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653 thoughts on “The case for neonatal circumcision

  1. The issue currently being debated in this thread are whether the risks outweigh the benefits, and many commenters feel that the benefits are not sufficient. That’s fine, but let’s not lose sight of the basic fact: there are real benefits, and defending on the population, those benefits can extend to hundreds of thousands of lives saved.

    There’s no need to invoke nefarious motives of anyone, least of all those people who devote their professional lives to looking for ways to stop the deadly HIV epidemic.

    I’m sure that by now we are quite clear on the concept that some people believe that neonatal circumcision is ethically unacceptable regardless of the benefits. But, beyond the risk of individual complications, no one has yet shown any harm of any kind from widespread neonatal circumcision. That’s not, of course, an argument in favor of neonatal circumcision, but it is quite clear that widespread neonatal circumcision does not harm populations and may even benefit them in the long term.

  2. joep says:

    Amy said: “But, beyond the risk of individual complications, no one has yet shown any harm of any kind from widespread neonatal circumcision. That’s not, of course, an argument in favor of neonatal circumcision, but it is quite clear that widespread neonatal circumcision does not harm populations and may even benefit them in the long term.”

    The individual risk is really the first risk (and likely the only risk) I am going to think about. What do you say to a child who suffered one of the more extreme complications of a procedure that was not of clinical need for him? I am sorry son we were trying to reduce your lifetime risk of disease X by one or two hundredths of a percent. No clearly it wasn’t necessary and yes even then there were better options for protection and yes you could have been included in the risk/benefit discussion at a later date but that vanishingly small difference appeared compelling.

    And I might qualify your ‘may even benefit’ with ‘under certain extreme conditions’ because it is far from clear when comparing the rates of STDs between say Europeans and Americans that there is any benefit at all. If nothing else the comparison shows that far better control of STDs in a population than we see in the US can be achieved in the absence of neonatal circumcision. If Americans want to see European rates perhaps we should take a look at what they are doing.

  3. Nick says:

    “Well said zoe and obviously equally true of Dr Tuteur and the extremist ideologues who are anti-circ. Both seem proud of the fact that they don’t think critically, while they’re both busy abusing science and pretending to be critical thinkers promoting a science-based position”

    And anti female circumcision people are also extremist ideologues ?
    Or do they need a more moderate point of view to appear credible ?

    Fiffy, you dodged some questions I asked you. I’ve always presented my arguments so discuss them and show me where I’m wrong. So far you have jsut been splashing around, nothing more.

    If an adult was suddenly strapped down against his will and was circumcised without his informed consent and without his anesthesia, it would be an obvious form of torture.
    Please tell me how is it different for babies if you claim neonatal circumcision isn’t torture
    You haven’t answered yet, I really would like to now.

    I also told you circumcision has NOTHING to do with science/medecine. What would we do with studies from African doctors who on the front want to “reduce HIV transmission,” through female circumcision?
    Circumcision has nothing to do with science, it’s a human right issue.
    I explained that these studies are likely to be flawed and even if there were correct ie male circ prevent HIV by 55%, it still doesn’t justify neonatal circumcision.

  4. “The individual risk is really the first risk (and likely the only risk) I am going to think about.”

    Fine, but that’s not the only factor in public health decisions, not should it be.

    Even if we all agree that adult circumcision in parts of Africa where there is high prevalence of HIV can save hundreds of thousands of lives, we’d still need to acknowledge that at the individual level some men will suffer complications. So the mere fact that individual complications can occur does not tell us whether a public health recommendation is beneficial.

  5. Plonit says:

    The issue of the harm of the procedure without pain relief can be separated entirely from the issue of circumcision per se, simply by ensuring that pain relief is used (local anaesthesia for the procedure and simple analgesia post-operatively if required).

  6. Nick says:

    “Sorry, that should have read reproductive *health* risks. I was referring to the increased risks of childbirth for women who have had FGM. AFAIK, male circumcision does not result in long-lasting and ongoing health risks for men who decide to reproduce.”

    Males and females are different as regards reproduction. Men haven’t childbirth issues so your argument is retarded. It’s like saying do you know a circumcised female that suffer from erection problems ?

    “What is the evidence that circumcision makes a difference either to sexual function or sexual pleasure? ”

    Many people show different articles regarding this problems :

    You cannot alter form without altering function. When a male’s foreskin is amputated, it affects him for life and his partner’s sex life is affected as well. The mechanics of sex must be altered to compensate for what was lost. As CJ Fallier wrote in JAMA in 1970, “…the fundamental biological sexual act becomes, for the circumcised male, the satisfaction of an urge and not the refined sensory experience it was meant to be.”

    You decide to ignore these posts

    “Pleasure is subjective. It makes sense to say “You haven’t lost as much blood as you think you have” – because we can measure that objectively. It doesn’t make sense to say “You haven’t had as much pleasure as you you think/feel you’ve had” – because pleasure is defined by the person experiencing it.”

    I could use these same circular arguments to claim female circumcision doesn’t reduce sexual pleasure. After all, pleasure is subjective, isn’t it ?
    If pleasure is defined by the person experiencing it, you can’t scientifically prove that FGM reduce pleasure.

    “The huge *quantity* of studies showing benefits of circumcision do not, in my view, provide a basis for recommending routine infant circumcision.”

    If you’re talking sexual benefits, there isn’t a huge quantity of studies, just a couple. Most them don’t show benefits anyway but say that it doesn’t reduce sexual pleasure. Quite different.

  7. joep says:

    Amy said: “Even if we all agree that adult circumcision in parts of Africa where there is high prevalence of HIV can save hundreds of thousands of lives, we’d still need to acknowledge that at the individual level some men will suffer complications. So the mere fact that individual complications can occur does not tell us whether a public health recommendation is beneficial.”

    You should really do a better job of compartmentalizing the issue. Whereas you were speaking about low prevalence neonatal you now are focusing on high prevalence adult .

    In fact I have never said that an adult should be prevented from choosing to seek out circumcision, under any circumstances. Just like they should be allowed to get tattoos or piercings on or through what ever they care. They can be presented with the risks and potential benefits. Any complication they suffer from choosing the intervention is then on the adult to deal with.

    In some location in Africa that might be presented as a modest protection against HIV when a condom is not used. In most other industrialized countries that would have to be changed to a trivial (almost immeasurable) reduction in lifetime risk. And because it’s trivial in those industrialized countries, neonatal should not even enter ones mind.

  8. Robert Samson says:

    Amy, this is for you..

    “there are real benefits, and defending on the population, those benefits can extend to hundreds of thousands of lives saved.”

    Amy, I have repeatedly asked for SCIENTIFICALLY CREDIBLE evidence for ANY benefit. You have ignored this request, yet keep repeating this mantra as if it was valid. You have tried to conflate HAVING a study with it being automatically BEING a VALID study. So unless and until you can provide one, mere repetition is not credible.

    “But, beyond the risk of individual complications, no one has yet shown any harm of any kind from widespread neonatal circumcision.”

    Look, just because you refuse to read and address the Taylor and Sorrels study, hardly adds credilbility to this notion of no harm–ignorance of the evidence (ESPECIALLY CHOSEN ignorance) hardly makes it disappear.

    “Fine, but that’s not the only factor in public health decisions, not should it be.”

    But the crucial factor you are choosing to ignore is that you have yet to provide a single SCIENTIFICALLY CREDIBLE benefit..and your mantra falls flat without this.

    “Even if we all agree that adult circumcision in parts of Africa where there is high prevalence of HIV can save hundreds of thousands of lives, we’d still need to acknowledge that at the individual level some men will suffer complications. So the mere fact that individual complications can occur does not tell us whether a public health recommendation is beneficial.”

    But the crucual problem is that we do NOT agree–and we do not agree because, as we have pointed out again and again, that the studies suggesting this are predicated solely on KNOWN flawed studies and fail to fulfill the prediction inherent in those studies..

    At the bottom is you ASSUME something is valid that is NOT.

    Please humor me and go to this link, and debate the points therein before you keep repeating your mantra.

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

  9. Fifi says:

    Dr Tutuer – That’s a very reasonable position to take NOW but you still haven’t taken responsibility for your words or actions, or the fact that you weren’t actually weighing the evidence and apparently go out of your way to be inflammatory. Even when called out by a respected and established SBM blogger, you avoided taking responsibility for your words and obvious intention to be inflammatory. You haven’t actually engaged in an evidence-based discussion regarding circumcision, instead you continued to be inflammatory in the comment section. The fact that you are still avoiding being accountable and now trying to present as if you are being reasonable and have been all along is merely an indication that you’re mainly interested in image control (and how you look or having people look at you) and will continue to behave as you did originally.

    To claim that you’re actually on some moral high ground regarding AIDS and HIV at this point – when it’s clear that AIDS is something you were merely using to promote your agenda, a fact made evident by your avoidance of discussing safer sex practices when initially brought up by many posters here – is yet more image massaging that is no different than the anti-circ/intactivist claim to be holding some moral high ground. Your use of the suffering of others in this manner is just as unethical and narcissistic as it is when it is done by the anti-circ/intactivist camp. You’re simply the other side of the same ideological coin and you’re playing exactly the same game – which isn’t engaging in discussions that respect science-based medicine or compassionately engaged in a discussion about human rights and reducing suffering.

  10. “You cannot alter form without altering function.”

    Evidently in the case of circumcision, you can do so.

    Are there any metrics on which circumcised and uncircumcised men differ?

    Ability to have intercourse? No.
    Frequency of intercourse? No.
    Ability to reproduce? No.
    Number of children? No.
    Reported sexual satisfaction? No.
    Ability to urinate? No.
    Long term health sequelae? No.
    I could go on and on, but I think you get the point.

    There’s no evidence that circumcision alters function in any way.

  11. Plonit says:

    I’m not arguing FOR circumcision, and I’ve not made any claims for sexual benefit.

    If you argue FOR prohibition, you must show clear evidence of harm.

    The prohibition of FGM is not based solely or mainly on evidence that sexual pleasure is reduced, but rather on a wide-range or harm to health.

