Articles

653 thoughts on “The case for neonatal circumcision

  1. Annabel says:

    I think it’s also important to note that the vast majority of intact adult men don’t choose circumcision for themselves, even in the United States. I can’t find the link, but it was around 1 in 250 intact men ever need or want circumcision for themselves in the US, and the number is much lower in countries where circumcision is less common( if someone knows the link, I would appreciate it!). Even though the number is higher in the US than other countries, 1 in 250 is still a great minority of men. So is it ethical to perform a surgery that, statistically speaking, a boy most likely wouldn’t choose for himself given the choice?

    I understand that many parents feel that their rights are at stake on this issue. But children have rights, too. Their rights don’t come into effect once they are old enough to talk, they have rights the moment they are born, and the same rights as little girls. Why do I never hear an American parent lament the fact that their right to circumcise their daughter is taken away from them as well? Why do they so want the right to circumcise their son but not their daughter? Here is what the WHO says about FGM :

    “FGM is recognized internationally as a violation of the human rights of girls and women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person’s rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.”

    They then go on to list the different forms of FGM, a lot of which are understandably more severe than male circumcision. But not all. Here is what type four of FGM reads on the WHO website:

    4) Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

    If girls are have the right to physical integrity shouldn’t boys have the same rights?

  2. Zetetic says:

    Hmmmm…. Adult males asking for circumcision. In my 40+ years in healthcare, I’ve only encountered maybe a half dozen cases. Interesting reasons, some clinical and some sociological:

    - Girlfriend requested – they liked circumcized penis better (a couple of them)
    - An Indian (from India) who thought American girls like the circumcised penis more
    - Circ done to remove significant HPV warts
    - A phimosis correction

  3. Plonit says:

    If girls are have the right to physical integrity shouldn’t boys have the same rights?

    +++++++++++

    It’s a good question.

    I expect the explanation lies in the fact that at the time of description and legislation FGM was regarded as a continuum of practice ranging from pricking/incising through to the complete removal of clitoris and labia with infibulation. Law-makers would have found it difficult to proscribe some practices and not others, for fear of creating a range of legal defenses for more extreme practices. As I said upthread “if you allow Type Ia, then you can going to see a lot of intentionally ‘botched’ procedures to get around the law, especially given that Type Ia has always accounted for a small percentage of procedures amongst a much more damaging continuum.”

    Contrast this with male circumcision. With the exception of castration (not practised today, AFAIK) there is no continuum of male genital surgery. Or rather the continuum involves removing more or less of the foreskin, making all male circumcisions equivalent to Type Ia. If the practice of penectomy (structurally equivalent to Type Ib FGM) or removal of the penis and scrotum (structurally equivalent to Types II & III FGM) were current and widespread, then I could imagine that removal of the male foreskin might similarly be outlawed, as a by-product of the campaign to erradicate the more extreme practices.

    The different treatment of male and female prepuce in terms of legal protection may be more a consequence of this difference in context (i.e. existence of Type Ib, II & III FGM, for which there is no current analogous practice in men) rather than intentionally unequal treatment. Indeed, had all FGM been of the Type Ia variety, I find it hard to believe that it would ever have been outlawed.

  4. Annabel says:

    “I expect the explanation lies in the fact that at the time of description and legislation FGM was regarded as a continuum of practice ranging from pricking/incising through to the complete removal of clitoris and labia with infibulation.”

    I have to disagree with some of your statements. There was a case in the United States where a Somalian family wanted just a ceremonial prick done to their daughter, and it was deemed illegal to do so. (http://www.law.duke.edu/shell/cite.pl?47+Duke+L.+J.+717)

    I doubt many would argue that a small needle prick is less dangerous and causes less psychological harm than complete removal of foreskin. A pin prick most likely wouldn’t leave any long term scars or physical markings. I also don’t really see how a pin prick performed by a competent surgeon could result in the accidental removal of the clitoris. Removal of the clitoris would require some sort of scalpel incision. Sure, I can accept that there is an extremely miniscule chance that the pin prick could get infected resulting in the loss of other structures, including the clitoris. I would argue that the chance of that happening is at least as likely and probably smaller than the chance of a penis getting amputated during a routine circumcision. Why is the risk of a clitoris getting amputated unacceptable but the risk of a penis getting amputated acceptable? When parents of females want to have the surgery done on their daughters for many of the same reason parents want the surgery done to their sons? Why the double standard?

  5. Plonit says:

    I was speculating as to the intent of legislators, that is to say – they wanted to avoid a legal loophole, given the existence of more damaging forms of FGM. In discussing intentional ‘botching’ I was not referring to the risk of complications/errors, but to the risk of creating a legal loophole in which practitioners can deliberately perform Type Ib FGM, while claiming to have intended Type Ia.

    I don’t know the ins and outs of legal discussions having to do with the framing of anti-FGM legislation, but the existence of more serious varieties of FGM would seem to be at least part of the answer to your question about double standards.

  6. Annabel says:

    “In discussing intentional ‘botching’ I was not referring to the risk of complications/errors, but to the risk of creating a legal loophole in which practitioners can deliberately perform Type Ib FGM, while claiming to have intended Type Ia.”

    I don’t think there is any evidence to this claim. If you are talking about doctors intentionally botching female circumcision, I don’t think that is very plausible. The legal ramifications for such a thing would be astronomical, just as they would be for intentionally botching a male circumcision, and would not be worth it. It would be very hard for a doctor to explain how a pin prick to the labia resulted in an accidental removal of the clitoris. You would almost have to literally stab it until it was no longer functional.

    If you mean parents accidently botching a female circumcision, that already happens. Parents that want their daughter circumcised often resort to family members or local elders, and even fly to their home countries where the risk of complication is significantly higher. If anything, making it legal would be safer for girls from those countries living in the United States. Much like the argument that making abortion illegal would just make abortions more dangerous, as people would always find a way if they want it bad enough.

  7. Archangl508 says:

    “He started out supportive of circumcision for a potential son but when he really looked at the issue said he wouldn’t do it but at the same time couldn’t support a prohibition for many of the reasons you cite. ”

    That would be the place where I am. If I were to have a child I think I would carefully consider the various information and make the best choice for the child. But I would still want to have that choice to make. If the available information were to swing much farther towards the “harm” side of the issue, then I would join you in favor of prohibition of the practice.

    I also thank you for giving me something to think about and your reasoned responses. It was good to see that within a discussion that had previously seen much inflammatory, emotional language (that I was also guilty of; i.e. multilation/victim/etc.). That sort of discussion and use of rhetoric does nothing to help either side of the debate. All that does is inflame passions and shut down reasonable thinking.

    I wish you luck in finding better information to more securely prove your case and at that time I would be happy to support your position.

  8. Annabel,

    Just going waaay back to one of the numbers you presented.

    “Here are some numbers. The risk of a man contracting HIV from a woman, which is the only HIV route circumcision has proven to reduce risk, is .04% or .0004 in the United States. One in every 2,500 sexual acts. Exactly how many men do you think are going to be having sex 2,500 times before the age of 18 when they can make an educated decision for themselves about whether or not the risk reduction is worth it? Even the most conservative risk complication rate of circumcision is WELL above .0004.”

    If the chance of of a man’s contracting HIV during a a single, random encounter with a non-injection-drug-using woman is 0.04%, then after 2,500 encounters there’s a 63% percent chance he will have become HIV+.

    After 1,250 encounters the chance is 39%.
    625 encounters: 22%.
    26 encounters: 1%.

    But wait! The rate of 0.04% is for a combination of circumcised and uncircumcised men. Circumcision seems to reduce transmission by about 56%, and 75% of American men are circumcised. The rate should be about 0.03% for circumcised men and .07% for uncircumcised men.

    A circumcised man would have a 1% chance of contracting HIV after 33 random unprotected encounters with a low-risk woman.

    An uncircumcised man would reach a 1% risk after just 15 random unprotected encounters.

    There are many, many young men out there who will have had unprotected sex 15 times before their 18th birthdays. Is a 1% chance low enough?

    Remember, we are talking about 15 unprotected encounters with low-risk women in the US. We are not talking about high-risk partners or high-prevalence regions, and I’m working with your numbers.

    The theoretical, perfect-use level of protection condoms offer against pregnancy is 98% over the course of a year. If a couple are having sex twice a week, that’s 13 acts of intercourse that could have resulted in pregnancy. Working backwards, a perfectly-used condom seems to fail 0.16% of the time.

    At that rate, using a condom perfectly during sex with a low-risk female partner will result in 1% of diligent circumcised men seroconverting after 21,500 random encounters; a diligent uncircumcised man would not have to work quite as hard, reaching a 1% risk of seroconversion after 9,200 encounters. That still requires sex twice a week for 88 years, so that’s probably good enough.

    Real-world, typical-use failure rates of condoms are higher, however: 15% by the end of a year. So in the real world, at this rate 1% of ordinarily imperfect circumcised men would seroconvert after 2,700 random encounters; an ordinarily imperfect uncircumcised man would reach a 1% risk of seroconversion after 1,150 encounters — 11 years of sex twice a week. (Agreed, very few teenagers will reach 1,150 encounters by the time they are 18, but it’s not impossible.)

    Again, this math applies to low-risk partners in a low-prevalence region.

    These numbers are based on various assumptions, and they are all calculations. If they are accurate, it’s just by chance. The point is that if you aren’t familiar with probability they can work out to something quite different from what your intuition tells you. An average 0.04% chance of seroconverting after a single unprotected encounter sounds pretty safe. Most people would never think that’s equivalent to a 1% chance of seroconverting after 15 unprotected encounters if you’re uncircumcised. If a parent understands this, it is likely to shape their decision-making.

    There are men who remember being frisky and irresponsible teenagers and who think it’s likely their infant son will grow up to be a frisky and irresponsible teen too. Sure, you can lecture your kids about condom use. But there are parents who would be a lot more comfortable with the notion of their son having 33 unprotected encounters versus 15, before reaching a theoretical risk of 1%.

    You might not think it’s worth it, or fair, or ethical. But 15 unprotected encounters is not that many. And it would be unreasonable to forbid parents to take that into consideration.

    Yes, it would be much better if everyone were a perfect condom user; it would be best of all if young men never had sex before their eighteenth birthdays; and we would avoid the entire ethical dilemma if there were no reason to think that circumcision reduces transmission rates. But they aren’t, they do, and there is, at least for now.

  9. Annabel says:

    “If the chance of of a man’s contracting HIV during a a single, random encounter with a non-injection-drug-using woman is 0.04%, then after 2,500 encounters there’s a 63% percent chance he will have become HIV+.”

    You have misunderstood the study. Here is a paragraph from the study :

    “Pooling the data from studies in high-income countries, the researchers calculated that the risk of transmission from an HIV-positive man to his female partner was 0.08% per sexual act: in other words, it was likely to occur once every 1250 sexual acts. When it was the female partner who was HIV-positive, the male partner’s risk of acquiring HIV was 0.04% per sexual act – in other words, once every 2500 sexual acts.”

    I really don’t know how you get numbers like “After 1,250 encounters the chance is 39%.”

    That is an astronomical number. There isn’t any data from the CDC or WHO that shows a man has a 39 percent chance of getting HIV after 2500 sexual acts. Or that he has a 1 percent chance of contracting HIV after 26 sexual acts. Could you please provide the math or statistics that lead to this number?

  10. Robert Samson says:

    C’mon folks, can we have a little logic here..

    People who are trying to use the threat of HIV to promote circumcision, need to provide the following:

    Scientifically credible studies showing circumcision reduces HIV that have no KNOWN flaws.

    The prediction of reducing circumcision reducing fails to manifest itself every time?

    THESE are the crucial points that determine if a theory is scientifically credible and/or valid.

    Now all studies have many and fatal flaws,

    The real world stats show that this reduction does not always exist…in fact in many cases, the exact opposite.

