevalence of HIV tend to have high rates of circumcision already. Such high rates of circumcision may be contributing to the low prevalence.

    ++++++

    Please can you give some evidence for this assertion.

  66. Amy Tuteur, MDon 07 Jan 2010 at 4:29 pm

    Perfect! A look at the science and a discussion of how they might relate to the real world. Exactly what I hope for from SBM.

    (Well, almost perfect. We have NNT and also NNH—newborn but not NNH—adult.)

    Amy, I’m truly curious. If you can write a clear, interesting and informative resumé of the science, why don’t you do it more often? Is your goal with your SBM really just to generate complaints — including complaints from people who agree with you? (In other words: are your posts deliberate trolls?)

  67. Zoe237 says:

    “The answer to that question is not as straightforward as anti-circ activists claim. That’s because countries with low prevalence of HIV tend to have high rates of circumcision already. Such high rates of circumcision may be contributing to the low prevalence.”

    That’s not true either. Many countries in Europe and Japan have low circumcision rates and low rates of HIV. In fact the US. has one of the highest HIV rates of the developed world. And highest circ rates.

    I’m also questioning the confidence intervals in the Weiss report (and whether the data matches the conclusions), but it’ll have to wait until later when I can actually read it.

    Interesting about the AAP positions through the years too. Honestly, I’m wondering if Dr. Tuteur said it was raining, I should go outside to check.

  68. joep says:

    Amy said: “The issue is whether we are willing to go where the scientific evidence takes us.”

    And if there is data to suggest it is necessary in the neonatal period then we can examine the strength of that data and whether the intervention meets the normal ethical standards practiced in medicine. At this point we are far from that place.

  69. Robert Samson says:

    OK, now I am wondering if there is censorship going on here..I posted two comments–one apparently never made it through moderation (yet never even shown as awaiting moderation), and the second is now awaiting moderation–can I expect to see either one make it through your process?

    IF they do not make it through moderation, will I be informed as to why not?

  70. David Gorski says:

    I think Jason is right – I don’t think the AAP ever recommended routine neonatal circumcision.

    I concur. It doesn’t look to me as though the AAP ever recommended routine neonatal circumcision, at least not within the last 40 years.

  71. David Gorski says:

    In my judgment, at the moment there is not enough data to recommend routine neonatal circumcision in populations with low prevalence of HIV.

    I’m afraid that’s not the impression you gave with your original post.

  72. EricG says:

    @ Allison Cummins

    – Eric G,
    “the docs are accountable to present the evidence as it is appears. do with it what you will.”

    -AC
    “Actually, doctors are accountable for interpreting the science for us, not just list PubMed references. This is hard to…”

    How about:

    the docs are accountable to present *and interpret* the evidence as it appears. do with it what you will. ??

    a quibble, but point taken.

    i hope no one here thinks that a doctor’s opinion/assessment/advice precludes their own autonomy…given the trivial nature of the issue…well, carry on.

    I suspect it’s more that we all want validation that we are “doing the right thing.” No one *wants* to be wrong.

    @ archangl508

    “As a matter of fact I do not even give it any thought whatsoever, ”

    Ditto. much ado about nothing.

  73. mjrobbins says:

    Amy Tuteur: “I agree (not surprisingly).”

    Then why did you write your post in such an aggressive fashion? You flat-out accuse the AAP of manipulating the evidence on the basis of pressure from “anti-circ activists” in their 1999 policy statement, yet you’ve failed to address that statement, or the evidence in it, and explain where they went wrong.

    You must realise that you can’t make these sorts of unevidenced accusations, then claim that it’s just your opponents who are ‘ranting and raving’?

    At the very least, you need to address the evidence presented by organizations like the AAP – who based on far more substantial reviews of the current literature than you’ve provided continue to find the totality of the evidence not strong enough to recommend routine circumcision – rather than simply asserting that you’re right on the basis of hand-picked individual studies.

    It’s also worth noting that you have still not addressed the question posed by the article’s title, and by a number of commenters – what is the case for *neonatal* circumcision? The last time I checked, most infants don’t have a lot of sexual partners, and won’t do until their mid-to-late teens. Why deny them choice? Why not wait until they’re old enough to decide for themselves what precautions they would like to take?