    Just because someone wrote “the fundamental biological sexual act becomes, for the circumcised male, the satisfaction of an urge and not the refined sensory experience it was meant to be” in JAMA in 1970 doesn’t make it so. Is it the case that the sexual act for the circumcised male is “not the refined sensory experience it was meant to be”? How would we measure this? (self-reporting?ability to achieve and sustain an erection? to achieve orgasm? length of time to orgasm?). That is the research question to be addressed.

  12. “I have repeatedly asked for SCIENTIFICALLY CREDIBLE evidence for ANY benefit.”

    And you’ve ignored the evidence. There is no doubt that circumcision decreases transmission of HIV and other sexually transmitted diseases, and is associated with reductions in cervical cancer and penile cancer.

    That it not enough to support an argument that all male infants should be circumcised, but the scientific evidence itself is not in doubt.

  13. Fifi says:

    Dr Tuteur – It’s also highly irresponsible and ignorant to talk about AIDS in Africa (particularly Uganda) without addressing the very concerted effort made by the US to block access to sex education and condoms. Proposing circumcision as a solution, while ignoring the reality of ideological interference with sexual healthcare and education, and access to condoms and other forms of birth control, is yet again simply trying to further your agenda/opinion while ignoring reality. You really are no friend of SBM, you clearly just like how you think pretending to be one makes you look and the reaction you can get from people you like to feel superior to.

    It’s perhaps as irresponsible as proposing that circumcision is a good thing in America because it protects from AIDS or STDs when everyone should be using barrier methods if they’re not in a long term, committed, monogamous relationship. As someone who has lost friends to AIDS, I find your narcissistic use of AIDS offensive and your claims to be somehow helping and caring self-serving and dishonest.

  14. Robert Samson says:

    “What is the evidence that circumcision makes a difference either to sexual function or sexual pleasure?”

    Sensations and sensitivity are part of the “function” and pleasure

    http://www.cirp.org/library/anatomy/taylor/

    http://www.urotoday.com/42/browse_categories/erectile_dysfunction_ed/finetouch_pressure_thresholds_in_the_adult_penis.html

    Fine-Touch Pressure Thresholds in the Adult Penis l

    http://www.nocirc.org/touch-test/bju_6685.pdf

    “Analysis of results showed the glans of the uncircumcised men had significantly lower thresholds than that of circumcised men (P = 0.040). There were also significant differences in pressure thresholds by location on the penis (p < 0.0001). The most sensitive location on the circumcised penis was the circumcision scar on the ventral surface. It was remarkable that five locations on the uncircumcised penis that are routinely removed at circumcision had lower pressure thresholds that the ventral scar of the circumcised penis.

    This study suggests that the transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. It appears that circumcision ablates the most sensitive parts of the penis."

    http://www.prweb.com/releases/2007/3/prweb512999.htm

    "A new study in the British Journal of Urology International shows that men with normal, intact penises enjoy more sexual sensitivity — as much as four times more — than those who have been circumcised. Circumcising slices off more of a male's sensitivity than is normally present in all ten fingertips. "

    "Pleasure is subjective."

    Without nerves and sensations, there can be no pleasure–subjectively or objectively!

    "Similarly, where is the evidence that circumcision causes erectile impairment?"

    "The nerves in the foreskin apparently provide an impulse to aid erection. Circumcision has long been associated with an increased incidence of impotence. Glover reported a case in 1929. Winkelmann suggested impotence as a possibility in 1959.6 as did Foley in 1966. Stinson reported five cases in 1973. Palmer & Link reported two cases in 1979. More recently, additional evidence of sexual dysfunction after circumcision has emerged. Coursey et al. reported that the degradation in sexual function after circumcision is equivalent to the degradation experienced after anterior urethroplasty. Fink et al. reported statistically significant degradation in sexual function. A survey carried out in South Korea found that circumcised men reported painful erections, and diminished sexual pleasure, and a few reported curvature of the penis upon erection. Shen et al., in a study carried out in China, reported erectile dysfunction in 28.4 percent of the men in the study after circumcision, and 'weakened erectile confidence' in 34.7 percent."

    http://www.cirp.org/library/sex_function/ (File revised 28 February 2004)

    If you require more, just ask.

    "Similarly, when I look at the totality of studies showing harms of circumcision, I find them dificient in various ways. The huge *quantity* of studies showing harms of circumcision do not, in my view, provide a basis for prohibiting routine infant circumcision."

    Sorry, but until and IF circumcisers can provide SCIENTIFICALLY CREDIBLE evidence of benefit, it is hardly fitting to arbitrarily dismiss prohibition by simply stating YOU do not find SUFFICIENT harm…First do NO harm!

    "The issue of the harm of the procedure without pain relief can be separated entirely from the issue of circumcision per se, simply by ensuring that pain relief is used (local anaesthesia for the procedure and simple analgesia post-operatively if required)."

    Sorry, but this apologia does not fly simply because ANY KNOWN pain relief method used on infants does NOT eliminate pain–only reduces it.

  15. Nick says:

    “Ability to have intercourse? No.
    Frequency of intercourse? No.
    Ability to reproduce? No.
    Number of children? No.
    Reported sexual satisfaction? No.
    Ability to urinate? No.
    Long term health sequelae? No.
    I could go on and on, but I think you get the point.

    Ability to urinate? No.
    Long term health sequelae? No.
    I could go on and on, but I think you get the point.”

    Yes I get the point, but it’s not the point it’s YOUR point, not the one I was trying to make. Basically your point is a circumcised man can still have intercourse and have children etc…My point is that circumcision have impacts on sexuality (both as regards quality and quantity) :

    the fundamental biological sexual act becomes, for the circumcised male, the satisfaction of an urge and not the refined sensory experience it was meant to be.

    Also, at the end of life, the exposed, calloused, desensitized, glans becomes more and more difficult to stimulate. It’s no surprise that males in the US have a high rate of erectile dysfunction, and the USA has the highest sales of Viagra in the world.

    This has nothing to with ability of reproduction, circumcision etc…

  16. Robert Samson says:

    ME:“I have repeatedly asked for SCIENTIFICALLY CREDIBLE evidence for ANY benefit.”

    AMY:”And you’ve ignored the evidence. There is no doubt that circumcision decreases transmission of HIV and other sexually transmitted diseases, and is associated with reductions in cervical cancer and penile cancer.”

    NO, I have critically and scientifically evaluated the evidence–YOU obviously have not!

    All you are doing with your endless repetition is showing you are scientifically illiterate. And by you not going to the link provided and actually discussing the SCIENCE in regards to your “evidence” is showing that you are CHOOSING to remain ignorant of the scientific process.

    “That it not enough to support an argument that all male infants should be circumcised, but the scientific evidence itself is not in doubt.”

    I am afraid you use the term “scientific evidence” without understanding what it really is.

    Once again, please go to the link and actually debate your “evidence” based on the real scientific process.

    Your empty repetition is tiring beyond belief.

  17. Nick says:

    “And you’ve ignored the evidence. There is no doubt that circumcision decreases transmission of HIV and other sexually transmitted diseases, and is associated with reductions in cervical cancer and penile cancer.”

    Could you explain why US has both the highest rates of circumcision and HIV among industrialized countries ? Why other countries like Sweden, Finland etc…where circumcision rate is close to 0% have the lowest rates of HIV in the world ?
    Why empirical evidence doesn’t confirm these studies ?

  18. “My point is that circumcision have impacts on sexuality (both as regards quality and quantity)”

    Yet there’s absolutely no evidence of that.

  19. Nick says:


    “My point is that circumcision have impacts on sexuality (both as regards quality and quantity)”

    Yet there’s absolutely no evidence of that.

    I show you a couple of studies saying it does. Why these studies have zero credit according to you when at the same time you are very happy to show a study from Africa claiming it doesn’t have any impact on sexuality ? Why these studies coming from Africa have more than value than mines ?

  20. joep says:

    Amy said: “And you’ve ignored the evidence. There is no doubt that circumcision decreases transmission of HIV and other sexually transmitted diseases, and is associated with reductions in cervical cancer and penile cancer.”

    Well fair is fair, you have ignored the ethical considerations, where it relates to neonatal, which is at least equally important.

    I always liked the cervical cancer and penile cancer argument. Especially when we’ve had not just one but two HPV vaccines which are in excess of 90% efficient available for what four years now? I am curious Amy, do you agree with the British Medical Association’s view:

    “Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. ”

    A yes or no should be sufficient.

  21. Robert Samson says:

    “You cannot alter form without altering function.”

    Evidently in the case of circumcision, you can do so.

    Are there any metrics on which circumcised and uncircumcised men differ?

    Ability to have intercourse? No.
    Frequency of intercourse? No.
    Ability to reproduce? No.
    Number of children? No.
    Reported sexual satisfaction? No.
    Ability to urinate? No.
    Long term health sequelae? No.
    I could go on and on, but I think you get the point.

    There’s no evidence that circumcision alters function in any way.”

    Oh, god, where to start on this????

    “Ability to have intercourse? No.”

    YES!! especially when one is dead, lost glans, suffer from erectile impairment.

    “Frequency of intercourse? No.
    Ability to reproduce? No.
    Number of children? No.”

    YES–see directly above

    “Reported sexual satisfaction? No.”

    YES.

    http://www.cirp.org/library/sex_function/kim2006/

    http://www.cirp.org/library/sex_function/fink1/

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14979200&dopt=Abstract

    http://www.nzma.org.nz/journal/116-1181/595/

    http://www.cirp.org/library/sex_function/vissing1/

    http://www.blackwell-synergy.com/doi/abs/10.1111/j.1464-410X.2006.06685.x

    http://www.blackwell-synergy.com/doi/abs/10.1111/j.1464-410X.2006.06646.x?prevSearch=keywordsfield%3A%28%22Circumcision%22%29

    http://www.cirp.org/library/anatomy/taylor/

    AND the Sorrels study posted earlier.

    “Long term health sequelae? No.”

    Now, go back and look at the list of complications I posted earlier.

  22. Nick says:

    Amy,

    Please read this study and tell me where they are wrong :

    http://www.circumstitions.com/Images/sorrellsvm&j-poster.pdf

    You claim in your article :
    “But recent studies make it clear that sexual satisfaction is not affect by circumcision”

    It really isn’t clear and there were no studies about sexual satisfaction, just a survey

  23. Robert Samson says:

    “Could you explain why US has both the highest rates of circumcision and HIV among industrialized countries ? Why other countries like Sweden, Finland etc…where circumcision rate is close to 0% have the lowest rates of HIV in the world ?
    Why empirical evidence doesn’t confirm these studies ?”