    Now, since this supposedly a science-based discussion, we need to actually discuss the scientific aspects–merely repeating over and over the results of flawed studies hardly advances this discussion.

    Here is a link that actually looks at the scientific basis..so until and if people actually read and debate the critical points here, all we have is a lot of flooby dust being tossed into the air.

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

    So, can we expect this to be a science-based discussion or the back and forth of bogus and/or questionable science and invalid assertions?

  11. Robert Samson says:

    Discussing FGM vs. MGM, there seems to ba a lot of opinions and denial..

    Before people dismiss MGM as being less harmful than all of the forms of FGM, they need to include the more drastic forms of MGM..

    Subcision–slitting the penis down the length

    Yemeni circumcision–amputating the foreskin and flaying all of the skin from the navel to the crotch..

    Now can anyone find a form of FGM that is worse than this? If not, then the crucial question remains..
    RATIONALLY WHY is any form of FGM illegal yet MGM is legal?

  12. Annabel says:

    “Before people dismiss MGM as being less harmful than all of the forms of FGM, they need to include the more drastic forms of MGM..
    Subcision–slitting the penis down the length
    Yemeni circumcision–amputating the foreskin and flaying all of the skin from the navel to the crotch..”

    I think this is an interesting point. Especially in light of the arguments that Plonit makes that since more severe forms of female genital mutilation exist, all should be illegal because of the potential of “intentional botched circumcisions” that might be performed as a round about way of getting the desired result of the more severe forms of FGM.

    Now, I don’t think that either of those is plausible in the United States, because the legal ramifications that would ensue if a doctor was found to be performing intentional botched circumcisions for boys or girls would be astronomical. Losing a life’s worth of work and medical license and imprisonment for a surgery most doctors in the US would deem unethical seems implausible.

    But it does raise and interesting question : Why are ALL forms of female circumcision, even ones equivalent or less severe than complete removal of foreskin, illegal in the United States but not all forms of male circumcision? At least in the context of minors.

  13. joep says:

    @Alison

    With regard to chances of HIV infection in non-iv heterosexual men in low prevalence countries, the Australian Federation of AIDS Organizations estimated that the lifetime risk for those men in Australia is approximatly 0.02% which I believe is an upper bound. So the difference circumcision could make for an individual over there lifetime would be on the order of perhaps hundreths of a percent. I will provide the link when I can get it.

    I have, in the past, worked out that the risk in the US is about the same, a bit higher though since we don’t seem to do quite as well with regard to STD prevalence. Funny when we have an adult circumcision prevalence of at least 80%. *shrug*

  14. Annabel says:

    “With regard to chances of HIV infection in non-iv heterosexual men in low prevalence countries, the Australian Federation of AIDS Organizations estimated that the lifetime risk for those men in Australia is approximatly 0.02% which I believe is an upper bound.”

    Here is the information from that study :

    “An Australian-born man is estimated to have a 0.02% (0.0002) risk of HIV acquisition if he does not
    inject drugs or have sex with men.11 This very low risk means that the population health benefit of an
    intervention like generalised circumcision programs would be negligible. However it has been argued
    by Professor Alex Wodak in the mainstream press, that circumcision would play a valuable role in
    assisting to prevent the emergence/development of a heterosexually mediated epidemic in Australia.
    This view is not currently supported by a consensus or statement from any organisation currently
    involved in Australia’s HIV partnership. ”

    11
    This estimate was supplied by the National Centre in HIV Epidemiology and Clinical Research in February 2009, based on median lifetime
    partners, sexual acts within partnerships over time, estimated prevalence within the female population of 0.03-0.05%, and average transmission
    rates and condom use within partnerships

    (http://www.afao.org.au/library_docs/policy/BP09_Circumcision.pdf)

  15. Annabel, I didn’t misunderstand the study: I didn’t read it! (I do have to agree with Amy on this one: one needs to read the study oneself!) I relied on your quote of someone else who may have read a study fourteen years ago, and fed your numbers back to you.

    “‘A 1996 Wall Street Journal article on AIDS reports that the chance of contracting HIV from random unprotected sex with non-IV drug using heterosexuals is “smaller than the risk of ever being struck by lightening.”’ I think it’s safe to say that the risk of dying during a circumcision is greater than the risk of contracting HIV from a horny “slip up” with a non drug using heterosexual female.”

    and

    “Here are some numbers. The risk of a man contracting HIV from a woman, which is the only HIV route circumcision has proven to reduce risk, is .04% or .0004 in the United States. One in every 2,500 sexual acts. Exactly how many men do you think are going to be having sex 2,500 times before the age of 18 when they can make an educated decision for themselves about whether or not the risk reduction is worth it? Even the most conservative risk complication rate of circumcision is WELL above .0004.”

    If you misrepresent the numbers, then don’t complain when they are fed back to you incorrectly. If you meant to say (you and Amy are alike in this: you complain that people don’t understand what you mean to say, we very annoyingly respond to what you do say) “The risk of an HIV- man contracting HIV from an HIV+ woman, which is the only HIV route circumcision has proven to reduce risk, is .04% or .0004,” then you should have said that. Mentioning 2,500 sexual acts by a teenager is misleading, because those acts would all have to be with HIV+ women to correspond to your figures. If that is accurate, then you are saying that an HIV- man and an HIV+ woman could have unprotected sex twice a week for 24 years and the man would still have only a 63% chance of seroconverting. That’s miniscule. (Why do we even care if straight people in the US use condoms at all, then, since it’s a low-prevalence region? Is it just about the herpes?)

    Here is the math, based on your figures. (As I said previously, these are calculations. Reality is messy and may differ.)

    A man has a 0.0004 chance of being infected with HIV when he has sex with an HIV+ woman.
    He therefore has a 0.9996 chance of not being infected with HIV when he has sex with an HIV+ woman.

    To not seroconvert after repeated encounters, he needs to be in the 0.9996 category each time.

    After 1 encounter, he has a 0.9996 chance of not seroconverting. (Chance of seroconverting is 1-0.9996, or 0.0004.)
    After 2 encounters, he has a 0.9996*0.9996, or 0.9992, chance of not seroconverting. (Chance of seroconverting is 1-0.9992, or 0.0008.)
    After 3 encounters, he has a 0.9996*0.9996*0.9996, or 0.9988, chance of not seroconverting. (Chance of seroconverting is 1-0.9988, or 0.0012.)

    After 26 encounters, the chance of not seroconverting is 0.9996^26, or 0.9897. (Chance of seroconverting is 1-0.9897, or 0.0103, or 1%.)

    After 2,500 encounters, the chance of not seroconverting is 0.9996^2,500, or 0.3678. (Chance of seroconverting is 1-0.3678, or 0.6322, or 63%.)

    The math is correct, but the results are only as good as the inputs.

  16. Robert Samson says:

    Anabel, plausibility is irrelevant, as is intention and risks..

    IF the rationale for the banning of ALL forms of FGM is that MGM is less harmful, then the mere presence of a form of MGM worse than a minor form of FGM negates this rationale..

    And worse, if there is a more severe form of MGM than ANY form of FGM, then this is an irrational basis for banning FGM and not MGM..

    And the nail in the coffin for this excuse is that there IS a more severe form of MGM than any form of FGM.

  17. Robert Samson says:

    I am tired of people playing with numbers and not examining the basic scientific credibility of the claim of circumcision reducing HIV..

    Basic tenets of science: These can be used as a litmus test for claimed benefits.

    1. Conclusions based solely on known flawed data cannot be considered valid.
    2. All studies have known flaws – flaws of commission and/or flaws of Omission.

    Flaws = not scientifically compelling

    The worth of a theory is determined by its ability to make accurate predictions.

    No predicted reduction or elimination is found in the real world.
    Failure to fulfill prediction = not scientifically credible.

    The rates of these are HIGHER in many circumcising countries than in many intact countries, hence the alleged predictions are contradicted by empirical evidence. Unlike “medical science,” SCIENCE demands that prediction be fulfilled EVERYTIME to be credible.

    The link I provided earlier cited links to the flaws in the African studies..

    Here is the critical analysis of how well the theory fulfills its prediction..

    Failure of prediction-In science, it only takes ONE exception to invalidate a hypothesis or theory.

    Circumcision rates:
    Japan 10 % in all cultures…

    OR

    That even though people in Ethiopia can barely afford food and shelter, they can afford 88X the recreational drugs than Japan and 8X that of the USA.

  18. Annabel says:

    “IF the rationale for the banning of ALL forms of FGM is that MGM is less harmful, then the mere presence of a form of MGM worse than a minor form of FGM negates this rationale..
    And worse, if there is a more severe form of MGM than ANY form of FGM, then this is an irrational basis for banning FGM and not MGM..
    And the nail in the coffin for this excuse is that there IS a more severe form of MGM than any form of FGM.”

    I agree. Was that directed at me? I am a tad confused, because I agree with you.

  19. Annabel says:

    You said : “If you meant to say (you and Amy are alike in this: you complain that people don’t understand what you mean to say, we very annoyingly respond to what you do say) “The risk of an HIV- man contracting HIV from an HIV+ woman, which is the only HIV route circumcision has proven to reduce risk, is .04% or .0004,” then you should have said that. ”

    In my statement that you quoted I said :

    Here are some numbers. The risk of a man contracting HIV from a woman, which is the only HIV route circumcision has proven to reduce risk, is .04% or .0004 in the United States. One in every 2,500 sexual acts (http://www.aidsmap.com/en/news/E1249D29-0DDE-4CFF-9CC7-16B3FADB3E59.asp) .

    If you notice, I linked the study that I was referring to, so that people could read it if they had questions about the numbers. I obviously wasn’t intentionally trying to dupe people or I wouldn’t have linked the study. If anything, not saying HIV negative man and HIV positive woman would skew the results in favor of the pro circumcision group, as the chance that an average man getting HIV from an average women is lower than studies that show the risk of sexual relations with ONLY HIV positive women.

    As far as my question of ” how many men do you think are going to have sex 2,500 times before the age of 18 ” is a valid question. Let’s make up a number that when having sex with an average woman who may or may not be HIV positive a mans chance of contracting HIV is is 1 in 5,000. It makes sense to take the lesser of those two numbers ( 1 in 2500 vs 1 in 5,000) to demonstrate that even the most extreme case ( that every-time a man has sex it will be with an HIV positive individual ) it is still unlikely that he would accumulate that many sexual acts before the age of 18.

    But this is silly, why waste all this time over a few words when I linked the study I was referring to?

  20. Nick says:

    “I wondered how long the anti-semitic strain of anti-circumcision could hold back.

    Can we end the thread here? Or do we actually have to wait until someone says that doctors are worse than Nazis to call Godwin?”

    How is it anti-semetic to say that a Jewish doctor advanced the idea that circumcision reduced HIV.
    It just shows that there’s a obvious conflict of interest.

  21. Robert Samson says:

    “I agree. Was that directed at me? I am a tad confused, because I agree with you.”

    No, not at you at all–merely a succinct summation and examination of the rationale for the banning of FGM, and allowing MGM.

    I hardly think the rationale holds up to rational examination.

  22. Cochrane report on monogamous heterosexual seroconversion rates:
    http://apps.who.int/rhl/reviews/langs/CD003255ru.pdf

    If they never use condoms: seroconversion rates of 1.14 per 100 person-years (roughly 2 months to reach 1% risk and 7 years to reach 25% risk).

    If they always use condoms: seroconversion rates of 5.75 per 100 person-years (roughly 10.5 months to reach 1% risk and 38 years to reach 25% risk).

    If they sometimes or usually use condoms: they weren’t included in the study.

    They didn’t break this down by men vs women or by circumcised vs uncircumcised. The “nevers” seemed to have about the same rate of seroconversion in the US, Italy and Africa. The “always” folks varied from study to study, so they used the studies where the couples stayed together longest, which tended to be couples where the HIV+ partners were hemophiliac or transfusion patients.