  74. EricG says:

    well, one thing is for sure. Dr. T, you sure know how to generate some traffic!

  75. joep says:

    I do find it interesting that among developed countries the US is the only one that is really thinking about circumcision and HIV with regard to their population. Articles like this give an interesting perspective on how those from countries where circumcision is rare see our zeal to justify the practice:

    http://news.bbc.co.uk/2/hi/health/7960798.stm

    “Dr Colm O’Mahony, a sexual health expert from the Countess of Chester Foundation Trust Hospital in Chester, said the US had an “obsession” with circumcision being the answer to controlling sexually transmitted infections.”

  76. Plonit says:

    I’m afraid that’s not the impression you gave with your original post.

    ++++++++

    @David Gorski

    Surely this is within your remit, as managing editor of this site?

  77. David Gorski says:

    OK, now I am wondering if there is censorship going on here..I posted two comments–one apparently never made it through moderation (yet never even shown as awaiting moderation), and the second is now awaiting moderation–can I expect to see either one make it through your process?

    IF they do not make it through moderation, will I be informed as to why not?

    You probably triggered the spam filter somehow. As you can see, I released your comments, as I do nearly all nonspam comments that get caught up in the spam filters.

    Be aware, however, that I do not sit at my computer all day doing nothing but moderating comments so that commenters like you do not have to wait one second to see your comment appear. I have a very demanding day job. Generally, during business days I check every few hours if I can. If it’s a day that I happen to be busy in the O.R. or clinic, it can take several hours before I get around to checking the spam filter. Be patient. Just because your comment got hung up for moderation and I didn’t get to it for–gasp!–nearly a whole hour does not mean there is any “censorship.”

    Yes, I’m being sarcastic. Commenters insinuating that they are being “censored” (presumably because they are disagreeing with one of our bloggers) brings that out in me. Mea culpa. No, on second thought, I make no apologies. Just be aware that censorship of that sort is a characteristic of CAM blogs and anti-vaccine crank blogs like Age of Autism, not of Science-Based Medicine.

  78. joep says:

    mjrobbins said:

    “Why deny them choice? Why not wait until they’re old enough to decide for themselves what precautions they would like to take?”

    I think it’s because when you present the issue to most rational thinkers as, to reduce your risk of HIV you should:

    Get circumcised, always wear condoms, and be choosy about your sexual partners.

    or

    Always wear condoms and be choosy about your sexual partners

    The first choice isn’t too compelling. “Minor” surgery is always surgery performed on someone else.

  79. Hugh7 says:

    So far as I know, the AAP has never recommended non-therapeutic circumcision. It has only adjusted its position on the fence from time to time.

    The supposed correlation between intactness and UTIs was only discovered in 1982, long after the custom of circumcision was well-established in the US. Ironically, all the 1982 paper did was quite casually note that “95% of the [male] infants [with UTI] were uncircumcised.” without mentioning that virtually no babies born at that hospital (Parkland in Dallas, Texas) were circumcised. The paper went on: “All infants responded promptly to antimicrobial therapy.”

    The main proponent of circumcision to prevent UTIs has been Thomas Wiswell, but his huge sample sizes (in the hundreds of thousands) were not random, being all born in military hospitals, where intactness would have been rare and largely confined to premature babies. In fact the huge sample sizes raise doubts about his methodology.

    “parents who choose to circumcise their sons are “mutilators”. In more than 10 years in the Intactivist movement, I have NEVER seen that descriptor for parents, only (rarely) doctors.

    A good critique of the three RCTs for HIV is at http://www.futuremedicine.com/doi/full/10.2217/17469600.2.3.193

    “These findings are also supported by observational studies conducted in the United States.” Many studies in the US have failed to find any such correlation. For example, Zenilman et al. found “Women with uncircumcised current partners are not at increased risk for B[acterial] V[aginosis].” (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758232/) News stories often headline non-significant correlations, or correlations in small, high-risk subgroups, as though they were significant or generalised.

    A flurry of pro-circ studies has come out in the last few years, but strikingly all from the same small group of researchers (Daniel Halperin, Robert Bailey, Stefan Bailis, Stephen Moses, Malcolm Potts, Ronald Gray, Thomas Quinn, Helen Weiss, Brian Morris, Jeffrey Klausner, Edgar Schoen, Thomas Wiswell and a handful of others. Sure enough, this one is by Gray and Quinn.)