    YES!! I wish she would please do so, as this ability to always fulfill prediction is a critical and crucial requirement for scientific credibility–as she would realize if she actually went to the link provided discussing her claims as they relate to the SCIENTIFIC PROCESS.

    But apparently she instead choose to remain ignorant of SCIENCE so she can then pretend that her claims are valid.

    And I find it amusing that she seems to believe known flawed studies have more weight than EMPIRICAL evidence (in science–this is the strongest form of evidence). Oh, well!

  24. Plonit says:

    Correlation is not (on its own) evidence of causation. There may be a lot of confounders, which is why the presence of low or high circumcision withe low or high HIV rates doesn’t (on its own) tell us a lot about the effect of circumcision. There was a nice post last week on this site which will help you make sense of this (Causation and Hill’s Criteria). Sometimes, and where it is possible/ethical to design a good trial, it is necessary to use RCTs to clarify these issues and remove confounding factors.

    But at least your observations on the *correlation* (not causation) of circumcision and HIV in Sweden and the US is accurate, unlike Dr Amy’s assertion upthread that “countries with low prevalence of HIV tend to have high rates of circumcision already” which is demonstrably not true.

  25. Robert Samson says:

    I would like to add something on my post of 10 Jan 2010 at 1:05 pm

    Ability to urinate:

    Meatal stenosis 8%

    Meatal stenosis – Complications
    “Persistent urinary problems including abnormal stream, painful urination, frequent urination, urinary incontinence, blood in the urine, and increased susceptibility to urinary tract infections can be complications.”

    And iatrogenic phimosis:

    http://www.cirp.org/library/complications/williams-kapila/\

    *****Insufficient excision of the foreskin and inner preputial epithelium may result in wound contraction and cicatrization of the distal foreskin. The fibrotic ring so produced may result in true phimosis, an event observed in 2 per cent of cases in one UK series15. In severe cases urinary obstruction may ensue19.”

  26. Robert Samson says:

    “But at least your observations on the *correlation* (not causation) of circumcision and HIV in Sweden and the US is accurate”

    The true importance of this empirical evidence is that it shows that the hypothesis that circumcision reduces HIV is not fulfilled, and hence not SCIENTIFICALLY valid.

    And any conjecture WHY this is not fulfilled without HARD numbers of the other alleged co-factors and used in a working model that explains the discrepancy is nothing but a speculative excuse–and SCIENCE accepts neither speculation nor unsupported excuses.

  27. Robert Samson says:

    “There is no doubt that circumcision decreases transmission of HIV and other sexually transmitted diseases, and is associated with reductions in cervical cancer and penile cancer.”

    While we are looking at real world rates vs claims of circumcision reducing them..

    WHY are the rates of all of these HIGHER in the USA than in other intact counties?

    HOW CAN these rates be higher in the USA with high circumcision rates when the circumcision rates are lower in those other countries with lower rates of these diseases?

    Or are we supposed to just ignore logic and even common sense?

  28. Plonit says:

    Well, the claims of risk reduction relate mainly to female-to-male transmission. Most HIV in the US is either transmitted male-to-male, or IV drug use. In the former case, no evidence exists to show benefit of circumcision, in the latter case there is no plausible biological mechanism for reduced transmission. So, the efficacy of circumcision in risk reduction will depend on the populations/prevalence/mode of transmission in a given country/context.

  29. “Please read this study and tell me where they are wrong”

    Read the study and explain why it is clinically relevant? The fact that a phenomenon can be demonstrated in a small group of people doesn’t tell us whether it is real, or even if it is real, whether it has any clinical effects.

    Millions upon millions of men have been circumcised. If there were clinically significant differences, we would see them in large populations and we would have seen them long ago.

  30. Nick says:

    “Well, the claims of risk reduction relate mainly to female-to-male transmission. Most HIV in the US is either transmitted male-to-male, or IV drug use. In the former case, no evidence exists to show benefit of circumcision, in the latter case there is no plausible biological mechanism for reduced transmission. So, the efficacy of circumcision in risk reduction will depend on the populations/prevalence/mode of transmission in a given country/context.”

    If it’s true Africa and America are very different in many ways, but Europe and US have almost the same level of education, access to condoms, safe sex etc…
    If circumcision really prevent HIV by 55%, even if correlation is not evidence of causation, you should at least expect US with lower rates than European countries. But in fact it’s just the opposite !
    If there are other factors to consider into the equation, why not studying these factors instead on focusiing only on circumcision ?

    And these studies are also debatable for many reasons :

    The circumcised men in the study were given a head start, not to mention, the studies were ended early. The circumcised men were told to abstain from sexual activity for 6 weeks following their operation. Furthermore, they were instructed in the use of condoms. The credit of “HIV reduction” was given, not to the education and condoms the circumcised men received, but their circumcisions. How can this even be called a “study?”

    Links to the studies can be found here:

    Consenting to avoid sexual contact (except with condom protection) during the 6 weeks following the medicalized circumcision”
    http://clinicaltrials.gov/show/NCT00122525

    “When you are circumcised you will be asked to have no sexual contact in the 6 weeks after surgery. To have sexual contact before your skin of your penis is completely healed, could lead to infection if your partner is infected with a sexually transmitted disease. It could also be painful and lead to bleeding. If you desire to have sexual contact in the 6 weeks after surgery, despite our recommendation, it is absolutely essential that your (sic) use a condom.”
    http://medicine.plosjournals.org/archive/1549-1676/2/11/supinfo/10.1371_journal.pmed.0020298.st003.pdf

    The conductors of these “studies” have conflicts of interest; Robert Bailey is a known long-standing circumcision advocate, and Daniel Halperin is Jewish, where infant circumcision is central to his cultural and ethnic identity, and he has openly stated he wants to continue his grandfather’s legacy. The authors of these studies have compelling reasons to skew the information in favor of circumcision, and it is evident that they have.

  31. stephend50 says:

    The highest profit making anything in the Pediatric Hospitalist group affiliated with the Internal Medicine Hospitalist group I am a member of is…. circumcision.

    The leading cause of STDs is sticking things in places they shouldn’t be stuck. And Dr. Tuteur, please refrain from projecting onto the male half of the species your thoughts about our motivations. Peoples’ motivations are complex.

    Oh, as Robin Williams pointed it out, “it’s a rediculous piece of skin! Look it’s a snake wearing a sweater!” But it’s a part of me that I was born with, it’s attached. Is there any research looking into negative outcomes of circ? What are the theories about why we — as in class mammalia — evolved with foreskins? The end of my coccyx is a vestigal tail, but I’m not looking for an orthopod or neurosurgeon to cut if off.

  32. Plonit says:

    but Europe and US have almost the same level of education, access to condoms, safe sex etc…

    +++++++++++

    They are also similar insofar as most HIV transmission is male-to-male sexual transmission, or associated with IV drug use. We have no evidence that circumcision has any impact on male-to-male sexual transmission, and we have no reason to suspect that circumcision makes a difference to transmission associated with IV drug use. If circumcision makes no difference for these routes of transmission, then we wouldn’t expect diferences in circumcision rates to make a difference in countries where HIV is transmitted primarily by routes upon which circumcision has no effect.

  33. Nick says:

    “They are also similar insofar as most HIV transmission is male-to-male sexual transmission, or associated with IV drug use. We have no evidence that circumcision has any impact on male-to-male sexual transmission, and we have no reason to suspect that circumcision makes a difference to transmission associated with IV drug use. If circumcision makes no difference for these routes of transmission, then we wouldn’t expect diferences in circumcision rates to make a difference in countries where HIV is transmitted primarily by routes upon which circumcision has no effect.”

    In that case where making a case for circumcision, more precisely neonatal circumcision, in US ?

  34. Annabel says:

    Amy,

    I still haven’t seen you link any scientific evidence that neonatal circumcision offers any more or even equal benefit than adult circumcision. As others have asked multiple times, why NEONATAL?

    Aside from the ethical difference of circumcisions performed on *adult* *volunteers*, circumcision on infants is physically different than the circumcision of adults. In adults the foreskin is, in almost all cases, fully retractible. In infants, it is fused to the glans much like a fingernail. The foreskin must be forcibly separated from the glans before it can be removed. Could this make a difference in the benefits of HIV transmission risk reduction? It could, we don’t know. Until you or someone from the pro circumcision camp can find a study that proves that INFANT circumcision shows the same benefits that adult circumcision does, you need to explain why you recommend it be done on neonates.

    Just because something can be achieved, doesn’t mean it is ethical to do so. Sure, I could keep my child in an underground bomb shelter the first 18 years of life ( while still getting food, water, and home school education) to prevent her from dying in a car accident, or getting struck by lightning, or dying in a tornado. Does that mean I SHOULD do this? just because the desired result CAN be achieved this way? This example is intentionally ridiculous, but it is proving a point.

    Would you also recommend removing the breast buds of infants? It would save thousands of more lives than a 60 percent risk reduction in HIV in the United States, where 1 in 8 women will get diagnosed with breast cancer. If not, why? Is non essential breast tissue different than non essential foreskin? It could be safer when done to babies, since there is less breast tissue to remove, and it would be less invasive.

  35. joep says:

    Just so this doesn’t get buried, I am curious Amy, do you agree with the British Medical Association’s view:

    http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp

    “Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. ”

    A yes or no should be sufficient.

  36. Plonit says:

    In that case where making a case for circumcision, more precisely neonatal circumcision, in US ?

    +++++++++++

    I agree. The differences between the contexts of the trials and the US/Europe certainly undermine any case for routine infant circumcision in the US.

  37. Robert Samson says:

    “Millions upon millions of men have been circumcised. If there were clinically significant differences, we would see them in large populations and we would have seen them long ago.”

    WE have!

    Just because you refuse to even look at the evidence, speaks volumes.

    I have yet to see you post anything of substance other than your denial to look at the evidence.

  38. joep says:

    Plonit said: “I agree. The differences between the contexts of the trials and the US/Europe certainly undermine any case for routine infant circumcision in the US.”