    Whether looked at per act of intercourse or per year, *always* using condoms seems to reduce transmission rates by about 80% compared to *never* using condoms.

    Which is interesting to compare to the Kenyan and Ugandan studies where circumcision seems to reduce transmission rates by about 53% to 60%. If you think condoms (80%) are almost perfect, then circumcision (about 56%) is not that bad.

    Caveat: I did not read all the Cochrane report studies. Neither have I read the Kenya and Uganda studies.

  23. Robert Samson says:

    Nick, I agree, and frankly am tired of people throwing out the antisemitic term just because it is pointed out that a Jewish doctor started the circumcision/HIV speculation. Truth is truth–even if uncomfortable.

    If the Pope put out an article on abortion it would automatically be construed as a conflict of interest, so why should not this likely probability in the case of a circumcision speculation by a Jew–why should he get a special exemption?

    This whole antisemitic name-calling is simply another attempt to sabotage the discussion.

    Would it be more antisemitic to also point out that this speculation was promoted by other Jews?

  24. Robert Samson says:

    Sorry my post about the scientific credibility of the claim of HIV reduction by circumcision was truncated..

    the gist is that the discrepancy of prediction for the USA, Ethiopia, and Japan is 1100% and 8800% respectively.

    and that

    The largest acceptable error in science is 1 sigma = 5%

    Those advocating circumcision to reduce the incidence of HIV either ignore this empirical and contradicting evidence, or try to dismiss it with various excuses, like: Intravenous drug usage or homosexual activities.

    However, they never provide any hard numbers of these factors for various countries or a model that should include them to explain this discrepancy.

    For these excuses to be credible, one would need to assume:

    That the US has 11X as many homosexuals than Japan; and Ethiopia has 88X as many as Japan—when it is widely accepted that the rate of homosexuality is 5 –>10 % in all cultures…

    OR

    That even though people in Ethiopia can barely afford food and shelter, they can afford 88X the recreational drugs than Japan and 8X that of the USA.

  25. Robert Samson says:

    “Which is interesting to compare to the Kenyan and Ugandan studies where circumcision seems to reduce transmission rates by about 53% to 60%. If you think condoms (80%) are almost perfect, then circumcision (about 56%) is not that bad.”

    STILL trying to pretend that the African studies are scientifically credible?

    Do you plan to read the link debunking the studies and their prediction? or do you plan on pretending the information was not presented to you, and continue to play the questionable numbers game?

    Not reading the critical and crucial analysis of the information is a prime example of ignoring SCIENCE in this discussion.

    Until and if the information can be shown to be scientifically credible, all this back and forth is predicated on nothing objective…and essentially useless!

  26. Annabel says:

    “Which is interesting to compare to the Kenyan and Ugandan studies where circumcision seems to reduce transmission rates by about 53% to 60%. If you think condoms (80%) are almost perfect, then circumcision (about 56%) is not that bad.”

    First, I have seen studies that showed numbers higher than an 80 percent effectiveness of condoms. Second, condoms work for everybody. The 50-60 percent risk reduction is only applicable to heterosexual men who have vaginal intercourse with an HIV+ women, which is incidentally one of the rarest forms of HIV transmission in the United States. So 80 percent risk reduction for everybody is significantly better than a 60 percent risk reduction for a very specific group of individuals who are unlikely to get HIV regardless. Just because there is a difference of 20 percent between 60 and 80 doesn’t mean that condoms are only 20 percent better, when looking at the United States as a whole.

    I’d like to see studies that show how effective condoms are at preventing HIV when the woman has HIV and a man does not.

  27. Annabel, as I said, I should have read the study myself, but didn’t. I didn’t bother because I assumed (and I shouldn’t assume either) that you were linking to the old WSJ article you’d mentioned previously. (I have just pulled up the aidsmap article you linked to and it’s a plain-language article, not the published study.)

    The point I was making, and the reason I wasn’t too worried about where the numbers were coming from, was that even if 0.0004 sounds miniscule it can look surprisingly different when you bring frequencies into it. That’s all. It could have been 0.0001, or 0.00001, and I could have illustrated the same phenomenon.

    I am actually quite relieved that random sex with a low-risk woman doesn’t carry a risk of 0.0004 for a serodiscordant man! That would be huge, and the implications were worrying me.

  28. Annabel,

    “The 50-60 percent risk reduction is only applicable to heterosexual men who have vaginal intercourse with an HIV+ women, which is incidentally one of the rarest forms of HIV transmission in the United States.”

    Yes, you’re absolutely right. The big issue right from the beginning was how and why this finding should be applicable to AAP recommendations. Amy said the Uganda/Kenya studies should result in the AAPs revising their recommendations. It appears that she simply didn’t know what the AAP recommendations are, and was never able to be specific about what she thought should be revised.

    The thing is, when somebody says “everybody should be using condoms, condoms are almost perfect, nobody should be considering circumcision,” the words “everybody” and “nobody” mean Swazis and johns too unless you specifically exclude them.

    If someone is saying that the entire planet should reject circumcision because they don’t need it, because condoms are almost perfect, they really need to be able to address the figures of 80% vs 56%; the fact that some people are high risk; that some people do live in high-prevalence areas; that some risks can be known or estimated at the time a child is born.

    That doesn’t mean they will come to any particular conclusion. But it does mean we have numbers to talk about, which is what Science Based Medicine should be all about.

    I really wish Amy were able to come to the table with proper numbers and analyses thereof. I work in business and I’m flying by the seat of my pants. I want to understand the numbers, and I have a little bit of experience with rudimentary statistics, but I don’t know anything about the field. So I look here and there and play with a spreadsheet and talk about If Then (IF the odds are 0.0004 THEN 26 encounters is 15) but I don’t actually know if the odds are 0.0004 or what that means, for who.

    From the beginning, I’ve been asking how the Ugandan/Kenyan studies might affect decision making in the US, and I still don’t know. But I have learned that in the real world, the effectiveness of always using condoms appears to be not that far off from the effectiveness of being circumcised in preventing HIV transmission, which is absolutely not something I had expected to learn.

  29. Nick says:

    Why nobody talks about that adult circumcision was found to INCREASE the proportion of HIV in partners of subjects in Uganda ? Researchers abandoned the trial because of the “futility” of carrying on with it.

    “It was found that a higher proportion of women were infected with HIV in the intervention group (18%) versus the control group (12%).”

    Not to mention circumcised men are more likely not to use condoms because they rongly think they are protected from HIV. This is exaclty what is happening in Africa :

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

    It’s obvious that these researchers are more interested in promoting infant circumcision than a better HIV prevention.

  30. “It’s obvious that these researchers are more interested in promoting infant circumcision than a better HIV prevention.”

    That’s because the researchers make so much money from circumcision … oh, wait, they don’t benefit in any way.

    Maybe it’s because they want lots of people to die of AIDS so they are deliberately recommending useless (and evil) strategies … oh, wait, they don’t benefit in any way from more people getting HIV and dying of AIDS.

    What is it you are trying to say?

  31. Annabel says:

    “But I have learned that in the real world, the effectiveness of always using condoms appears to be not that far off from the effectiveness of being circumcised in preventing HIV transmission, which is absolutely not something I had expected to learn.”

    Why don’t you actually look at the fallacies of the African studies that others have linked before you come to this conclusion? the numbers 50 and 60 percent are questionable at best, and medical professionals are divided on the research.

    Not one other western country ( UK, New Zealand, Australia, and Canada) have been impressed with the studies done in Africa as it applies to their country.

    British Medical Assosiation :

    “There is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research”

    Royal Australasian College of Physicians revised statement in August 2009:

    “Recently there has been renewed debate regarding both the possible health benefits and the ethical concerns relating to routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, and in adults HIV infection and cancer of the penis. The frequency of these conditions, the level of protection offered by circumcision and complication rate of circumcision do not warrant a recommendation of universal circumcision for newborn and infant males in an Australian and New Zealand context.

    After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed”

    The College of Physicians and Surgeons of British Columbia, September 2009 revised statement :

    “Until recently, only public health and religious views were taken into consideration in the debate over infant male circumcision. However, our understanding of medical practice must change as research findings become available. The College is issuing this guide for physicians regarding routine infant male circumcision in light of evidence-based medicine and contemporary principles in ethics, law and human rights.

    Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention. From a religious standpoint, infant male circumcision is acknowledged to be an important ritual and an integral part of Jewish and Islamic religions. Male circumcision is also practiced in other parts of the world as a rite of puberty.

    Circumcision is painful, and puts the patient at risk for complications ranging from minor, as in mild local infections, to more serious such as injury to the penis, meatal stenosis, urinary retention, urinary tract infection and, rarely, even haemorrhage leading to death. The benefits of infant male circumcision that have been promoted over time include the prevention of urinary tract infections and sexually transmitted diseases, and the reduction in risk of penile and cervical cancer. Current consensus of medical opinion, including that of the Canadian and American Paediatric Societies and the American Urological Society, is that there is insufficient evidence that these benefits outweigh the potential risks. That is, routine infant male circumcision, i.e. routine removal of normal tissue in a healthy infant, is not recommended.”

  32. joep says:

    @ Alison

    “They didn’t break this down by men vs women”

    This is a very important distinction since efficiency of transmission is far greater from men to women, I’ve seen numbers up to 8 times. It also depends largely on viral load in the positive partner and whether there are coinfections present among other things. In fact, just last year, a group of Swiss researchers in their HIV agency completed a study and made the statement that condoms were not necessary for long term heterosexual couples that were serodiscordant (think married couples) where the positive partner is being treated. That is to say being on anti-virals was enough to make the positive partner non-infectious (other conditions applied such as coinfections status).

    If I recall though as far as condom vs. no condom there is at least an order of magnitude difference i believe this was discussed in: Reducing the Risk of Sexual HIV Transmission, Varghese et al, Sexually Transmitted Diseases, January 2002 if I recall.

    However, as noted above some organizations such as AFAO have provided lifetime estimations for risk of infection.

  33. “It also depends largely on viral load in the positive partner and whether there are coinfections present among other things.”

    Yes, that’s a very good point about the difficulty of assessing risk of seroconversion when the risk doesn’t depend primarily on the diagnosis of HIV/AIDS but on many other factors as well.

    “condoms were not necessary for long term heterosexual couples that were serodiscordant (think married couples) where the positive partner is being treated.”

    Right, which applies when the HIV+ partner is being treated. What if the HIV+ isn’t being treated, as is too often the case in poor countries? What should they do then?

  34. # Amy Tuteur, MDon 08 Jan 2010 at 5:47 pm

    [in response to Nick]

    “What is it you are trying to say?”

    He’s already said it a couple of times. Circumcision is a Jewish Conspiracy.

    Being as I’m of Irish Catholic descent, may I respectfully request that Nick be put on moderation? May I strongly urge it?

  35. Annabel says:

    “Being as I’m of Irish Catholic descent, may I respectfully request that Nick be put on moderation? May I strongly urge it?”

    Why? denying that there are biases in research is ignorant.

  36. Nick says:

    ““It’s obvious that these researchers are more interested in promoting infant circumcision than a better HIV prevention.”

    That’s because the researchers make so much money from circumcision … oh, wait, they don’t benefit in any way.

    Maybe it’s because they want lots of people to die of AIDS so they are deliberately recommending useless (and evil) strategies … oh, wait, they don’t benefit in any way from more people getting HIV and dying of AIDS.

    What is it you are trying to say?”

    The problem with the “studies” and the people behind them is that they’re not focusing on HIV prevention; their stated agenda has always been to legitimize circumcision. These resaerchers (Halperin, Bailey etc…) are known circumcision evangelists.