    The Ugandan study found no difference in sexual satisfaction after circumcision, because it found virtually perfect sex in almost every man both before and after circumcision. This does not correlate with findings in the developed world. Either Uganda is a sexual paradise, or the questions were too insensitive to find any difference.

    Though they are inclined to stay silent in the US, men with foreskins generally appreciate having them for the direct sexual pleasure they give (described as not just “more sensitive” but “a symphony of sensation”) and would not willingly give them up.

    Stunningly absent from all this is any consideration of the ethics of non-therapeutic surgery on neonates. Judging by the sales of devices, many tens of thousands of men are unhappy about what was done to them, and go to considerable trouble to reverse it. Changing the policy will increase that number.

  80. geskoi says:

    “Why does the issue of what other parents choose for their sons generate so much heat?”

    The reason is because it was not the victims’ choice. It is sexual abuse to amputate sexual tissue from an infant, whether it be male or female. Imagine being the victim of a circumcision you didn’t want. Imagine that your sexuality is affected.

    How can you possibly question that sex is important to men? How can you possibly know that circumcision didn’t affect any particular man’s sex life? The only sensible thing is to leave the poor infant alone, and let the man decide when he is of age.

  81. joep,

    “The first choice isn’t too compelling.”

    I think it depends very much on how many of your friends, relatives and sexual partners have died horribly of AIDS. My understanding is that many Ugandans are actually quite keen on anything that will reduce their risk, including circumcision.

  82. FYI:

    If I post a comment that doesn’t immediately show up, and I really want it to be a part of the discussion right way, I can usually figure out what likely triggered the holdup (key words, too many links, etc- it’s not too hard to figure out) and compose a substitute comment to suffice until the original gets approved.

  83. joep says:

    @Allison

    Indeed, which is why this is a context sensitive and individual decision. I wouldn’t begrudge a teen or adult in that situation or not to make that decision so long as the choice is his. However, if I noticed my friends dropping dead around me from HIV and knowing the efficiency of condoms, I sure wouldn’t ever forget it.

  84. “where rates of circumcision in the population are easily below 5%”

    You need to distinguish between current rates of neonatal circumcision and prevalence of circumcision within sexually active populations. While the rates of neonatal circumcision have been declining in a number of first world countries, prevalence of circumcised adults males is still quite high.

  85. Plonit says:

    You need to distinguish between current rates of neonatal circumcision and prevalence of circumcision within sexually active populations. While the rates of neonatal circumcision have been declining in a number of first world countries, prevalence of circumcised adults males is still quite high.

    +++++++++++

    Some citations please!

    What are you defining as ‘still quite high’? Can you name some of these ‘first world countries’?

  86. magra178 says:

    Thank you Dr. Tuteur, I enjoyed your article very much! I think parents having boys should be informed and consider both sides before making their decision. As Africa and India face AIDS epidemics, is circumcision being recommended and are rates increasing in these areas? (I read where you said it “should” be recommended in areas with high HIV rates, but was unclear if any of those areas are recommending it).

  87. joep says:

    Amy said: “You need to distinguish between current rates of neonatal circumcision and prevalence of circumcision within sexually active populations. While the rates of neonatal circumcision have been declining in a number of first world countries, prevalence of circumcised adults males is still quite high.”

    Current rates in most first world countries haven’t changed in generations because it’s never been common in places like continental Europe among others. Yet they have among the lowest rates of HIV prevalence.

    You might be right about England where it was somewhat common until 1948 after which the rates of neonatal and child circumcision declined significantly. Neonatal rates there are easily under 5% and it’s in fact quite difficult to find a doctor willing to do it. I doubt the prevalence in the adult population is much more than 20%, mostly men born before the 1960s. It is perhaps a bit higher in New Zealand (they didn’t start to discourage it until the 1960s) now the neonatal rate is less than 1% and the adult prevalence is perhaps now below 50% and Australia where it is 10% and 50%.