    I would have to agree too, it is clear that this discussion isn’t really being properly compartmentalized. There are four cases as I see it: neonatal in a place like Africa, adult in a place like Africa, and the same two options in industrialized/low prevalence countries. You could currently make a plausible case in Africa and ethically I think you have to limit it to consenting adults. There are big hurdles to it though which I think have been and will be ignored. But on the actual subject of this post I can’t see any rational thinker making a case for neonatal circumcision in the US.

  39. Robert Samson says:

    BTW Amy,

    Have you looked at the link looking at the scientific credibility of the claim of HIV reduction yet?

    IF so, any rebuttal you wish to offer?

    If you haven’t looked at it yet, why not?

    So you don’t need trouble yourself to look for the link, here it is again:

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

    I will await your response…..

  40. human2010 says:

    I agree that female circumcisions on infant girls and female teens prevent HPV, HIV infectious disease transmissions to the male partners. In a study by CDC, the circumcisions of female teens & infants at birth reduced the spread of HPV & AIDS transmissions later in lfe by 92%, as well as is more hygienically sound.
    Can’t argue with science and facts.
    I prefer a circumcised female partner because of the smell.

  41. Plonit says:

    Oh, well now we have moved into different territory.

    Nick, do you contend that HIV is not the cause of AIDS?

  42. Nick says:

    Nick, do you contend that HIV is not the cause of AIDS?

    The article wasn’t about origin of AIDS and has nothing to do with it. It just mentions the flaws of HIV&Circumcsion studies without questionning origin of AIDS. Also the site isn’t saying HIV is not the cause of AIDS but HIV is not the necessary and sufficient cause of AIDS.

  43. Robert Samson says:

    “Nick, do you contend that HIV is not the cause of AIDS?”

    How did you get from pointing out some of the many flaws in the African studies to the notion that HIV does not cause AIDS????

    BTW, all three of these trials are the same–and based on the nonsense dreamed up by Bailey–and all have the same fatal flaws.

  44. Robert Samson says:

    here is some food for thought:

    The CDC itself has debunked the notion of epithelia transmiting the HIV virus–which lies at the very foundation of the circumcision/HIV hypothesis.

    http://www.cirp.org/library/disease/HIV/dezzutti/
    Communicable Disease Center, June 1998

    [278/32124] Mechanisms of HIV Transmission through Epithelial Cell Barriers
    Charlene S. Dezzutti
    R.B. Lal. CDC, Mail Stop G19,
    1600 Clifton Rd,
    Atlanta, Ga 30333,
    USA
    Abstract
    Objectives: Previous studies have shown that HIV can be transcytosed across epithelial cell line barriers; however, there is no information concerning primary epithelial cells. Our objectives were to determine if primary epithelial cells have the ability to harbor and transmit HIV and to determine if primary epithelial cells can transcytose HIV.

    Methods: For HIV transmission, primary prostate epithelial cells (PrEC) and two epithelial cervical carcinoma cell lines, ME-180 and CaSKI, were inoculated with HI and washed. Various concentrations of resting or activated CD8-depleted PBMCs were added before or after the epithelial cells were trypsinized.

    Supernatants were monitored every 2 days for HIV expression using a p24 ELISA. DNA PCR was performed on the pot-trypsinized epithelial cells to evaluate proviral integration. For HIV transcytosis, the epithelial cells were cultured on 0.4 mM transwell filters until confluent (day 7). Cell-free HIV (LAI; MOI .001) or cell-associated (18 hours, TNF a-induced OM10.1 cell line) HIV was added to the apical side. The basolateral medium was sampled for HIV p24.

    Results: Without trypsinization, HIV was recovered by day 3 from ME-180 and CaSKI cell lines and by day 7 from the PrEC cells y activated PBMCs but not by resting PBMCs. For all epithelial cells, at least 5 [times] 105 activated PBMCs (2 PBMCs to 1 epithelial cell) were required for HIV recovery. Trypsinization of the epithelial cells resulted in a loss of recoverable HIV from PEC, but not ME-180 and CaSKI cells, even though all transiently had provirus. We next explored HIV transcytosis. PrEC developed a tight-junction monolayer as seen by high transepithelial resistance (433 W [times] cm2). CaSKI cells developed a moderate tight-junction monolayer (50 W [times] cm2), while the ME-180 cells failed to make a tight-junction monolayer. Consequently, cell-free HIV was readily transcytosed through ME-180 cells by 1 hour and through CaSKI cells by 2 hours. Cell-associated virus began to transcytose through ME-180 and CaSKI cells by 24 hours. Importantly, PrEC did not transcytose cell-free or cell-associated HIV.

    Conclusions: Both primary and immortalized epithelial cells have the capacity to transiently sequester HIV, but primary (PrEC) cells are incapable of transmission. Further, formation of a tight-junction monolayer by PrEC did not allow transcytosis of cell-free or cell-associated HIV. Collectively, these data suggest that the in vivo mucosal epithelial barrier protects against HIV transmission, and that factors, such as STDs, affecting the integrity of transepithelial tight-junctions may allow viral entry and thus have implications for sexual transmission.

    http://www.cirp.org/library/disease/STDnew/geneva/

    GENEVA, Jul 02 (Reuters) — Healthy epithelial cells that line the body cavities and cover structures such as the cervix and prostate resist HIV infection, according to a report presented Thursday at the 12th World AIDS Conference by researchers from the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia.

    But this protection against infection is lost when the cells have been altered by infection with other sexually transmitted diseases (STDs).

    “This is the first study to demonstrate that normally functioning epithelial cells are incapable of transmitting HIV,” said CDC researcher Dr. Charlene Dezzutti in a press statement. “But STDs and other factors which damage these cells can play a major role in the sexual spread of this epidemic.”

    “The normally functioning cells formed a tight bond between cells that would not allow HIV to pass through, while the (diseased) cells failed to develop a tight bond and did allow passage of the virus,” according to the CDC statement.

    So, why is the CDC seriously looking into possibly recommending circumcision??

    This commentary from a lawyer attending their conference might probvide us a clue:

    http://www.circumcisionandhiv.com/

    This week I attended the CDC sponsored 2009 National HIV Prevention Conference in Atlanta, Georgia where I live. The assembled CDC worthies were promoting circumcision on the basis of three African Randomized Controlled Trials (RCTs), the conclusions of which were presented by one speaker as being “beyond a reasonable doubt.” [Those trials purport to show a dramatic reduction in HIV acquisition in circumcised adult men. They have been subjected to considerable criticism and doubt by others including noted physicians and public health professionals. See http://www.circumcisionandhiv.com. Katrina Kretsinger, MD, of the CDC was asked if the RCTs would be repeated in the U.S. She replied that they would not be because it would be unethical to do so! Then how were they ethical to start with? When I attended the session where Deborah Gust of the CDC presented a paper demonstrating that circumcision made no difference in the acquisition of HIV by insertive gay males, I asked why these results did not bring into question the conclusions of the RCTs since the anus supposedly contains more HIV than the vagina. The reply, as I understood it, was that since the insertive males also were sometimes receptive males you could not say how they got HIV. Of course, if that is the case, then the study was worthless. But since it was presented as being worthy (otherwise why present it?), I am of the opinion that it does bring into question the validity of the RCTs, as does the known fact that the U.S. has the highest rate of HIV in the industrialized world (a fact one speaker brought up), the highest STD rate in that same world, and the highest rate of male circumcision in that same world. So much for the great American circumcision experiment! It has already failed! Why would reasonable scientists want to repeat it?

    At one of the last sessions the speaker from “Operation Abraham”, a Jerusalem, Israel group that apparently hopes to be engaged to assist the U.S. in circumcising the black and Hispanic males who are not circumcised, put a photo of an intact male up on the screen. The figure of an elephant had been drawn around the penis so that the intact penis looked like an elephant’s trunk. The words “Please circumcise me” had been added to the photo. I remonstrated loudly until this smear against intact males was taken down. I then promptly left the session. I am still awaiting a deserved, written, direct apology from Dr. Peter Kilmarx, Chief of the Epidemiology Branch of the Division of HIV/AIDS Prevention of the CDC, who was in attendance and from whom I demanded an apology. I think this shows the mindset of the CDC. They seem to have abandoned all scientific objectivity to promote a useless and mutilating surgery. I expect the men are all circumcised and the women are all married to circumcised men. So the trauma repeats itself and those who have been traumatized fulfill their need to traumatize others. [See http://www.circumcision.org. And apparently they think it is socially and ethically acceptable to denigrate a normal body part and to attempt to humiliate all intact boys and men into submitting to circumcision.

  45. Nick says:

    “Nick, do you contend that HIV is not the cause of AIDS?”

    The article wasn’t about origin of AIDS and has nothing to do with it. It just mentions the flaws of HIV&Circumcsion studies without questionning origin of AIDS. Also the site isn’t saying HIV is not the cause of AIDS but HIV is not the necessary and sufficient cause of AIDS.

  46. Nick says:

    Nick, do you contend that HIV is not the cause of AIDS?

    To answer your question I dunno probably not.
    But one thing is sure : The more I read Amy’s articles the less I believe in “official” science.

  47. Xero says:

    Dr. Tuteur, in response to your quote below, please answer the following questions:

    1. Is sensory perception a function of the human body?
    2. Does the tissue that would be removed by circumcision perform a sensory function in intact men?
    3. Can you cite any evidence which contradicts Sorrells’ measurements of fine-touch pressure thresholds in anatomy possessed only by intact males? (Full text here: http://www3.interscience.wiley.com/cgi-bin/fulltext/118508429/HTMLSTART )
    4. Do you accept objective loss of sensory capability as a “clinical effect”, or do you consider such loss not “clinically relevant” and therefore irrelevant?
    4. Will you separate science and medical evidence from policy advocacy propped up by cultural sacred cows unconstrained by principles of medical ethics?

    Dr. Tuteur wrote:
    “Are there any metrics on which circumcised and uncircumcised men differ?

    Ability to have intercourse? No.
    Frequency of intercourse? No.
    Ability to reproduce? No.
    Number of children? No.
    Reported sexual satisfaction? No.
    Ability to urinate? No.
    Long term health sequelae? No.