    1. This obsession of circumcision and the very idea that foreskin is something “wrong” is nothing ne in US. Circumcision in US has a long reputation for being a cure in search of a disease. HIV is just the latest candidate. Please read hoistory of circumcision : http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=31&Itemid=54

    2. Many reasons can explain this obsession. First : money.
    Circumcisions aren’t free. Doctors who circumcise must protect their reputations and careers especially when rates are decreasing in US.
    It’s a long chain of money making….first there’s the doctor who pockets the cash from the surgery, then there is the ped who sees the kid for meatal stenosis, who then refers the child to a ped urologist who does another surgery to open up his urethral opening, then there’s the personal lubricant industry who manufacturers something to help restore some gliding action taken away with the foreskin. Not to mention, neonatal foreskin is highly valuable to the medical industry. It is processed and sold in a variety of products ranging from beauty creams to artificial skin grafts.

    3. Second reason : tradition and culture. All doctors promoting circumcision are circumcised men. The fact that these men come from cultures where it is INFANTS that are circumcised tells me that the circumcision of infants was the target of their “studies” all along. The fact that the say HIV+ men should be circumcised to avoid having to reveal their status to them, the fact that they explain away the recent studies in women and insist men be circumcised anyway reveals to me that it is circumcision, not the reduction of HIV, with which they are concerned with.

    Much of their identity is based on circumcision. There is not a doubt that part of what drives these men is self-validation and a problem of ego.

    I don’t think we need to get into the trouble that circumcised men go to deny to themselves the fact that circumcision is needless mutilation, and that they were victims to it.

  37. Nick says:

    ““It’s obvious that these researchers are more interested in promoting infant circumcision than a better HIV prevention.”

    That’s because the researchers make so much money from circumcision … oh, wait, they don’t benefit in any way.

    Maybe it’s because they want lots of people to die of AIDS so they are deliberately recommending useless (and evil) strategies … oh, wait, they don’t benefit in any way from more people getting HIV and dying of AIDS.

    What is it you are trying to say?”

    Amy,

    The problem with the “studies” and the people behind them is that they’re not focusing on HIV prevention; their stated agenda has always been to legitimize circumcision. These resaerchers (Halperin, Bailey etc…) are known circumcision evangelists.

    1. This obsession of circumcision and the very idea that foreskin is something “wrong” is nothing ne in US. Circumcision in US has a long reputation for being a cure in search of a disease. HIV is just the latest candidate. Please read hoistory of circumcision : http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=31&Itemid=54

    2. Many reasons can explain this obsession. First : money.
    Circumcisions aren’t free. Doctors who circumcise must protect their reputations and careers especially when rates are decreasing in US.
    It’s a long chain of money making….first there’s the doctor who pockets the cash from the surgery, then there is the ped who sees the kid for meatal stenosis, who then refers the child to a ped urologist who does another surgery to open up his urethral opening, then there’s the personal lubricant industry who manufacturers something to help restore some gliding action taken away with the foreskin. Not to mention, neonatal foreskin is highly valuable to the medical industry. It is processed and sold in a variety of products ranging from beauty creams to artificial skin grafts.

    3. Second reason : tradition and culture. All doctors promoting circumcision are circumcised men. The fact that these men come from cultures where it is INFANTS that are circumcised tells me that the circumcision of infants was the target of their “studies” all along. The fact that the say HIV+ men should be circumcised to avoid having to reveal their status to them, the fact that they explain away the recent studies in women and insist men be circumcised anyway reveals to me that it is circumcision, not the reduction of HIV, with which they are concerned with.

    Much of their identity is based on circumcision. There is not a doubt that part of what drives these men is self-validation and a problem of ego.

    I don’t think we need to get into the trouble that circumcised men go to deny to themselves the fact that circumcision is needless mutilation, and that they were victims to it.

  38. Nick says:

    4. Trauma of circumcision :

    Persons who have lost body parts must grieve their loss.The first stage of grief is denial of the loss. Fitzgerald and Parkes state that “Anything that seriously impairs sensory or cognitive function is bound to have profound psychological effects, not only on the person who is affected but also on family, friends, workmates, and caregivers.” The thought of permanent loss of sensory function is so painful that persons deny their loss in order to avoid facing the painful feelings.41 Denial of loss causes a flight from reality. Parkes et al. state that persons in denial may minimize their loss. Circumcision causes the loss of a body part and all of its functions including a drastic loss of erogenous sensory function, so denial of loss is not uncommon in circumcised males. Van der Kolk identified a compulsion in traumatized persons to repeat the trauma. This frequently results in circumcised fathers adamantly insisting that a son be circumcised. And this is also true for all these circumcised reseaechers that promote “universal circumcision”. HIV is just a poor excuse to achieve their goals and legitimize circumcision.

  39. Annabel says:

    @ Amy

    Also, look up where the majority of erectile dysfunction medications are sold, such as viagra. If you don’t think that circumcising babies is a multi million if not billion dollar a year industry in the US, you are in denial or ignorant of the facts.

    “The May 1998 issue of Business Week provided a glimpse into this sadistic industry. “One piece of foreskin can produce four acres of engineered skin”. Skin that sells for more than $3,000.00 a square foot. The February 1998 issue of Wired magazine quotes one of these companies, “The cells from a single foreskin can produce 200,000 units of manufactured skin”. “That’s enough skin to cover about 250 people.”"

  40. Nick says:

    “He’s already said it a couple of times. Circumcision is a Jewish Conspiracy.

    Being as I’m of Irish Catholic descent, may I respectfully request that Nick be put on moderation? May I strongly urge it?”

    I’ve never talked about conspiracy. I just mention that the idea that circumcision prevent HIV came from a Jew : Aaron Fink.
    Claiming my posts are anti-semitic is a weak way to avoid a real debate about circumcision.

  41. “The problem with the “studies” and the people behind them is that they’re not focusing on HIV prevention; their stated agenda has always been to legitimize circumcision.”

    If it’s there stated agenda, then you should be able to provide their statements. Where are they?

    “Doctors who circumcise must protect their reputations and careers especially when rates are decreasing in US.”

    Can you name EVEN ONE HIV researcher, infectious disease specialist or public health professional who makes even a dollar from circumcision? Of course not.

    Do you even know who actually pockets the money from circumcision?

  42. Annabel,

    Unless you can show that the people who recommend circumcision for HIV prevention make any money from it, you’re just spouting conspiracy theories.

    Are you trying to suggest that it is the HIV researchers, infectious disease specialists and public health officials who are surreptitiously selling foreskins to industry? If so, you need to provide proof for such an outrageous accusation.

  43. joep says:

    Alison said: “Right, which applies when the HIV+ partner is being treated. What if the HIV+ isn’t being treated, as is too often the case in poor countries? What should they do then?”

    I agree this is a problem and as I’ve said before under certain situations I am not necessarily opposed to men being offered circumcision in high risk countries. In fact, like tattoos or piercings, I don’t care if men anywhere get circumcised for any or no reason. All I care about if infant/child what an adult does to themselves is their own business and their own problem.

    In the poor countries that we are talking about despite the possibility of circumcision being potentially useful I still have significant misgivings and I think there are problems that will get overlooked in the zeal to apply this high tech quick fix. For example:

    1. I am significantly concerned about men overestimating the level of protection and abandoning condoms all together. Hardly an article on this issue is written that doesn’t interview a bunch of mopes praising their new virtual condoms.

    2. I am concerned about women’s ability to negotiate safe sex when men over estimate the level of protective effect of their circumcision.

    3. I am not confident that circumcision at any level can be provided in countries where the doctor patient ratios are measured in the tens of thousands in some cases. Where do those with severe complications go?

    4. I am not convinced that this will be successfully combined with “other safe sex messages” such as condoms since as it stands most men in many of these places only have access to a small number of condoms each year. If we can’t deliver condoms how can we deliver circumcisions?

    5. I am concerned about the under reported phenomenon of nonsocial infections which is said to be a significant contributor to the HIV problem yet is under reported. A recent string of papers by Potterat et. al. in the International Journal of STD and HIV estimated at least 1 in 5 new infections in these countries are caused by that vector. How is a circumcision champaign in a place where clean water is a luxury going to manage this?

    6. One of the reasons stated for starting this champaign was to provide a way to get men into clinics to talk about the more effective strategies and get tested (but only if they want to get tested). If you then move to infants or children, when how will you then get the message to them?

    This is just a short list off the top of my head. Like I said I am not saying men shouldn’t be allowed to opt for it but the risk reduction in the west is vanishingly small and I think in poor countries there are a number of hurdles and unforeseen problems that I fully expect to get the bureaucratic push aside.

    If they want to go to the trouble of actually getting around to setting up clinics then make sure they have condoms, clean water, and access to testing for the whole population first. We’ve never even come close to that yet but we need all of those things anyway to support the potential of offering circumcision to men.

  44. Nick says:

    Since 1995, Dr. Bailey has devoted most of his research activities to the issue of male circumcision as a possible HIV prevention strategy. He has conducted circumcision-related studies in varying communities in Uganda, Kenya, Malawi, Zambia, and the U.S. He has studied adverse events and conducted needs assessments associated with medical and traditional circumcisions in Kenya.

    Dr. Bailey is the principal investigator of the randomized controlled trial of male circumcision to reduce HIV incidence in Kisumu, Kenya, and he has served as a consultant to WHO, UNAIDS, UNICEF, the World Bank, USAID, the CDC, and other national and international governmental and non-governmental agencies.

    This also wouldn’t be the first study he heads regarding circumcision. Robert Bailey has been trying to find the ultimate alibi for circumcision, and has been trying seriously hard to make HIV circumcision’s cash cow. He is known to get extremely frustrated when countries and municipalities reject his calls to implement mass circumcision. This man has an axe to grind. He is on a mission. He has a vested interest in rigging his “studies” and manipulating his figures, and it is written in plain sight that he has.

  45. “Robert Bailey has been trying to find the ultimate alibi for circumcision”

    Where is the evidence that he has received even one dime from circumcisions?

  46. Annabel says:

    @ Amy

    Are you implying that the only bias that could possible exist is one related to money?

    Look at this recent report :

    “Dr David Shaw, lecturer in ethics at Glasgow University, argues that circumcising boys for no medical reason is unethical.
    He wrote in the journal Clinical Ethics that any doctor who does perform circumcision without a medical reason could be guilty of negligence and in breach of the Human Rights Act as the child cannot consent to the operation and it can be argued it is not in their best interests.

    Dr Shaw wrote: “Imagine a situation where two adherents of a minority religion ask their doctor to pull off their son’s thumbnails, as this is part of the religion in which they want to bring up their son.
    “The pain will be transient, and the nails will grow back, but the parents claim that it is an important rite of passage. I think it is reasonable to say that the doctor would send them packing.
    “In the case of non-therapeutic circumcision, the foreskin will not grow back; why should this procedure be treated differently simply because of the weight of religious tradition?”
    The controversial view is likely to cause a storm among Jewish populations who routinely circumcise boys when infants.
    He said guidance to the medical profession on the issue from the General Medical Council and the British Medical Association are flawed and should be revised.
    He added that the only medical reason for circumsing men is that there is some evidence it may prevent HIV in countries where cases are very high but that will not be relevant for doctors working in Britain. ”

    “Non-therapeutic circumcision (NTC). The SMF continues its work towards ending NTC in the UK. At the end of November they chaired a meeting combining senior members from several organisations working to develop a joint strategy and action plan.

    The Daily Mirror reported on a 20 year old man initiating legal proceedings against the doctor who performed a NTC on him as an infant because of his parents’ religious beliefs. The young man has been in regular contact with the SMF.

    The Daily Telegraph reported on a paper recently published in the Journal Clinical Ethics concluding that current GMC and BMA guidance to doctors is itself unethical in that it allows parents to procure a non-therapeutic, irreversible surgical procedure on their children to satisfy their own religious beliefs. The author of the paper, Dr David Shaw, is a lecturer in ethics at Glasgow University.