    So what you say might be true for Anglican countries but of those who practiced circumcision at one time in the recent past (England, Australia, and New Zealand) most discontinued it and those men at highest risk (say 25 – 35) are predominately not circumcised.

    Further most of the relevant medical authorities in those countries don’t seem quite as persuaded by the effectiveness of circumcision in their populations.

  88. Annabel says:

    “You need to distinguish between current rates of neonatal circumcision and prevalence of circumcision within sexually active populations. While the rates of neonatal circumcision have been declining in a number of first world countries, prevalence of circumcised adults males is still quite high.”

    http://hivinsite.ucsf.edu/global?page=cr-00-02

    Look at the HIV prevalence in Japan, China, Greece, Finland, Vietnam, Russia. None of these countries have ever routinely circumcised infants and they maintain some of the lowest HIV rates in the world.

    The majority of babies haven’t been circumcised in the UK since the 1950′s when campaigns were done to show that there was no medical need to perform them on infants. As it is now 2010, it is safe to say that the majority of men 18-55 are not circumcised in the UK, and they have a lower prevalence of HIV than the US.

  89. Kausik Datta says:

    @Karl:

    I can usually figure out what likely triggered the holdup (key words, too many links, etc- it’s not too hard to figure out)

    Good for you that you can figure it. I have had this happen to me with the most innocuously worded post, without any hyperlink. Possibly it has something to do with the Spam filtering plugin that this version of WordPress is using. But I agree that there is no censorship going on. As David indicated, that is the policy of crank, pseudoscience sites like AoA and AiG.

    @Plonit:

    Surely this is within your remit, as managing editor of this site?

    In the same vein, all the authors of this SBM blog are responsible for determining the accuracy and veracity of what they post, and any reaction their post generates are to be handled by them, too. It is not David’s function – even as managing editor of the site – to censor or sanction posts. He would rather – heck, I’d rather he did – encourage a debate based on the scientific merit of the post, and argue points of evidence – which he did and does adequately.

    @Dr. Tuteur: I am intrigued by the accusation of false equivalences by you towards those who are protesting the reason for routine neonatal circumcision. At random, let me take the figures from a 1990 paper in the American Journal of Epidemiology, which stated that in the US, the lifetime risk of appendicitis was 8.6% for males and 6.7% for females; the lifetime risk of appendectomy is 12.0% for males and 23.1% for females. Going by your logic for advocating neonatal circumcision, would it also not justify neonatal appendectomy?

    The issue of circumcision is bound to raise emotions, since it is often firmly linked to religious and cultural practices. Adult circumcision is different; the adults have a choice.

    I don’t much buy the lack of neonatal choice argument, since (a) neonates are incapable of conscious, informed consent, making the point moot, and (b) parental consent is considered sufficient for a plethora of difficult decisions in favor of invasive practices when medically warranted. But alone on the off-chance that the person in his adulthood would be exposed to STDs and HIV by engaging in risky behaviour, can the routine deployment of this procedure be justified?

  90. Kausik Datta says:

    Annabel’s sound question above is IMO very pertinent.

    http://hivinsite.ucsf.edu/global?page=cr-00-02

    Look at the HIV prevalence in Japan, China, Greece, Finland, Vietnam, Russia. None of these countries have ever routinely circumcised infants and they maintain some of the lowest HIV rates in the world.

    The majority of babies haven’t been circumcised in the UK since the 1950’s when campaigns were done to show that there was no medical need to perform them on infants. As it is now 2010, it is safe to say that the majority of men 18-55 are not circumcised in the UK, and they have a lower prevalence of HIV than the US.

    Could you please address this, Dr. Tuteur?

  91. Plonit says:

    The prevalence in the non-religious circumcision in the UK adult population is estimated to be 6% (UNAIDS figures, 2007).

  92. Plonit says:

    It is not David’s function – even as managing editor of the site – to censor or sanction posts.

    ++++++++++++++++

    Sanction is in the form of inviting someone to become a contributor to SBM, which suggests that minimal standards of accuracy and veracity will be upheld as a matter of course.

  93. “At random, let me take the figures from a 1990 paper in the American Journal of Epidemiology, which stated that in the US, the lifetime risk of appendicitis was 8.6% for males and 6.7% for females; the lifetime risk of appendectomy is 12.0% for males and 23.1% for females. Going by your logic for advocating neonatal circumcision, would it also not justify neonatal appendectomy?”