    I could go on and on, but I think you get the point.

    There’s no evidence that circumcision alters function in any way.”

  48. Plonit says:

    Please don’t judge science by Dr Amy’s articles. She is a controversialist, and shows scant regard for science when it gets in the way of her prejudices.

    I’m not sure I know what you mean when you say you probably believe that “HIV is not the necessary and sufficient cause of AIDS.”

    If HIV is a not a necessary cause of AIDS, that implies that AIDS can have other causes. What are those other causes?

    If HIV is not a sufficient cause of AIDS, do you mean that some other factor(s) must *always* be present for HIV to cause AIDS? If so, what are those other factors?

  49. Fifi says:

    Nick – You’re very obviously here to troll this blog and are anti-SBM. How is this obvious? You’re even arguing with people who don’t support circumcision when we call you on promoting the anti-science and Scientology-connected insanity of infamous quacks like Rima Laibow as evidence. If you truly were here arguing out of a concern for infants and actually had any respect for science – and weren’t just using it as an ideological tool like Dr Tuteur also did in this blog post – you wouldn’t keep resorting to pseudoscience, attacking people who make reasonable and non-ideological arguments against neonatal circumcision.

    To present your own words again and to reveal just how unethical you really are…

    *Nick – “Those who promote ethical and legal practices have no need to be accountable for their words and actions.”*

  50. Akheloios says:

    Dr. Tuteur is tarnishing the name of Science-Based Medicine.

  51. joep says:

    Oh my, this seems to be getting off the mark again. Let’s get back on track. Just so this doesn’t get buried, I am curious Amy, do you agree with the British Medical Association’s view:

    http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp

    “Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. ”

    A yes or no should be sufficient.

  52. Nick says:

    fiffy,

    What is your obsession with scientology and Rima Laibow? What interesting scientific articles did you bring so far ? What scientific arguments did you bring ?

    Why are you writting the same posts again, again and again ?
    It’s just ridiculous or boring at best.

    Do you need science to be against FGM ?
    Is anyone strongly against FGM also biased and has an axe to grind ?
    What would we do with studies from African doctors who on the front want to “reduce HIV transmission,” through female circumcision?

    “Those who promote ethical and legal practices have no need to be accountable for their words and actions.” : if someone was saying that as regards FGM, would it be also unethical ? Or do they need science to justify their positions ?

    It’s obvious the only trolling is you and nobody else

  53. Nick says:

    “If HIV is a not a necessary cause of AIDS, that implies that AIDS can have other causes. What are those other causes?

    If HIV is not a sufficient cause of AIDS, do you mean that some other factor(s) must *always* be present for HIV to cause AIDS? If so, what are those other factors?”

    This is probably not the right topic to answer these questions. I’m not qualified enoug to answer these question, maybe ask fiffy ?

    Also did you read this article ? It says that the studies were flawed because the circumcised group were given condoms which clearly means that you have to support the official hypothesis (HIV origin of AIDS) to give this article some credit

  54. Nick says:

    Ethic and circumcision :

    http://www.circumcision.org/ethics.htm

    “Like all professions, medicine has its own ethical code and principles of conduct. One rule of conduct is “First, do no harm.” Removing a normal, healthy body part and causing unnecessary pain is doing harm.”

  55. Ian Wilkinson says:

    Dear Dr Teuter,

    I am an Australian Medical Professional who practices on the science-practitioner model and have recently studied the Royal Australasian College of Physicians 2009 Statement on Infant Circumcision. They have taken into account the very studies you mention to argue your case however concluded the following:

    When considering routine infant circumcision, ethical concerns have focused on recognition of the functional role of the foreskin, the non-therapeutic nature of the operation, and the psychological distress felt by some adult males circumcised as infants. The possibility that routine circumcision contravenes human rights has been raised because circumcision is performed on a minor for non-clinical reasons, and is potentially without net clinical benefit for the child.

    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.

    AS one scientist speaking to another I need to hear what scientific evidence and ethical philosophy you have used to come to such a different conclusion to the RACP, one of Australia and NZ highest respected medical Authorities.

  56. Nick says:

    Male genital mutilation is a crime against humanity :

    http://www.youtube.com/watch?v=WaZMHUdY70I

  57. edgar says:

    But wait, aren’t the more extreme form of male circ performed on adults?
    Why should they be banned (and I could have gone my whole life without knowing about those two forms. Gack)

  58. Nick says:

    “Nick – You’re very obviously here to troll this blog and are anti-SBM. How is this obvious? You’re even arguing with people who don’t support circumcision when we call you on promoting the anti-science and Scientology-connected insanity of infamous quacks like Rima Laibow as evidence. If you truly were here arguing out of a concern for infants and actually had any respect for science – and weren’t just using it as an ideological tool like Dr Tuteur also did in this blog post – you wouldn’t keep resorting to pseudoscience, attacking people who make reasonable and non-ideological arguments against neonatal circumcision.”

    Fiffy,
    It is not up to those opposed to circumcision to justify their demands. It is up to those who advocate circumcision, who need to justify their actions legally and ethically. The ridicule and vilification of opponents of circumcision (as well as victims who object to this unlawful intrusion upon their bodies) by accusing them of being radical, or belonging to special interest groups, is the only means left to these charlatans. They are unable provide explanations regarding the ethics of performing surgery for which there is no medical necessity.

  59. edgar says:

    Why would parents go to the doc for a ceremonial pinprick?

    And How do ‘they’ know 1A is the least common? it would seem to me that it would the kind least likely to have complications, thus the least likely to be detected.

  60. Fifi says:

    Ian Wilkinson – Thanks for being a voice of reason and advocate of science-based medicine on this subject. Let’s see if you can be heard over the intentional noise creation or will be drowned out by the ideologues! It really would be nice to read, for once, a rational discussion about this topic. There seems to be a lot of penis waving going on from both sides (and by both genders)!

  61. edgar says:

    “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.”

    This is a very interesting issue. Obviously Amy states what the Jewish faith and tradition claims. And it is a social construct to be sure. Jewish folks believe that if your mother is Jewish then you are, too.
    Muslims believe that ALL newborn babies are inherently Muslim.
    So the difference is what the faith believes to be so, and what the individual person believe to be so. They may or may not coincide. Since we have freedom of religion in this country, where does that leave us? I am sure I don’t know the answer.

    And another though, as I have mentioned in the past, I work in Indian country, and the nuance of cultural differences and having practices be ‘banned’ scares me to some degree, because we have seen over and over, that loss of traditional cultural ceremonial practice and illness(mental and physical)go hand in hand. I would not go so far to say that ‘banning circumcision causes diabetes.’ But the imperialism in which we approach health issues may or may not apply to all cultures. mass hysteria and banning of practices (or overzealous promotion of others) can have far reaching negative consequences.

  62. edgar says:

    “there are real benefits, and defending on the population, those benefits can extend to hundreds of thousands of lives saved.”

    No. There are absolutely no benefits at all to RNC.

  63. Jason says:

    Ian Wilkinson wrote:

    “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.”

    Thank you for your comments. It is interesting that ethical considerations were included in the formulation of the RACP policy.

    I would like to ask about your observation that urinary tract infections may be an important consideration with regard to infant circumcision. Has the RACP in fact studied and documented a linear increase in male infant UTI as the infant circumcision rate has fallen in New Zealand and Australia since about 1970? Or has the RACP simply absorbed the US claim that circumcised male infants and children are at lower risk for UTI?

    After almost 30 years of scrutiny, it is abundantly clear that Wiswell’s 1982 data review that made this claim was deeply flawed. It was not a controlled prospective study; it failed to take into account congenital irregularities from premature birth (likely a large component of the relatively few intact subjects); and most important, it failed to control for proper care of the penis. As it has become better understood that the healthy foreskin may not become freely mobile on its own until puberty (previously thought to be expected by about age 3), premature retraction of the foreskin has been implicated in the transmission of bacterial and viral infections. It is counterintuitive that circumcision would reduce UTI, since the procedure removes an effective cover with muscle tissue that closes in a unique whorl fashion to protect the urethra from irritants and pathogens, as well as the meatal lips that protect the urethra but are routinely damaged through circumcision.

    The RACP should clarify its basis for claiming a circumcision-UTI connection. If the basis is its own study or observations, this would carry more weight than merely repeating the conclusions of one large data review in American military hospitals from a generation ago. To my knowledge, there have been no published reports of statistically significant increases in male infant UTI in Canada, Australia or New Zealand during that time period.

  64. Ian Wilkinson says:

    Jasonon

    The full research paper of the RACP 2009 Statement is not available last time I looked on their website, However the Chairman David Forbes was reported in the media as stating that the more we find out about renal function in the role of UTI’s the less relevant circumcision becomes.

    Dr Tueter,

    It would benefit the science-based medical community if you could share your scientific evidence and ethical philosophy that appears to contradict the RACP 2009 Statement.

    In particular I would like to hear your views, about the level of protection offered by circumcision as analysed and assessed by the RACP is deemed to not warrant infant circumcision.

    Also the acknowledgement that the foreskin is functional anatomy, what is your view on this?

    Further that there are ethical concerns about performing a non-therapeutic clinical procedure on an infant that cannot consent?

    And that in a western medical context such as Aust & NZ that circumcision is not warranted. Would you place the USA in a similar medical context to Aust and NZ?

    Further that the RACP acknowledges that some men experince psychological harm due to their circumcisions, do you acknowledge this or deny this?

    The answer to these questions would further the the scientific discussions, there are many Aust & NZ Medical practitioners interested in your response to these questions?

  65. Ian Wilkinson says:

    Science Based Medicine

    DR Tueter
    AS you have not responded I will ask again, and clarify my questions further:
    To further science it is important that we provide the scientific rational for our public statements including scientific data, a cost benefit analysis of that data, and the ethics and philosophy surrounding this data.
    I and my Aust & NZ colleagues would be most interested in hearing your views on the following:
    The RACP stated ethical concerns have focused on recognition of the functional role of the foreskin, Do you consider the foreskin as functional anatomy? If not was is your evidence? If it is functional anatomy what is your ethical position on removing this from a non-consenting infant?

    The RACP stated that routine infant circumcision is non-therapeutic in the nature of the operation, What is your view on this?