    The SMF will be contacting both the BMA and the GMC asking them to revisit their respective guidelines. Members of the NSS may wish to contact their MPs, NHS trusts and local media to bring these developments to their attention and to raise public awareness. ”

    http://www.secularism.org.uk/116437.html

    It is a big fear for people of the Jewish faith that if they don’t maintain the idea that circumcision is medically beneficial, numbers will continue to drop and more questions are going to start being asked about the legality of infant circumcision. I think that this could clearly be a bias in research.

  47. Actually, Nick, it was you who said: “Many reasons can explain this obsession. First : money.”

    So if money comes first, show me the money.

    “It is a big fear for people of the Jewish faith that if they don’t maintain the idea that circumcision is medically beneficial, numbers will continue to drop and more questions are going to start being asked about the legality of infant circumcision.”

    That’s baloney, like so much else of what you’ve written. Circumcision is a religious obligation and medical benefit has nothing to do with it.

  48. joep,

    Many of the concerns you express relate to the difficulty of providing safe circumcision facilities.

    Upthread, Amy quoted a 2007 UNAIDS report as follows:

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

    What this means is that in regions with poor health care, neonatal circumcisions are simple enough that they can be done by the local health care provider, whoever that is.

    Adolescent or adult circumcisions are more difficult and need to be done in a properly supplied clinic with trained and experienced staff.

    While we might take these more complex health facilities for granted and assume that an adolescent or adult can access them as needed, this may not be true elsewhere. In these situations, the only way of ensuring that circumcision is available is to offer it to infants.

    I know many people have said that they “feel” or “think” that adult circumcisions must be easier to do than infant circumcisions, and that they simply disbelieve health care workers who say that really, it is more difficult to circumcise an adult. But nobody has actually cited research to show that circumcision is easier to perform on adults. So far, the information we have is that it’s less complex to circumcise an infant. Presumably it can be done at home by someone with a razorblade and a bottle of alcohol. The elaborate health infrastructure only really needs to be there if you’re going to restrict circumcisions to adults.

    No, it’s not perfect. It doesn’t have to be. It just has to be better than the alternative.

    Yes, of course there is pain and risk. That’s why it needs to be balanced against the pain and risk of the alternatives. In the US, the balance is not the same as in, say, Rwanda.

  49. Annabel says:

    “That’s baloney, like so much else of what you’ve written. Circumcision is a religious obligation and medical benefit has nothing to do with it.”

    First of all, I am not Nick. Second of all, circumcision is unique in that a parent of any other religious minority would not be allowed to permanently mark their child for religious reasons. Not a tattoo, not a small incision, not a small burn- nothing. A baby cannot say whether or not he is Jewish. There is no way of knowing whether or not he will want to be a part of the Jewish religion as an adult, therefore it is unethical. As long as people believe there is a medical benefit it will most likely continue to be a legal procedure. It would be unethical for doctors to say ” You can only circumcise your son if you are Jewish,” that would be discrimination. Either everyone can or everyone can’t. If there are no medical benefits, the procedure is likely to eventually fall out of favor in America like it has with every other Western country.

  50. joep says:

    @Alison

    I disagree with your assessment. Primary concerns focus on overestimation of effect, womens’ issues, and nonsocial infections, and infrastructure. If they may be doing it with a razor blade and a bottle of alcohol as you suggest then it’s worse than I thought.

  51. joep says:

    @Alison

    And just to give you a feel for the situation here is a report from last year that discussed the complication rates of circumcisions in medical settings in these ‘deployed’ clinics.

    http://www.aidsmap.com/en/news/03B54A29-5328-43FE-80D8-735C78D21F56.asp

    18% in medically performed ones.

    So how many urologists does this country have to clean up such a mess?

    I reiterate in a place where we have failed to provide basic services I don’t see how this will be successfully implemented. If they go after infants, I don’t see how they will “integrate” safe sex messages. And I don’t see how they will manage nonsocial infections.

  52. Nick says:

    “That’s baloney, like so much else of what you’ve written. Circumcision is a religious obligation and medical benefit has nothing to do with it.”

    The problem isn’t about medical benefits but basic human rights ang bodily integrity. Now, more and more peole are considering circumcision to be an ethical issue. FGM was banned recently in US (in 1996). Scandinavian doctors refuse to perform male circumcision without solid medical reasons. Several parliamentary parties are considering creating legislation that would spare all children from circumcision. Considering these facts, it’s important for religious authorities to find new excuses (like HIV prevention) to legitimize circumcision when it appears that religious reasons aren’t enough to perform infant circumcision.

  53. Nick says:

    “So if money comes first, show me the money.”

    I’ve already written how circumcision is a long chain of money making. There is money to be made in circumcision, not only for doctors, but also manufacturers of circumcision equipment, such as Gomco clamps, Circumstraints, PlastiBells, etc., not to mention that foreskins are sold to pharmaceutical companies, and not to mention there is a line of products created from the foreskins of children, for example, Oprah Winfrey’s SkinMedica.

  54. joep says:

    I just have to add Alison that with respect to the complications ect. The numbers cited must come from western (US) sources it’s the same figure used by the AAP, the British and Australians site about a 2% rate BTW. I have little doubt it will be higher in Africa as I have no faith in their health care delivery system to execute this plan any better than condom distribution, safe sex education, or really most anything else.

    But even given that a complication like minor bleeding might occur less often in an infant, the risk of a major complication for an adult is much less. For example, please provide me an example of an adult death in a western medical circumcision. I know I can find examples of infant deaths but I’ve never heard of an adult death.

  55. Joep,

    1. I am significantly concerned about men overestimating the level of protection and abandoning condoms all together.

    If men abandoned condoms (more effective) once they were circumcised (less effective), then infection rates would drop. That’s not what has been seen in the studies to date, which is why circumcision is now thought to be a health benefit in high-prevalence areas.

    2. I am concerned about women’s ability to negotiate safe sex when men over estimate the level of protective effect of their circumcision.

    In my experience, too often men are not worried about what they can transmit nearly as much as they worry about what they might catch. If a woman is thought to be STD-free, there’s a good chance she’ll have trouble convincing a male partner to use condoms no matter where she is in the world. I don’t see circumcision changing that.

    3. I am not confident that circumcision at any level can be provided in countries where the doctor patient ratios are measured in the tens of thousands in some cases. Where do those with severe complications go?

    Nowhere. Ditto those with AIDS. If you are more likely to get deadly circumcision complications than AIDS, then circumcision is not a good bet for you. If you are more likely to die of AIDS, that changes the equation.

    Severe complications requiring a professional clinic are less likely with neonatal circumcision — see my previous comment.

    4. I am not convinced that this will be successfully combined with “other safe sex messages” such as condoms since as it stands most men in many of these places only have access to a small number of condoms each year. If we can’t deliver condoms how can we deliver circumcisions?

    If condoms aren’t available today, circumcision isn’t going to change that. So that’s an argument for circumcision, not against it.

    Circumcision has been performed for thousands of years, long before the existence of medical clinics. See my previous comment about easier infant circumcision.

    5. I am concerned about the under reported phenomenon of nonsocial infections which is said to be a significant contributor to the HIV problem yet is under reported. A recent string of papers by Potterat et. al. in the International Journal of STD and HIV estimated at least 1 in 5 new infections in these countries are caused by that vector. How is a circumcision champaign in a place where clean water is a luxury going to manage this?

    It will reduce transmission from women who contract HIV from their drinking water to their male partners.

    6. One of the reasons stated for starting this champaign was to provide a way to get men into clinics to talk about the more effective strategies and get tested (but only if they want to get tested). If you then move to infants or children, when how will you then get the message to them?

    STI clinics. Billboards. Radio.

    If they want to go to the trouble of actually getting around to setting up clinics then make sure they have condoms, clean water, and access to testing for the whole population first.

    Any public health agency is going to look at what is most cost-effective. If subsidising condoms will get better outcomes more consistently for more people for the same money as promoting infant circumcision, then they will do that. I don’t think you need to worry about other people’s budgets.

    Why test? It’s expensive and could reduce motivation to use condoms. Testing is for monogamous people who want to stop using condoms and can pay for the tests.

    We’ve never even come close to that yet but we need all of those things anyway to support the potential of offering circumcision to men.

    What do you mean “we”?

    An African public health organization would need to provide some of those things to support circumcision for adult men. Supporting circumcision for neonates would require less infrastructure. It’s their call.

    If they may be doing it with a razor blade and a bottle of alcohol as you suggest then it’s worse than I thought.

    How do you think country people do it today, all over the world?

  56. Akheloios says:

    Steve Novella regularly points out that almost everyone has a sacred cow that they won’t have attacked, and that they’ll often go out of their to cherry pick evidence in support of that sacred cow, even when the majority of evidence is either neutral or against.

    One of Dr. Tuteur’s sacred cows seems to be neo-natal circumcision. She’s managed to cherry pick a study on adult circumcision which show a marginal improvement in STD transmission rates.

    If adult circumcision does in fact reduce transmission rates, why call for neo-natal circumcision? The evidence at hand does not support it in any way, in fact the investigations cited in her post make it clear that we have enough males that were circumcised as adults to have enough data to see if adult circumcision is just as effective.

    The call for neo-natal circumcision is not supported by the evidence, and adult circumcision is only supported in circumstances where the almost perfect protection offered by condoms and safe sex is not universal.

    As I’ve pointed out above, male circumcision appears only to be of benefit in poor and/or uneducated populations without access to condoms.

    As circumcision is far less effective than condom use, the only excuse to use it is where the will to improve education, standard of living and condom availability is lacking.

    Dr. Tuteur must know that circumcision is far less effective than poverty relief, education and condom use.

    I must conclude that Dr Tuteur is therefore supporting circumcision not for any supposed medical benefits, but for ideological reasons. If she doesn’t want to feel guilty about performing irreversible, unneeded surgery on males unable to give explicit consent, then she should stop doing it, rather than finding fig leaves to cover her suppressed guilt.

  57. David Gorski says:

    I’ve already written how circumcision is a long chain of money making. There is money to be made in circumcision, not only for doctors, but also manufacturers of circumcision equipment, such as Gomco clamps, Circumstraints, PlastiBells, etc., not to mention that foreskins are sold to pharmaceutical companies, and not to mention there is a line of products created from the foreskins of children, for example, Oprah Winfrey’s SkinMedica.

    You’ve gotten ridiculous in your conspiracy-mongering now, given that the researchers advocating circumcision don’t share in this loot. (Or maybe Oprah and Big Circ bought them off.) Moreover, do you have any idea just how big an industry this is? My guess would be: Not very.

    There are reasons to doubt whether the benefits of circumcision are with the high NNT and the potential complications, but Big Circ paying off the researchers isn’t one of them.

  58. joep says:

    @Alison

    I’ll have to look at the rest later but this stood out most.

    Alison said: “Why test? It’s expensive and could reduce motivation to use condoms. Testing is for monogamous people who want to stop using condoms and can pay for the tests.”

    Because a program of testing and then going on antivirals if you’re positive would do far more to alleviate the situation in 10 years than circumcision could do in 20 years.

    Link: tinyurl.com/yc23pha

    Link: tinyurl.com/ao2aty

    The major hurdle sited:

    * The ethical problem of implementing a universal HIV testing program;
    * The ethical problem of starting treatment when one has contracted HIV but still has a high CD4 count.

    An ethical problem? Surely they must be joking.

  59. joep says:

    @Alison

    I’ll have to look at the rest later but this stood out most.

    Alison said: “Why test? It’s expensive and could reduce motivation to use condoms. Testing is for monogamous people who want to stop using condoms and can pay for the tests.”

    Because a program of testing and then going on antivirals if you’re positive would do far more to alleviate the situation in 10 years than circumcision could do in 20 years.