    In general, parents choose circumcision for non-medical reasons, often religious, cultural or just to have sons “look like” Dad. Rarely do parents choose circumcision for medical reasons, and I don’t think the data on STD transmission is strong enough to recommend routine neonatal circumcision for public health reasons.

    My main point is that the accusation that circumcision has no medical benefit is simply untrue. I have emphasized all along that if individuals don’t wish to circumcise their sons, they shouldn’t do so. But those who do wish to circumcise should not be vilified for “mutilating” their children with no medical benefit.

    As regards appendectomy, if removing the appendix were as simple as removing the foreskin, I suspect it would be recommended as a routine preventive health measure.

  94. Jason says:

    My gosh, this disinformation just flows out: “While the rates of neonatal circumcision have been declining in a number of first world countries, prevalence of circumcised adult males is still quite high.”

    Dr Tuteur has successfully sidestepped the point being made by fudging about ONLY Canada, Australia and New Zealand with the vague phrase “a number of first world countries”. Perhaps she would like to leave visitors with the impression that infant circumcision has been “prevalent” in developed countries at some time in the past. The truth is that infant circumcision has never risen above 2% in any Western European or developed Asian country, except for the England region of the United Kingdom and, of late, South Korea. And in England, neonatal circumcision rates never reached 35% and have been under 2% for more than 50 years.

    The comparison suggested was the US with Europe. Tuteur hemmed and hawed something about “a number of first world countries”. No. Circumcision is not practiced in Western Europe. It is disingenuous go to off on a tangent with veiled references to a couple of former British commonwealth countries (which have now followed the lead of the UK in abandoning infant circumcision).

    Approximately half of sexually active adult males in Canada and Australia are circumcised, and the percentage declines annually.

    The clear trend in developed countries with regard to circumcision is marked movement from low to much lower, with favorable outcomes.

  95. “Look at the HIV prevalence in Japan, China, Greece, Finland, Vietnam, Russia. None of these countries have ever routinely circumcised infants and they maintain some of the lowest HIV rates in the world.”

    The prevalence is affect by other factors besides circumcision. Perhaps in low prevalence environments where circumcision is uncommon, increasing circumcision may make no difference. However, that does not change the fact that circumcision does reduce transmission of HIV and other STDs.

  96. Jason says:

    To David Gorski and Harriet Hall:

    For clarification, the AAP’s 1971 Position Statement on circumcision was its first-ever pronouncement regarding the practice. That is why the chronology provided only went back that far.

  97. Plonit says:

    Perhaps in low prevalence environments where circumcision is uncommon, increasing circumcision may make no difference.

    +++++++++++

    And the logical corollary for low prevalence environments where circumcision is common? that decreasing circumcision may make no difference?

  98. “UNAIDS figures, 2007″

    Yes, the same report also concludes:

    “There is substantial evidence that male circumcision protects against several diseases, including urinary tract infections, syphilis, chancroid and invasive penile cancer, as well as HIV. However, as with any surgical procedure, there are risks involved. Neonatal circumcision is a simpler procedure than
    adolescent or adult circumcision and has a very low rate of adverse events, which are usually minor (0.2–0.4%). Adolescent or adult circumcision can be associated with bleeding, haematoma or sepsis, but these are treatable and there is little evidence of long-term sequelae when undertaken in a clinical setting with experienced providers. In contrast, circumcision undertaken by inexperienced providers with inadequate instruments, or with poor after-care, can result in serious complications.”

  99. Plonit says:

    Indeed, I have read the report. In fact, I commented (upthread) on one of the complexities alluded to in that paragraph: the difference between efficacy in controlled clinical trial settings and effectiveness in’ real life’ situations with lack of access to trained health professionals and safe equipment. A comment that you have chosen not address.

  100. geskoi says:

    “I have emphasized all along that if individuals don’t wish to circumcise their sons, they shouldn’t do so.”

    The problem is, where does that leave the poor victim that wishes to have his foreskin?

    Foreskin feels really good, anyone would want theirs, so you can’t preemptively take THEIR choice away.

Comments are closed.