    The RACP has acknowledged the psychological distress felt by some adult males circumcised as infants. Do you believe this is the case? If not what is your evidence to state this is not the case?

    The RACP has also stated “The possibility that routine circumcision contravenes human rights has been raised because circumcision is performed on a minor for non-clinical reasons, and is potentially without net clinical benefit for the child” is another reason not to recommend RIC. How do you respond to this?
    The RACP also stated “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.”
    How do you respond to the frequency of the conditions in a western medical context not warranting a recommendation of circumcision for infants.
    How do you respond to the level of protection for UTI, HIV and Penile cancer not warranting circumcision for infants?
    How do you respond to the complication rate of circumcision not warranting circumcision for infants?
    The RACP 2009 statement concluded with: “After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed”
    Have you conducted an extensive Literature Review? Have you performed a rigorous cost benefit analysis of the Literature’s findings and how this applies to an American context?
    I think it is critically important that you answer these questions in the name of Science-Based Medicine.

  66. joep says:

    @Ian

    With regard to Dr. Forbes the editorial he wrote can be read here:

    http://www.6minutes.com.au/articles/z1/view.asp?id=498029

    Where he noted:

    “Further the stated benefits of protection against urinary tract infection are marginal, and do not justify mass circumcision. Our changing understanding of the relationship between urinary tract infection and chronic renal disease further weakens the case for routine circumcision.

  67. Hugh7 says:

    @Amy Tueter “Are there any metrics on which circumcised and uncircumcised men differ?

    Ability to have intercourse? No.
    Frequency of intercourse? No.
    Ability to reproduce? No.
    Number of children? No.
    Reported sexual satisfaction? No.
    Ability to urinate? No.
    Long term health sequelae? No.
    I could go on and on, but I think you get the point.

    There’s no evidence that circumcision alters function in any way.”

    Carefully chosen metrics that slalom around all the ways circumcised sex differs from integral sex (lovemaking, the whole journey between arousal and orgasm). Circumcised men report that their frenulum (“the male G-spot”) is their most sensitive part. The frenulum is all that is left of Taylor’s ridged band, the concentration of Meissner’s corpuscles running around the inside of the foreskin that provide what has been called “a symphony of sensation”. Women who have experienced both report that circumcised men have to thrust harshly to achieve enough stimulation to reach orgasm. This emphasis on “reaching orgasm” may be what makes (circumcised) men so goal-directed. Intact men don’t have to work so hard so they can savour the journey more. With more nerves, they get more feedback, and hence have more control.

    Sure, this isn’t very science-based, but I think anyone will admit that the scientific study of sex hasn’t progressed very far. Masters & Johnson, in particular, were driven by their own prejudices in this area, making no measurement of the foreskin or study of circumcised vs intact sex whatsoever, before delivering their much-quoted opinion that circumcision has no effect on sex.

  68. Paul Wise says:

    A disclaimer is required, I suppose: I am myself circumcised; I was circumcised as an infant. I have never felt any lack from having had this done, and I have been more or less indifferent on the subject of whether or not it should be done. Up until now, my position has been: “If you feel strongly about it, then go ahead. If not, then don’t.”

    That said, if the science supports its usefulness, and there isn’t any non-ideologically motivated argument against it, then it seems like a sensible thing to do.

  69. J_ says:

    Tuteur claims that

    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.

    This is an astounding thing to say in a blog about science based medicine. Is there a Jewish gene that I don’t know about? Basically Tuteur is making a claim that is no different from saying that being in the Untouchable Class is not a choice: it’s inherited. The astounding part about her statement is its implicit agreement. Interestingly, Judaism has its own touch of caste system, codified by the rules of being a mamzer (Jewish bastard). This is a person born out of wedlock under certain rules, and in the supposedly secular state of Israel being a mamzer affects marriage, and it is a curse that is passed down through the generations. Of course, it’s all constructed: you can’t tell under a microscope that somebody is a mamzer, and you can’t test for it.

    And, Tuteur, I happen to know a lot about this subject, and the subject of botched circumcisions. Mamzerim are not spared the knife, and in my case I am sure that my mamzer status provoked an especially brutal bris. Give the mamzer a good tight circumcision, something he’ll remember.

    Tuteur would do well to walk this one back, but it seems she can’t bear the idea of admitting that on this point, she’s an idiot.

  70. BillyJoe says:

    Ian Wilkinson,

    Perhaps Dr Auteur is not responding because she has already answered most of those questions in her replies to others.

    It would be a simple matter to peruse these 500+ comments for those made by Dr. Amy Auteur. If you did so, you would find the answer to most of your questions:

    Q: Do you consider the foreskin as functional anatomy?
    A: No

    Q: The RACP stated that routine infant circumcision is non-therapeutic in the nature of the operation, What is your view on this?
    A: Agree. It is a preventative, not a therapeutic, operation

    Q: The RACP has acknowledged the psychological distress felt by some adult males circumcised as infants.
    A: I don’t think she has answered this one
    But would you please provide a reference that quotes NNT.

    Q:“The possibility that routine circumcision contravenes human rights has been raised because circumcision is performed on a minor for non-clinical reasons…”
    A: Disagree. It is a preventative activity similar to vaccination.

    Q: “…and is potentially without net clinical benefit for the child”
    A: Disagree. It can help to reduce the chances of contracting UTI, HIV (50%), HSV (30%), HPV (30%), vaginosis, trichomonas, cervical cancer, penile cancer.

    Q: “…[this] is another reason not to recommend RIC.
    A: Dr Auteur does not recommend routine/universal infant circumcision either. Moreover, Dr Auteur agrees with their following recommendation:

    “the RACP does not recommend that routine circumcision in infancy be performed, but accepts that parents should be able to make this decision with their doctors….In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. In the absence of evidence of substantial harm, parental choice should be respected.”

    Q: How do you respond to the frequency of the conditions in a western medical context not warranting a recommendation of [universal/routine] circumcision for infants.
    A: Dr Auteur does not recommend routine/universal infant circumcision.

    Q: How do you respond to the level of protection for UTI, HIV and Penile cancer not warranting [universal/routine] circumcision for infants?
    A: Dr Auteur does not recommend routine/universal infant circumcision.

    Q:How do you respond to the complication rate of circumcision not warranting [universal/routine] circumcision for infants?
    A: Dr Auteur does not recommend routine/universal infant circumcision.

    Q: The RACP 2009 statement concluded with: “After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed”
    A: Dr Auteur does not recommend routine/universal infant circumcision.

    Q: Have you conducted an extensive Literature Review?
    A: I don’t think Dr. Auteur has answered this question. However… have you? I suspect that, like yourself, Dr Auteur relies on the appropriate authorites to do this for her. There is no need to reinvent the wheel.

    Q: Have you performed a rigorous cost benefit analysis of the Literature’s findings and how this applies to an American context?
    A: Probably not. Have you? I suspect that, like yourself, Dr Auteur relies on the appropriate authorites to do this for her.

  71. BillyJoe says:

    Hugh,

    “Women who have experienced both report that circumcised men have to thrust harshly to achieve enough stimulation to reach orgasm. ”

    Was this a criticism or a support for circumcision? ;)

  72. untitled says:

    I really don’t understand the argument that it’s okay UNTIL proven harmful. That’s generally not the way we do things anymore. Quite the contrary, we don’t cut things off without a VERY good reason, especially when the person is unable to give their consent. Except foreskins. As far as I can tell, they only get special treatment because of tradition.

  73. Jason says:

    America’s experiment with infant circumcision has failed. While proponents of the surgery, nearly all personally affected by and invested in circumcision, leapfrog each other to come up with supposed benefits and advantages, no studies have ever conclusively shown circumcision to have improved overall health outcomes in the United States. It does not suffice to infer these outcomes from other studies, however well or poorly constructed and conducted, in non-comparable populations as a basis to make recommendations to parents or the medical profession as a whole. From a purely cost-benefit standpoint, infant circumcision has been a net disaster for almost a century, costing the healthcare sector approximately half a billion dollars a year at present levels in fees, materials and necessary surgical follow-up. Between 2 and 5 percent of the one million infant circumcisions performed annually in the United States require further treatment or surgical correction by a pediatric urologist or other physician; most “botches”, including skin tags, skin bridges, uneven scars, and meatal stenosis, go unreported and untreated.

    There is no question that infant circumcision alters the appearance of the genitalia, and this change is by no means universally welcome. It is an issue that circumcision proponents seldom want to acknowledge, or dismiss out of hand. Yet it is an undeniably valid concern of the owner of the penis, whose potential preference (likely preference, judging by those countries that do not practice circumcision) must be respected.

    Circumcision does not remove a flap of skin; it is not a simple procedure. It cuts through dense nerves and vascular tissue that contributes to the effective responsiveness and bloodflow of the penis. In the neonate, the synechia actually binds the foreskin to the glans, indicating incomplete development of the structures and contraindicating surgical interference. There is no evidence whatsoever that the foreskin is vestigial or superfluous; rather, its complexity surpasses that of most of the rest of the penis (certainly the glans) and impacts dynamics from temperature regulation to tumescence and detumescence.

    The foreskin provides ample tegument for comfortable erections with mobile shaft skin. In contrast, the shaft skin of many circumcised penises is stretched unnaturally taut upon erection and does not move at all, sometimes causing discomfort to the owner and his partner. Circumcision removes muscle tissue with known functions in both infancy and adulthood, as documented in the published literature, and lays down a dense network of fiber in its ring cicatrice. This fibrous tissue inhibits the penis’s natural range of motion and also blocks full nerve transmission, not to mention usually leaving an unsightly, untreated scar around the penis.

    The routine iatrogenic wounding of American youth happens without sufficient medical indication and with inexcusable disregard for its overall cost ineffectiveness. As other developed nations have moved away from the fad of infant circumcision over the past 50 years, they have not only maintained or improved overall health outcomes, but they have saved hundreds of millions of dollars a year and avoided tens of thousands of instances of surgical mishap and inflicted pain. On that, everyone should agree.

  74. Ian Wilkinson says:

    BillyJoe,

    I am not sure why you have responded on Dr Tuter’s behalf, are you her spokesperson, if so you need to identify yourself, and demonstrate where you have been given approval to speak on her behalf?