    Link: tinyurl.com/yc23pha

    Link: tinyurl.com/ao2aty

    The major hurdle sited:

    * The ethical problem of implementing a universal HIV testing program;
    * The ethical problem of starting treatment when one has contracted HIV but still has a high CD4 count.

    An ethical problem? Surely they must be joking.

    I am not sure if this keeps getting caught in the spam filter or not, I didn’t see a waiting for moderation message so if this pops up more than once I apologize.

  60. “There is no way of knowing whether or not he will want to be a part of the Jewish religion as an adult”

    You really need to learn a lot more about Judaism before you make claims about it. Being Jewish is not a choice. It is inherited through the mother. You can convert later if you want, but if your mother is Jewish, you’re Jewish, whether you want to be or not.

  61. “I’ve already written how circumcision is a long chain of money making.”

    You’ve accused people by name or by profession and you are obligated to prove it or withdraw it. Saying “some people” make money, is not enough.

  62. Akheloios says:

    “Being Jewish is not a choice. It is inherited through the mother.”

    Can you point to the place on the X chromosome where Jewishness resides?

    It’s a social construct. You’re no more a Jew at birth than a Catholic or a Republican or a Marxist.

    You’re really digging yourself in deeper with these completely innacurate and ideological bugbears.

  63. “You’re no more a Jew at birth than a Catholic or a Republican or a Marxist.”

    Clearly you need to do a little more research on religion.

  64. Akheloios says:

    “Clearly you need to do a little more research on religion.”

    And you need to do a serious revision of your basic biology textbooks. You can be born with dark skin, left handed, a redehead, or gay, or having any other number of genetically predetermind characteristics.

    What you can’t be born as is a part of a social construct. You can only be born to parents who are a member of a social construct, but seeing that has no effect whatsoever on your genetics or even epigentics, you’re a priori born without any political affliation to a social construct.

    Religious people might like to imagine that their children are members of their personal religion from birth, but wishing doesn’t make it so. They can force the child to undergo religious indocrination, but that by definition is post birth, and is most definately nothing to do with the child’s state at point of birth.

    Just because a religion claims something, doesn’t make it true. This is Science Based Medicine, and you just made a theological claim unsupported by any evidence whatsoever.

  65. Instead of guessing about Judaism and presenting your guesses as facts, why don’t you do a little research and let us know what you find?

  66. David Gorski says:

    You’re no more a Jew at birth than a Catholic or a Republican or a Marxist.

    Biologically, I suppose you could have a point, but culturally Judaism is passed through the maternal lineage. If your mother is a Jew, you are a Jew. Period.

    You’re just plain wrong here. Or you’re intentionally attacking a straw man (that somehow Judaism is genetically inherited through the mother) in order to troll.

  67. Akheloios says:

    “Instead of guessing about Judaism and presenting your guesses as facts, why don’t you do a little research and let us know what you find?”

    You’re avoiding the question entirely aren’t you. Can you make one scientific claim that supports your assertion that children are born belonging a priori to any religion because of their birth mother?

    Your retreat to theology only makes it clear that you have no grounds on which to support your scientific claims.

    Go and read some basic biology textbooks on heredity and see if you can claim that a social construct can be inherited biologically.

    I understand your arguments, I can point to any number of societies where legitimacy comes from the matriliniar line. This is a claim based on the fact that a wise person can only know his mother, and in societies where legitimacy is important is a quite clever solution.

    Still it does not say any more than about the child than it was born of that woman. Social constructs are not genetic, unless you’re claiming that certain religions are exclusive extended phenotypes, and that is clearly wrong as you can change your religion like any other social construct.

    (sorry if this is a double post, I couldn’t see that it had been posted but got a message that it had)

  68. Akheloios says:

    “Biologically, I suppose you could have a point, but culturally Judaism is passed through the maternal lineage. If your mother is a Jew, you are a Jew. Period.”

    No, what it says is that the only people who can be considered to be Jews are those born of a Jewish mother. That is something completely different than you are automatically a Jew if your mother is one.

  69. Robert Samson says:

    Condom efficacy…

    http://www.rho.org/html/cont-male_condoms.htm

    Male Condoms

    Overview
    A male condom is a sheath designed to fit over a man’s erect penis and prevent passage of sperm into the female reproductive tract. Most condoms are made of thin latex rubber; some are made of animal tissue or of polyurethane. Condoms come dry or lubricated with a water-based lubricant or spermicide. (See the condoms and nonoxynol-9 discussion below.) Condoms can be very effective in preventing pregnancy when used correctly and consistently with every act of intercourse (perfect use); however, they are less effective with typical use. A meta-analysis of the male condom in preventing HIV suggests that their effectiveness at preventing HIV is 87 percent (with a range from 60 to 95 percent depending on the incidence among nonusers) (Davis, 1999). Condoms do not affect breastfeeding or have hormonal side effects; no medical condition restricts a client’s eligibility for use of the method except allergy to latex. In addition to preventing pregnancy, latex condoms are effective in protection against sexually transmitted infections (STIs). Male condoms may be less effective in protecting against those STIs that are transmitted by skin-to-skin contact, since the infected areas may not be covered by the condom (WHO, 2001; NIAID/NIH/DHHS, 2001).

    Characteristics of condoms
    Effectiveness : 3% to 12% failure rate during first year of typical use; 3% failure rate during first year of perfect use.

    User issues
    Condoms in various forms have been used for centuries. Since the 1930s latex condoms have been used, though generally not extensively, in many parts of the world to prevent both pregnancy and STIs. The promotion of condoms for HIV prevention led to an increase in research and technical knowledge during the past decade and the first substantial modifications in manufacturing of condoms since the 1930s.

    If used consistently and correctly, condoms can be very effective. Reviews of literature confirm that condoms can prevent both pregnancy and STIs, including HIV (Lisken, 1990; FHI, 1998; PATH/Outlook, 1994; Gardner, 1999). Laboratory studies show that sperm and disease organisms cannot pass through an intact latex condom. Consistent condom use is very effective at preventing HIV infection, even among serodiscordant couples, where one partner is infected and the other is not. Studies have confirmed that, with consistent condom use, the HIV infection rate among the uninfected partners was less than 1 percent per year (de Vincenzi, 1994). Where one partner is definitely infected, however, inconsistent condom use can be as risky as not using condoms at all.

    In actual use, however, couples relying on condoms generally are not as successful at preventing unwanted pregnancy as users of many other methods. Evidence suggests that the individual—not the condom—is usually responsible for most condom failures and to inconsistent use, incorrect use, and breakage due to improper use. Breakage rates for high-quality condoms are quite low (less than 1 to 12 per 100 condoms) during either vaginal or anal intercourse. Substandard products, either manufactured badly or stored badly, may have holes or defects that lead to tearing the condom or leakage. Failure also may be caused by the condom user’s behavior. A recent study found that breakage related to: (1) having a male sexual partner, (2) infrequent condom use, (3) having the condom partially slip, and (4) the technique use to don the condom (Richters, 1995). Slippage was related to: (1) young age, (2) having less lifetime condom experience, *******(3) being circumcised******, and (4) the donning technique. These researchers suggest that condom counseling protocols should acknowledge the complexity of condom use.

  70. Robert Samson says:

    Amy, it is getting more than a little boring for you to demand others support each and every claim, yet you never support ANY claim you make..

    Incidentally, I am still waiting for YOU to provide a single scientifically credible benefit for circumcision..

    Lacking proof for one, it certainly is a double standard for you to demand this from others for every assertion.

    As for this Jewish claim of being born a Jew, that is a patently absurd claim made by Jews. NO one is born as any religious group, and chopping off part of their genitals does not make them one either.

    This “covenant” claimed by Jews is a made up mandate by Priests circa 550BCE–it was never part of the original covenant.

  71. Robert Samson says:

    “This post is not about defending circumcision. It is an explanation of the current state of research on the reduction in transmission of HIV and other STDs by circumcision.”

    Then perhaps, you might wish to provide some scientifically credible evidence that circumcision DOES reduce the rates of HIV and STD’s because frankly the empirical evidence in the real world refutes these claims–or are you scientifically illiterate?

    If so, then read the link I posted earlier on the scientific process–or choose to remain ignorant and then pretend that you never had the chance to remedy this ignorance.

  72. Fifi says:

    “You really need to learn a lot more about Judaism before you make claims about it. Being Jewish is not a choice. It is inherited through the mother. You can convert later if you want, but if your mother is Jewish, you’re Jewish, whether you want to be or not.”

    Wow, so you’re saying that religion is genetic or not a choice simply because it’s imposed upon a child? If you can convert to Judaism it’s obviously a choice. If you can denounce your birth religion, obviously it’s as much a choice as any other religion. Just because the Jewish religion decides to not recognize children born of a Jewish father and a gentile mother doesn’t mean that being born of a Jewish mother somehow makes you biologically a Jew and not biologically a Jew if only your father is Jewish. Is a child born to a Jewish mother but given up for adoption and raised Catholic still Jewish in your opinion? Do you believe one is born Muslim too? Religion is culture not biology – no matter how hermetic a religion it is and even if intermarrying may have created distinct genetic lineages (as happens in other hermetic religions or cultures, the hermetic culture of the Ashkenazi Jews is responsible for their distinct genetic heritage, not all Jews have the same genetic heritage, it’s specific to a group…people in the Lac St-Jean district of Quebec are also studied because of distinct genetic traits due to hermetic culture, do you believe they’re born Catholic? Icelanders as well.) You really are reaching far here and wandering into some strange territory that is certainly ideological and uncomfortably close to what people who hate Jewish people claim. Do you only have this rule for Jewish people or is everyone defined by the label slapped on them at birth and forever destined to be their parent’s religion?

    Seriously, I now suspect you just made your initial blog post in the first place to argue ideology from what your argument has devolved into (particularly since Harriet Hall had already posted about this topic before). You’re making a joke out of this being a science-based blog by clearly promoting an ideological perspective and pretending you’re doing it in the name of science. It’s a shame and I’m doubly appalled that you’ve pushing such ignorant ideas about safe sex and now religion.

  73. galway says:

    @ David Gorski:

    I’ve heard of foreskin being used for surgical repairs in the eye (as well as the amniotic sac). How does it get from point A to point B? Legitimate question here. Is it sold? Donated? I would imagine it would be deemed biological waste, but then what…?

    This “Jewish” argument has me confused.

    I thought that being Jewish was a faith, not genetics. Wikiepedia describes “Jewish people” as “an ethnoreligious group originating in the Israelites or Hebrews of the Ancient Near East.”

    Wouldn’t that mean religion.. not genetics?

    If you convert to Judaism, you are of the same status as people who were born into the Jewish faith.
    So a family who converts to Judaism, and has a son.. circumcises their son who was “born Jewish”who may or may not grow up to worship in the Jewish faith… but isn’t *genetically* an Israelite.

    Am I making any sense? Or do I have it completely fudged up?

  74. Annabel says:

    “You really need to learn a lot more about Judaism before you make claims about it. Being Jewish is not a choice. It is inherited through the mother. You can convert later if you want, but if your mother is Jewish, you’re Jewish, whether you want to be or not.”

    Wow. Ok, this takes the cake. That has to be one of the most ignorant things I have read on a circumcision blog or forum ever, and that is saying a lot.

  75. Robert Samson says:

    ““You’re no more a Jew at birth than a Catholic or a Republican or a Marxist.”

    Clearly you need to do a little more research on religion.”

    Amy, I suggest you do the same IF you believe that one is born Jewish or that the Jewish deity mandated circumcision.

    The first is a logical absurdity–an infant is born human and nothing else regardless of the silly notion that popping out of a womb of someone who follows a certain belief system somehow receives that belief system through her genes.

    The second is a completely ignorant assumption.

    Please try not to talk down to people who just might be more educated on a subject than yourself.

  76. Akheloios says:

    “If your mother is a Jew, you are a Jew. Period.”