    I have read most of the 575 replies and did not find any critical analysis of the data which convincingly disputed the RACP’s 2009 statement. The Data presented to make the case for infant circumcision was used from a scientific report based on the findings from African Studies, which do not reflect either the medical health resources of first world nations, the viral loads in first world medicine nations, nor do the African findings reflect the epidemiological data from First World Medical Nations. These are the main arguments of the RACP 2009 statement.

    I also believe you are playing with semantics, have you read Dr Tueter’s last line @’I believe the AAP should heed the Authors call’, what is implied is obvious to any scientific mind.

    When I am asked about circumcision by parents, I show them a copy of the RACP 2009 statement, and its previous research documents and go through these with them. if Dr Tueter has further information which disputes the RACP, then I would like to know what that is, so I can make an informed decision or at least do further reserach to investigate the matter.

    Eg. You say that Dr T would dispute that the foreskin is functional anatomy, what is this based on? Her argument where she espouses that the circumcised penis can still urinate etc. is most unconvincing from a scientific point of view, Taylor et al. documented the physiology of the foreskin including the gliding mechanism during intercourse and masturnbation, as well as the interaction effects of the foreskin and glans, which are lost to circumcision.

    If a scientist is going to make a public call about a public health matter then this needs to be backed by rigorous science, including an analytical cost benefit analysis of the pros & cons & I have not seen this demonstrated? It is contingent upon Dr T for her to have scientific credibility, to demonstrate a ananalytical cost benefit analysis has been undertaken, or there is a question mark left against her reputation as an impartial medical scientist?

    I would imagine Dr T is a very busy person and doesnt have the time to do such a rigorous analysis of the data, thats OK we’re all human, we all make mistakes……..A respected medical professional should not be tainted by an error like this, though would be helpful if she admitted her mistake, makes it easier for us all connect with her humanity then.

  75. BillyJoe says:

    Ian Wilkinson,

    I assume we are responding to Dr. Auteurs article AND her clarifications in the commentary.
    Her article was certainly ambiguous, but her comments have surely clarified her opinion.

    It should now be clear that she is not advocating “routine” infant circumcision.
    She is advocating that parents make a “informed choice” about whether or not their male infants will be circumcised.
    She is saying that parents need updated “information” in order to make this “informed choice”.

    This is not a matter of semantics.
    There is a very real difference between “routine” infant circumcision and “informed choice” infant circumcision.
    In case you don’t see the difference, let me explain:

    If the evidence for infant circumcision is overwhelming, the RACP would be advocating “routine” circumcision. In other words they would be encouraging all parents to have their infants sons circumcised.
    In fact the evidence is neither strongly for nor against circumcision.
    It is appropriate, in these circumstances, that they advocate that parents make an “informed choice” as to whether or not they personally will have their infant sons circumcised.

    Dr. Auteur is saying that the “information” supplied to parents making an “informed choice” should include the new evidence about the role of circumcision in the prevention of the various STDs etc.

    I agree this was not clear in her article, but it should be clear from her subsequent comments.

    As to the function question: Dr. Auteur quoted a paper which found no difference in sexual function between the circumcised and uncircumcised penis. I suppose, however, that what we need is the results of a systematic review. I don’t even know that one exists, but Cochrane would be a good place to find out.

    (Note: I am only responding on her behalf because I have read her commentary where she has effectively answered most of your questions and I imagine she might be a little loathe to keep repeating them)

  76. Ian Wilkinson says:

    I think you’ll find that the RACP 2009 statement clearly states that the current evidence does not warrant a recommendation of RIC, I wonder why this isn’t emphasised?

    I have young parents coming to my consulting rooms fearing their sons will die of AIDs if they are not circumcised, because of the misinformation that is caused by blogs such as this one.

    How ethical is it the some of our Medical Professionals are allowed to create such a climate of fear in young parents who live in low viral load HIV populations in the First World of Medicine? and Then when these so-called medical professionals are called to justify their statements with rigorous analytical science the name calling starts with inflammatory terms such as anti-circ activists and foreskin fetishists, is this rigorous medical science?

    I think the onus is on The Dr T’s of the world to make a rigorous scientific case or be called for their emotive unscientific defences. In the name of science be scrupulous & rigorous or be called out as unscientific.

  77. BillyJoe says:

    Ian,

    “I think you’ll find that the RACP 2009 statement clearly states that the current evidence does not warrant a recommendation of RIC”

    But I think you still don’t understand what this means.
    Here are relevant exerpts form their statement:

    (Note: They seem to use the words “newborn”, “infancy”, and “children” interchangeably. Similarly for the words “universal” and “routine”. I presume this will be tidied up in their final statement)

    “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.”

    In other words:
    They do not recommend UNIVERSAL circumcision for newborn

    “After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed but accepts that parents should be able to make this decision with their doctors”

    In other words:
    They do not recommend ROUTINE circumcision in infancy.

    “In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. In the absence of evidence of substantial harm, parental choice should be respected.”

    In other words:
    They recommend parents make an INFORMED CHOICE regarding circumcision for their children.

    Don’t you understand that: if the evidence was strongly in favour of infant circumcision, they would be recommending infant circumcision; if the evidence was strongly against infant circumcision, they would be recommending against infant circumcision; but because the evidence is not strong either way, they recommend that if parents enquire about circumcsion, they should be given the most up to date evidence so that they can make an informed choice.

    As for the fear tactics, unfortunately it exists on both sides of the argument.

  78. BillyJoe says:

    I cannot find anything in Cochrane, but here is lots of information collected and provided by “a review of the literature” by an academic, Professor Brian J. Morris, with no apparent vested interests.

    http://www.circinfo.net/socio_sexual_aspects.html

    http://www.circinfo.net/circumcision_sensitivity_sensation_sexual_function.html

    Here is some information about the author and his motives:

    http://www.circinfo.net/about_the_author_professor_brian_j_morris.html

    regards,
    BillyJoe

  79. Jason says:

    BillyJoe wrote:

    “It should now be clear that she is not advocating “routine” infant circumcision.
    She is advocating that parents make a “informed choice” about whether or not their male infants will be circumcised.
    She is saying that parents need updated “information” in order to make this “informed choice”.

    This is not a matter of semantics.
    There is a very real difference between “routine” infant circumcision and “informed choice” infant circumcision.
    In case you don’t see the difference, let me explain:

    If the evidence for infant circumcision is overwhelming, the RACP would be advocating “routine” circumcision. In other words they would be encouraging all parents to have their infants sons circumcised.
    In fact the evidence is neither strongly for nor against circumcision.
    It is appropriate, in these circumstances, that they advocate that parents make an “informed choice” as to whether or not they personally will have their infant sons circumcised.”

    Ahem.

    Not everyone shares your definition of routine infant circumcision (RIC). Your definition could also be termed widespread or universal circumcision. To others, the term “routine circumcision” means circumcision on demand without present medical indication. Many people believe that in a neutral environment in which circumcision is not encouraged by subsidy or lecture, there should be substantially less infant circumcision than the United States sees today. RIC could still be “routine” at 20% if there is no compelling medical reason to recommend it. “Routine” just means more than is medically necessary.

    What Tuteur actually seems to advocate is increased US circumcision from levels where they are today (you and she can claim all you want that it’s still not “routine”) through public and private funding and sales-pitches. One really has to wonder why. Which parents specifically are not making an “informed choice” today? Presumably, Tuteur means many of the parents who are not electing RIC for their sons. Or are you suggesting that she wants to inform parents more fully in order to prevent so many of them from blindly choosing circumcision, as they do today? More parents of intact sons have done their homework than parents of circumcised boys, because in the United States infant circumcision is still the default choice. Ask any new parent.

    Many people strenuously object to public dollars being spent on routine circumcision when they themselves see the surgery as unnecessary and harmful and have very happily not put their own children through it. States are in a deep budget bind, and circumcision is entirely elective. There are no real (observed, documented) health outcome differences for circumcised and intact children, other than the relatively high complication and re-do rates from the surgery. There is no ethical basis for paying other parents’ costs of unnecessary genital surgery on their children. Nor should parents have to go through a physician-prescribed gantlet to get their child home intact and healthy.

    Circumcision has failed every evidence-based examination of the practice and its outcomes. Great Britain, Canada, Australia and New Zealand have been roaring successes at reducing or eliminating the practice of infant circumcision with superb health outcomes and tremendously better cost-benefit ratios over several decades. Meanwhile, the United States inexplicably subsidizes surgery that few parents actually request (but are nearly always offered), especially physicians themselves.

    Infant circumcision is a hoax. It is a solution desperately in search of something to address. It has never been proven scientifically to improve health outcomes in the United States or anywhere else.

    Tuteur and her colleagues likely fear a movement afoot to make RIC illegal — it’s close to that in some European countries — but that is simple paranoia. There is no prospect of that in the US. Nevertheless, Tuteur strikes preëmptively to pitch circumcision in an effort to raise the baseline. There is no other explanation for her zeal to “educate and inform” every parents of the “benefits” of circumcision while ignoring the physiology of what it does and its unacceptable complication rate.

    Risk/benefit is a fallacy (even though RIC fails it)
    Advantage/disadvantage is the relevant comparison

  80. BillyJoe says:

    Jason,

    I was responding to Ian’s interpretation of the RACP 2009 statement on infant circumcision.

    My definition of “routine” is therefore in the context in which it is used in that statement.

    I believe my definition is correct and I have tried to show why by an analysis of that statement.

  81. Plonit says:

    make RIC illegal — it’s close to that in some European countries

    ++++++++

    Are you sure? Prohibition is quite different from regulation.

  82. Jason says:

    Sweden has regulated infant circumcision for almost a decade, requiring that it be performed only by a board-certified practitioner with a licensed anesthesiologist present if performed within the first 2 months of life, and only by a physician if performed at later than 2 months. Denmark and Finland have both had parliamentary bills introduced to discuss whether circumcision of minors is a criminal offense, and Sweden is not completely finished debating the legality of nontherapeutic circumcision of minors across the board. Ethical concerns have been raised that could trump religious arguments.