    A better illustration. I turn up to Synagogue and say that I’m Jewish, the Rabbi asks me if my mother was Jewish, I say yes. Then I’m Jewish.

    Or I turn up to Synagogue and the Rabbi asks me if my mother was Jewish, I say no. Then I’m not Jewish. Fine, it’s an exclusion principle based on matriliniar ancestry.

    I turn up the Atheist Alliance annual bake sale and debauchery festival and I’m asked if I’m an atheist and I say that, though my mother and father are Jewish, I’m an Atheist. Then I’m not Jewish.

    You can’t claim that just because you are Jewish, and you had children, that they are Jewish. You let them decide for themself.

    The same goes for every other religion. I was actually born to Catholic parents, though I have Jewish ancestors on my mother’s side, and now consider myself to be a 6.9 on the Dawkins scale, then I’m certainly not Catholic or Jewish or anything else that someone else may consider me to be just because of their conventions.

  77. Fifi says:

    Besides, you should really check into why circumcision started to be practiced within the Jewish faith.

    Amongst gentiles circumcision really does have roots in wacky anti-sex ideas, including that beloved grandfather of many things woo Kellog who promoted wacky anti-sex and anti-masturbation ideas.The idea it protects from disease – including the disease of sexual pleasure that rots mens’ minds – is equally rooted in antiquity. Really, in 2010 the way to protect oneself from STDs is via using condoms and barriers. Do you even teach women about using barriers other than condoms?

    I’m not anti-circumcision – I like a wide variety of penises, it’s who they’re attached to that makes them attractive ultimately – but I do question practicing unnecessary surgery on babies and there are members of the tansgender community that have had to live with doctors’ mistakes and then lies about the mistakes most of their lives (these mistakes are very often covered up). I think you’re entirely discounting their suffering in favor of promoting an ideological perspective (which is simply to say that even if this is an infrequent event – it’s hard to know since it’s often hidden from the victim and not reported historically – that the consequences can be extreme) . At the moment parents can choose whether to circumcise their children or not, why you’d want it to be recommended in the US when people should be using condoms and barriers (and good sense) to prevent getting an STD (fatal or otherwise) is just weird and irrational.

    Perhaps you should read about David Reimer
    http://en.wikipedia.org/wiki/David_Reimer

  78. “That is something completely different than you are automatically a Jew if your mother is one.”

    I’m not sure why you are having such difficulty with this concept. It’s a social construct just like citizenship. Just like citizenship, you are born with it, don’t get to choose, and cannot change it by whim. A boy born in Italy to Italian parents is Italian, whether he has chosen it or not. And no amount of wishing will make him Canadian as an adult.

  79. Fifi says:

    Really, you can’t entitle something ‘The case for neonatal circumcision’ and make a case for the recommendation of neonatal circumcision and then claim you’re not making a case for neonatal circumcision. You’re not weighing the evidence, you’re making a case for something and cherry picking the evidence and dismiss the reality of AIDS and safer sex and condom use to make your case for neonatal circumcision. Seriously, it’s just idiotic to claim you’re not promoting a particular perspective based upon one study.

  80. What does matrilineal ethnoreligious anything have to do with whether the apparent effectiveness of circumcision of Ugandan adults in reducing transmission of HIV has any bearing on the current AAP recommendations on routine neonatal circumcision?

    Judaism is a red herring. Circumcision is either effective or it’s not. If it’s effective, the benefits may or may not outweigh the costs. If they do, it may or may not be possible. If it is, it may or not be ethical. If it is, it may or may not be preferred. That’s science-based medicine.

    The studies could have been funded by the Taliban and conducted by the Illuminati. They still have to stand or fall on their own merits. If their findings are correct, then they are correct. If they aren’t, then future studies will demonstrate that.

    Someone who has a conflict of interest can be right just as much as they can be wrong. And we all have conflicts of interest somewhere. We’re human. We’re proud. We have friends. Whatever. What science does is provide a discipline for figuring out what’s really going on anyway, even though scientists are human. And this discipline does not involve conspiracy theories.

  81. Fifi says:

    Actually, if he wants to be a Canadian as an adult he simply has to apply for Canadian citizenship. That’s how it works in Canada, you are then Canadian. You seem to be the one that’s having issues with understanding what a social construct is and how labels work. You do understand that it’s quite possible to be born labeled as a man and then become a woman – as uncomfortable as mutable identities may make you, biological, national and cultural identities are mutable.

  82. “he simply has to apply for Canadian citizenship.”

    That’s right, and Canada may or may not decide to grant it after he completes certain requirements. However, he cannot simply announce that he is Canadian and thereby become Canadian.

    Moreover, unless he takes specific legal steps to renounce his Italian citizenship, he is still Italian, no matter how much he’d like to be viewed as something else.

    The same thing applies to Judaism. You are Jewish until you take specific steps to convert to something else. No amount of claiming to be an atheist changes the fact that you are Jew if you were born a Jew.

    Why is this so difficult to understand?

  83. Nick says:

    “The studies could have been funded by the Taliban and conducted by the Illuminati. They still have to stand or fall on their own merits. If their findings are correct, then they are correct. If they aren’t, then future studies will demonstrate that.”

    Does nobody think it’s kind of biased to be conducting studies centered around legitimizing an ancient religious rite?

    Are there any “studies” being done in the FEMALE microbiome and “the effect of female circumcision” on it?

    What would we do with studies from African doctors who on the front want to “reduce HIV transmission,” through female circumcision?

    What is with this compulsive obsession and fixation by certain researchers to try to discredit the existence of a normal part of the male anatomy since the beginning of mankind? Surely they could find, by their line of research, that excising female labia will give oxygen the chance to kill bacteria that researchers don’t like. Try proposing that! Most of the world laughs at America’s peculiar sexual hangups and notions that foreskins are unworthy. Foreskins are part of mammals, male and female.

    I think it’s about time we outlawed all of these circumcision “studies.” They’re not looking for a solution to a problem, they’re looking for problems to legitimize their pre-determined solution.

  84. untitled says:

    Amy Tuteur: “You really need to learn a lot more about Judaism before you make claims about it. Being Jewish is not a choice. It is inherited through the mother.”

    Your defenses are beginning to cast serious doubt on your objectivity. The semantics of what it means to belong to a religion are irrelevant to the point that Akheloios was making. Just because a child is born to parents of a particular religion does not justify permanently marking the child with the signs of that religion, when it’s obvious that the child didn’t choose that religion.

    Amy Tuteur: “Why is this so difficult to understand?”

    What does any of this have to do with Akheloios’ original point? Why can’t you address the issue that Akheloios raised, which is how being born to a Jewish mother justifies body modification? Why is this form of religious body modification okay, when others are not? And what does any of it have to do with science based medicine?

    David Gorski: “You’re just plain wrong here. Or you’re intentionally attacking a straw man (that somehow Judaism is genetically inherited through the mother) in order to troll.”

    I think it’s quite clear what Akheloios’ point was. It was Dr. Tuteur who sidetracked the issue and began obfuscating a viable point with pedantry.

    I’ve long been a defender of science based medicine, and for that reason I find this entire thread deeply troubling. The “pro-circ” crowd has revealed itself to be hypocritical, ideological, and anything but scientific.

    It’s clear that there is a double standard when it comes to the treatment of female versus male genitals in infants (previous commenters have provided descriptions of the extent and nature of both). A similar double standard exists with respect to religious traditions and infant body modification. Why is this? This has been brought up repeatedly in this thread, yet I haven’t seen anyone from the “pro-circ” camp comment on this, except to misrepresent the statements of others, or to trivialize what many of us have come to regard as institutionalized child abuse.

    It’s clear that infant circumcision is an unnecessary body modification, rooted in religion and misguided attempts at sexual repression, whose potential benefits, still questionable and only secondarily realized, can wait until the child is of an age to make the decision for himself. The “pro-circ” camp has not sufficiently explained why they think circumcision cannot wait until the individual is able to consent, and seems to consistently ignore this question, despite the frequency with which it has been raised. Once again, why can’t circumcision wait? Why must it be performed on infants? Please provide justification for this.

    It’s also clear that if there were no cultural precedence for infant male circumcision and it were a novel idea, very few would consider it acceptable — beneficial or not. Again, are members of the “pro-circ” camp really incapable of seeing the issue outside of the present cultural context? Attempts to downplay the severity of male genital mutilation by calling it “minor” and referring to those who use emotional language to describe their emotions as “inflammatory” are really quite distressing. Can anyone really be so unimaginative that they can’t see why some of us find this appalling? Can they not for one moment try to envision analogous procedures on toes, fingers, breasts, or other body parts, and appreciate the sense of horror that we feel? Historical precedence is not an excuse for suspending basic human rights. When you look at infant circumcision from an outsider’s perspective, it seems monstrous. The callousness with which some people write it off or try to downplay is all the more disturbing to me.

    The fact is we don’t know if there are psychological effects. And to steal from an earlier poster, we don’t know that society isn’t suffering from some form of Stockholm Syndrome that leads us to trivialize and even rationalize what might otherwise be considered child abuse. It certainly seems plausible that there are negative psychological consequences. Does the “pro-circ” camp have sufficient evidence to show that it is psychologically safe? Have they done rigorous testing on the psychological and emotional well-being of males who are circumcised as infants? If not, then why? If you’re going to perform an unnecessary surgery on someone without their consent, you really need to investigate the potential side-effects, both psychological and physical.

    But that is beside the point. Even if there is no psychological damage, it remains an unnecessary violation of one’s physical autonomy. How can this be justified? While merely anectdotal, I do know several circumcised men who lament their lack of choice. What would you say to these men, who had a part of their body taken from them for no good reason and can never get it back? I would say that they’ve been violated. Would you disagree? If so, then why?

    And why do people keep pretending that the only possible biases are monetary? I find this very disingenuous. Other commenters have already spelled out potential cultural, psychological, and religious biases. Acknowledging and weeding out bias is a vital part of science. Cherry-picking the comments about monetary bias and then calling them conspiracy theories while ignoring the comments about other forms of bias does not resolve the issue.

    Why continue to condone and even promote a violation of an individual’s “physical integrity” (to borrow a phrase from the WHO) that is neither ethically nor medically justified? These are not rhetorical questions, I want answers.

    The onus is on the “pro-circ” camp to provide sufficient evidence that necessitates violating a child’s right to choose, not the other way around. Such evidence has not been provided. This is the opposite of science based medicine. I think some of you should seriously consider whether your cultural biases are not interfering with your objectivity, and I will do the same.

    It would be interesting to see how medical professionals in the future will judge their predecessors.

  85. Annabel says:

    @ Amy

    Are you really comparing a legal citizenship to a religion? Seriously? Nowhere on any birth certificate or any drivers license or any passport do I see the word Jewish. Nor are there any legal proceedings a person must perform to become “un Jewish.” You are comparing apples and oranges. A person is not Jewish if they say they are not Jewish. We are not talking about a persons race, we are talking about a religion.

    “Why is this so difficult to understand?”

  86. Nick says:

    “If your mother is a Jew, you are a Jew.”

    This is true only if you consider yourself a Jew and are part of this religion, that means you must respect the rules. If you mother is Jew and you’re no longer interested in this religion, the fact you are Jew because your mother is (only according to Jewish law) doesn’t really matter anymore.

  87. Fifi says:

    But someone isn’t a Jew until someone announces they’re a Jew, what don’t YOU understand? In the Jewish tradition, uncircumcised men can’t get into heaven so it’s questionable if one’s truly a Jew if not circumcised (or a Catholic if not baptized, these are rituals of faith that are necessary to belong). If a Jewish woman had a baby, left it at a Catholic church and it was baptized and raised Catholic, is that child still a Jew if it hasn’t been proclaimed one? Your argument is specious and ultimately has nothing to do with circumcision as a medical procedure outside of religion. Particularly since the very origins of the more extreme form of circumcision was used as a means of making sure that Jews and didn’t wander off and stop being Jewish (it was to prevent Jews from trying to pass as gentiles). Really, it’s no different than branding people so they can’t escape their masters (in this case, the Rabbi).

    The hierarchal tradition of circumcision was challenged when Alexander the Great conquered Jewish lands between 334 B.C. and 331 B.C., and as a result, Greek culture swept through Jewish communities. It was counter to Greek beliefs to violate the natural human form, and this caused young Jewish men to try to appear to be uncircumcised, which greatly annoyed Jewish rabbis. In response, Jewish rabbis argued that the foreskin was an imperfection that needed to be cut off in order to reveal the correct human male form.

    Like I said, I’m against unnecessary surgery for babies but I have no preference for an circumcised or uncircumcised penis. Nor, unlike you, do I have a desire to impose or promote one or the other. There’s science that can be presented for and against – particularly by those who want to cherry pick the evidence – though most seems to lean towards allowing the person to make an adult choice (since safer sex isn’t a consideration for a child so that’s a specious argument on many levels, unless you’re advocating sex with children). Still, I’m much more tempted to side with the Ancient Greeks and modern nations that have universal healthcare (and actually practice real preventative medicine) on this one. Particularly since the roots of circumcision in Christian culture are so wacky and come from the same source as so much weird and anti-science new agey woo, and are distinctly based on the idea that masturbation is evil and creates sickness and circumcision is the cure. There really don’t seem to be any real benefits for babies or children and there are potential dangers – the risks do seem to outweigh the benefits. Adults can make up their own minds about body modification, whatever form it takes, and their sexual health.

    1. David Gorski says:

      In the Jewish tradition, uncircumcised men can’t get into heaven so it’s questionable if one’s truly a Jew if not circumcised (or a Catholic if not baptized, these are rituals of faith that are necessary to belong). If a Jewish woman had a baby, left it at a Catholic church and it was baptized and raised Catholic, is that child still a Jew if it hasn’t been proclaimed one?

      My understanding is that the answer to that question is yes, depending on the sect. Certainly orthodox and conservative Jews would consider such a child a Jew who was never raised Jewish. Reform Jews would probably still consider such a child Jewish by culture but it would probably be a moot point, given the child’s Catholic upbringing.

      Also, in Reform Judaism circumcision is not mandatory, and Reform Jews also have modified the law of matrilineal descent, declaring that a child is Jewish if either one of the parents is Jewish:

      http://judaism.about.com/od/whoisajew/a/amijewish.htm
      http://judaism.about.com/od/whoisajew/a/whoisjewdescent.htm

      In any case, this whole discussion of matrilineal descent as the determinant of who is and is not Jewish is all very interesting, but it is not about the scientific issues and is thus a distraction from the topic of this post, as far as I’m concerned.

  88. David Gorski says:

    I think it’s quite clear what Akheloios’ point was. It was Dr. Tuteur who sidetracked the issue and began obfuscating a viable point with pedantry.

    Yes, I do think it was quite clear what his purpose was: To construct a straw man and tear it down. He knew what Amy was talking about, but instead decided to try to make it sound as though she were making an argument that Jewishness is some sort of biological trait passed through the mother. It was pointless and served no useful purpose in the discussion.

  89. David Gorski says:

    The same thing applies to Judaism. You are Jewish until you take specific steps to convert to something else. No amount of claiming to be an atheist changes the fact that you are Jew if you were born a Jew.

    And this doesn’t even get into the dichotomy between cultural Jews and religious Jews. In fact there are quite a few atheists who consider themselves Jewish by culture because they were born to a Jewish mother into a Jewish family. There are secular Jews who take part in the religious rituals to varying degrees from not at all to just some extent. This whole argument about whether being Jewish is more religious or cultural is not a new argument. The bottom line is that, to the Jewish religion, a person is considered Jewish if his mother is Jewish. That person may choose to accept or reject Judaism, but even if that person rejects it the Jewish religion will still consider him Jewish and take him back if he ever changes his mind.

    But what does any of this have to do with the scientific evidence for and against circumcision? It’s acknowledged that to Jews circumcision is a religious obligation and not done for any health purposes. Let’s put it this way yet again. I’ve taken Amy to task in this thread for some things she’s said, but I really don’t see why in this discussion of Judaism it’s even an issue whether having a Jewish mother makes a person Jewish by birth. That is indisputable, because it’s part of the Jewish religion.

  90. untitled says:

    I apologize. It was Annabel who first said “A baby cannot say whether or not he is Jewish. There is no way of knowing whether or not he will want to be a part of the Jewish religion as an adult, therefore it is unethical.”

    Dr. Tuteur then responded to this with “You really need to learn a lot more about Judaism before you make claims about it.” Akheloios then took up the thread of that discussion, and I mistakingly attributed the original idea to Akheloios. However my point stands. The semantics of religious inclusion does not address Annabel’s original point.

  91. Fifi says:

    There are studies going on regarding infants and pain, perhaps the sane (and scientific and ethical) thing to do would be to wait until we know more and can truly make a science-based decision regarding non-religious circumcision. A radical idea, I know! (I say non-religious because at this point in time parents can pretty much choose to let their child die – refuse blood transfusions, needed medical care, etc – on religious grounds.)

    http://blog.taragana.com/health/2009/09/26/how-infant-pain-has-repercussions-in-adulthood-12578/

  92. Nick says:

    “There are studies going on regarding infants and pain, perhaps the sane (and scientific and ethical) thing to do would be to wait until we know more and can truly make a science-based decision regarding non-religious circumcision. A radical idea, I know! (I say non-religious because at this point in time parents can pretty much choose to let their child die – refuse blood transfusions, needed medical care, etc – on religious grounds.)”

    That’s very interesting !

    http://epublications.bond.edu.au/cgi/viewcontent.cgi?article=1036&context=hss_pubs

    http://www.asnatureintended.info/3/post/2009/11/male-neonatal-circumcision-trauma-and-brain-damage.html

  93. Nick says:

    Another interesting article :

    http://www.menweb.org/circtom.htm

  94. Fifi says:

    Dr Gorski – I agree but this doesn’t seem to have been about science from the start, just dressed up as being about science. It’s difficult to discuss this topic when people have so many obvious biases that they don’t want to acknowledge.

    I’m an atheist and don’t have a penis or a preference for circumcised or not circumcised ones in sexual partners (like I said, it’s who the penis is attached to that really counts). I’m not foolish enough to think that whether a man is circumcised or not has much impact on real world sexual safety (his sexual habits and previous partners are much more important than whether he has a foreskin or not in this regard). My bias is towards not performing unnecessary surgery on babies and letting adults make choices about permanent changes their body. The issue here is about whether a medical association should be promoting circumcision, if in real world terms circumcision really has anything to do with AIDS prevention, and whether there’s actually a real weighing of scientific evidence going on here or a perpetuation of personal and cultural biases. Simply looking at this one study, and not even considering studies done regarding infants and pain, seems negligent to me (and it seems as if we’ve got more research to do in this area). What’s the rush to circumcise? It’s not like babies or children are having sex. What happened to first do no harm?

  95. Annabel says:

    Thank you, untitled. You have summed up almost every question that I want the ” pro circumcision” camp to answer.

    Why neonatal circumcision?

    Why the double standard when comparing female and male genitals?

    Why the double standard with religious practices? If jewish parents can modify their children in the name of religion, why can’t parents of a minority religion do the same?

    “Does the “pro-circ” camp have sufficient evidence to show that it is psychologically safe? Have they done rigorous testing on the psychological and emotional well-being of males who are circumcised as infants? If not, then why?”

    “What would you say to these men, who had a part of their body taken from them for no good reason and can never get it back? I would say that they’ve been violated. Would you disagree? If so, then why?”

    “And why do people keep pretending that the only possible biases are monetary?”

    “Why continue to condone and even promote a violation of an individual’s “physical integrity” (to borrow a phrase from the WHO) that is neither ethically nor medically justified?” to add to this, why is it only female babies whose right to physical integrity is in violation, when male circumcision is more severe than some of the forms of FGM that WHO claims violates the physical integrity of females?

    I would really like some straight answers from the pro circumcision camp on these issues. They have been raised several times and have not been answered. I would especially like to hear from Amy, since she has remained mostly silent when these questions have been brought up.

    ( The quotes in parenthesis are from a previous post written by “untitled.” )

  96. Kiki,

    1) The AAP does not promote circumcision.
    2) While she was extremely unclear about this in her post, Amy says in the comments that she never thought there was enough evidence to recommend it though might be changing her mind based on new evidence.
    3) There might be a rush to circumcise neonates in poor African countries with a high prevalence of AIDS. Benefits might heavily outweigh risks, and the infrastructure in these countries might be able to handle infant circumcision more easily than adult circumcision.
    4) My guess that the reason nobody has explained why circumcision needs to be routine and neonatal in the US is that nobody has said it does.

  97. Annabel says:

    Thank you, untitled. You have asked almost every question that I want the pro-circumcision camp to address.

    Why neonatal circumcision?

    Why the double standard when dealing with male vs female genitals?

    Why the double standard when it comes to religious practices? If jewish parents can perform bodily modification in the name of religion, shouldn’t parents from a minority religion be allowed to do the same?

    “It certainly seems plausible that there are negative psychological consequences. Does the “pro-circ” camp have sufficient evidence to show that it is psychologically safe? Have they done rigorous testing on the psychological and emotional well-being of males who are circumcised as infants? If not, then why?”

    “While merely anectdotal, I do know several circumcised men who lament their lack of choice. What would you say to these men, who had a part of their body taken from them for no good reason and can never get it back? I would say that they’ve been violated. Would you disagree? If so, then why?”

    “And why do people keep pretending that the only possible biases are monetary?”

    “Why continue to condone and even promote a violation of an individual’s “physical integrity” (to borrow a phrase from the WHO) that is neither ethically nor medically justified?” adding to this, why is it only a females right to physical integrity that is violated, when there are several forms of FGM that are less severe than male circumcision? Do boys not have the same basic human rights as girls?

    ( all quotes are from a previous post written by “untitled”.)

    I would really like these questions addressed by the pro-circumcision camp. Especially Amy, since she has remained mostly silent on these issues when brought up, or has cherry picked a sentence out of an entire post three paragraphs long to respond to, avoiding these fundamental questions.

  98. Akheloios says:

    “Yes, I do think it was quite clear what his purpose was: To construct a straw man and tear it down.”

    Where is the straw man? You can’t inherit religion as though it’s a biological phenotype, and it’s highly unscientific of Dr. Tuteur to do so.

  99. Akheloios says:

    The point that the evidence presented deals with a decline in STD transmission rates in populations where sexually active males have been circumcised.

    Nowhere in her evidence does Dr Tuteur show that this circumcision has to be done to newborns.

    She has not presented any evidence whatsoever for the benefits of circumcising infants. People have rightly said that due to the side effects, the non-consensual nature of the surgery and the fact that it can be performed later WITH explicit consent, and that there is already a much better method of reducing STD transmission already available in the form of safe sex and condoms.

    Dr Tuteur has presented the straw man, and a huge one at that. That demonic bands of anti-circumcision activists roam the lands preventing good doctors from performing this life saving procedure on infants.

    She’s conflated adult circumcision with infant circumcision and ignored evidence of better alternatives. She hasn’t produced Science Based Medicine argument, she’s produced a straw man and both of you appear angry that people have pointed this out on the ‘Science-Based Medicine’ website comments.

  100. Oedipa says:

    “Instead of guessing about Judaism and presenting your guesses as facts, why don’t you do a little research and let us know what you find?”

    No you didn’t, Amy Tuteur. The three most obnoxious words in blog commenting – do the research. Translation: read stuff that agrees with me and you will see how wrong you are.

    It is the mantra of so many anti-vaxxers, I really cringed when you wrote that.

Comments are closed.