    Circumcision of male minors (under 16) is unlawful in South Africa except in certain cases of religious requirement or medical necessity, under the 2007 Children’s Act. The UK Law Commission has also initiated an inquiry into the legal status of nonreligious, nontherapeutic circumcision of minors.

    If by regulation you mean exceptions for health, then that is correct.

  83. Plonit says:

    No, by regulation I mean that specifying the presence of a licensed anaesthesiologist is not the same as prohibition.

    Demanding that practitioners be board certified is not the same as prohibition.

    Discussion of the legal status of circumcision is not the same as legislating against it.

    I’d be grateful for a link to or reference for the UK Law Commission inquiry, as I couldn’t find it on the Law Commission website.

    None of the European countries you mention have legislated to prohibit or restrict circumcision, only to regulate it.

  84. Robert Samson says:

    “That said, if the science supports its usefulness, and there isn’t any non-ideologically motivated argument against it, then it seems like a sensible thing to do.”

    This is the crux, contrary to Amy’s claim.. SCIENCE nor the real world does not support it–all that does are a bunch of MEDICAL questionable studies.

  85. Robert Samson says:

    To address all word games by Billy Joe..

    they boil down to a single statement–there is no scientifically-credible evidence for non-therapeutic circumcision and therefore cannot be rationally recommended regardless of the terminology used to defend Amy’s advocating circumcision.

    Circumcision forced or coerced onto any non-adult is an ethical and moral crime.

    INFORMED decision for adults is predicated on correct, valid, and complete information–not the garbage Amy is trying to pass off as legitimate.

  86. Robert Samson says:

    I find it both amusing and amazing that for a “science-based’ forum, how little SCIENCE is even posted. And when someone posts something containing science how totally it is ignored.

    This speaks volumes to the scientific literacy and understanding of most people here.

  87. Annabel says:

    Billyjoel,

    I, and I think a lot of “intactivists”, agree that neonatal circumcision should not be something that is ” up to the parents ” when urgent medical need is absent.

    If female circumcision ( even just the removal of the labia and/or clitoral hood ) showed a decrease in UTIs and HIV transmission, do you think the United States would reverse its anti FGM laws to accommodate? As other posters have shown, with links to an African study, females who were circumcised had lower HIV rates than females who were not. Why have doctors in the United States not actively sought out studies to show the benefits of female circumcision? I am not aware of any such studies.

    All things that male circumcision has been shown to have proven benefits ( UTIs, cancer, and STDs ) are all treated in girls without routine amputation of any healthy tissue, why should boys be different? Amputation is a last resort, and is neither the best, least invasive, or only means of achieving the desired result.

    As has been brought up several times, double mastectomies have been shown to reduce the risk of breast cancer by 97 to 99 percent, which effects thousands of more people than HIV in the United States, and effects women indiscriminately. Why do proponents of circumcision not also recommend performing mastectomies on babies or children?

    Foreskin is unique in that there is not any other instance where doctors routinely remove healthy functioning tissue or organs to prevent a future disease. We don’t remove spleens, or appendixes, or even tonsils (anymore) without medical need. Since HIV and other STDs are adult diseases, why should it not be up to the adult to decide whether or not the risks are worth the benefits? The penis is only a concern for the parent until the age of about six, when boys can then take care of themselves. So why should this decision be ” up to the parents ” when the result will effect the owner of the penis his entire life? The vast majority of men, even in the United States, never need or want a circumcision, and I think that is a strongly overlooked point.

  88. Robert Samson says:

    Brian Morris has no vested interests in promoting circumcision?
    This is a man whose hobby is traveling to and filming mass circumcisions.. his interests is what many people would term “circumfetishist”

    Now as to his credibility, here are a FEW examples of it..

    Let’s see what we know of Brian Morris..

    Rebuttal to the BM website:

    http://www.circumstitions.com/Morris.html

    His hobby-traveling to mass circumcision rituals to view and film:

    Quotes from “personal” website of Brian Morris:

    “I have some wonderful photographs of a group of Masai boys in their early teens that I met in Kenya in 1989 dressed in their dark circumcision robes, with white feathers as headwear, and white painted facial decoration that stood out against their very black skin.
    Each wore a pendant that was the razor blade used for their own circumcision. The ceremony that they had gone through is a special part of their tribal culture and was very important to these boys, who were proud to show that they were now ‘men’. In other cultures it is associated with preparation for marriage and as a sign of entry into manhood.”

    And his site links to proven circumfetish sites (and vice-versa).. and the usual testimonials present in all fetishist sites.

    http://circinfo.net/

    http://circinfo.net/htmlnew/circumcision_sources.htm

    http://circinfo.net/htmlnew/author_brian_morris.htm

    Reviews of his book which contains info from his site–including one from the Jam and from some of his fellow Austs..

    Brian Morris is a professor of Molecular Biology and hypertension-field of study at the Univ Of Sidney, Aust HE is NOT a MD nor a circumcision expert.

    The Journal of Australian Medicine (1999, vol.11, no.11, p.18), which has no apparent interest in either defending or condemning circumcision, has reviewed Dr. Morris’ book and given it a thumbs down. Here’s an excerpt from that very sensible review:

    “In those with a normal bladder and kidneys the argument for circumcision may be akin to suggesting prophylactic removal of the tonsils or the appendix; the latter are obviously as silly as taking seriously any study supposedly concluding that either version of the penis ‘looks better’.

    Also, is the author really serious in suggesting that routine circumcision is needed to prevent zipper injury? Unfortunately, once again, a presentation on the subject of circumcision has not advanced the development of a scientific approach.”

    Reviewer: A reader from Bond University Men’s Health Research Center, Gold Coast, Queensland, Australia September 2, 1999
    This book was reviewed (above) in “glowing terms” by a physician, who openly admits to having circumcised a large number of unconsenting minors (who happen to be boys). Consequently, he has a vested interest in promoting genital reduction surgery (erogenous foreskin amputation). Are physicians now to take their medical advice from obsessive genital cutters, rather than from recognized professional bodies? Not one national medical association anywhere in the world recommends unnecessary circumcision!

    This book selectively cites outdated studies many of which have been thoroughly discredited in the scientific medical literature for decades. For example, this book states that penile cancer is reduced by circumcision. Nothing could be further from the truth.
    Representatives of the American Cancer Society (Feb 16, 1996) stated that infant circumcision is not a valid or effective measure to prevent penile cancer which affects only one in 100,000 males.

    The Australasian Association of Paediatric Surgeons stated (April, 1996) that “neonatal circumcision has no medical indication.”

    The Queensland Law Reform Commission (Dec, 1993) stated that “routine circumcision could be regarded as a criminal act.”

    The primary dictum of ethical medical practice is “First do no harm.” Yet there is now overwhelming evidence that infant circumcision causes irreparable harm physically, sexually, and psychologically.

    Much of the life-long harm caused by imposed genital cutting (on unconsenting minors) is documented in the British Journal of Urology, 1999 (Vol 83, Supplement 1). Also see website: http://www.cirp.org listed by the British Medical Association.

    Gregory J. Boyle, Ph.D Professor of Psychology and Director, Men’s Health Research Centre Bond University, Gold Coast 4229 Australia

    BOOK LACKS SCIENTIFIC EVIDENCE AUSTRALIAN MEDICINE, 1999, Vol. 11 (No. 11), p. 18. by Professor Paddy Dewan

    Extract — “….[The author] understates the nature of the procedure, omits several potential complications and downplays the importance of circumcision to the income of American doctors. Also, Dr Morris omits to mention the medical treatment of phimosis, and he overstates the adverse events associated with phimosis when he states that “as a result of phimosis, males will be unable to urinate. The bladder fills up and urinary retention becomes a painful, alarming and dangerous experience”. This is a marked variance to the many boys who usually present with minimal symptoms with phimosis, which is easily treated by the application of steroid cream for four to six weeks.

    “The increased risk of urinary tract infection in uncircumcised boys is probably real, but it remains arguable if the data used to support circumcision is analysed more critically. Even so, circumcision for boys with renal anomalies, that is, those having intermittent catheterisation or with immune deficiencies, is probably appropriate–these arguments are not presented in Dr Morris’ book. In those with a normal bladder and kidneys the argument for circumcision may be akin to suggesting prophylactic removal of the tonsils or the appendix; the latter are obviously as silly as taking seriously any study supposedly concluding that either version of the penis “looks better”. Also, is the author really serious in suggesting that routine circumcision is needed to prevent zipper injury?
    Furthermore, he chooses to select penile cancer figures that support his argument, then proceeds to accuse the anti-circumcision group, NOCIRC, of “distortions, anecdotes and testimonials”, and Dr. Paul Fleiss of “off the wall statements” to support his case to keep the foreskin. Dr Morris then concludes, “if anything, circumcision by freeing the penis of the encumbrance of a foreskin can only serve to enhance penis size”.

    “In quoting a Forum magazine study, referring to the opinion of a “Seinfeld” character and stating that “the uncircumcised man may need several showers per day”, further undermines Dr Morris’ efforts to have us take seriously the data otherwise collected. Unfortunately, once again, a presentation on the subject of circumcision has not advanced the development of a scientific approach….”
    Professor Paddy Dewan is a Paediatric Urologist from the Royal Children’s Hospital, Melbourne.

    Dr. James Powell from Chicago, Illinois , October 28, 1999 A book without emotions…..or FACTS! I find it totally ridiculous that such a book exists in which the author makes his claims on completely anecdotal grounds. There are few facts presented in this book. You will not find the information you need to educate yourself about this topic in this book. If you want GOOD information from people that know what they are talking about, refer to the vast multitude of anti-circumcision facts that are on the internet, or the vast amount of more factual books available. And please avoid Mr. Morris’s own website as you will find nothing but the same delusions on it as in his book.

    Dr Morris recently wrote a letter to the Medical Journal of Australia to promote circumcision.
    Here is the response by the authors:

    http://www.mja.com.au/public/issues/178_11_020603/matters_arising_020603-5.html

    “The letter by Morris is more difficult to discuss as it relates, on the whole, to the use of routine circumcision, which was not the focus of our article. The issues raised by Morris seem to be at complete odds with the 2002 Policy Statement on Circumcision by the RACP — which is also consistent with the recommendations of the Canadian Paediatric Society and the American Academy of Paediatrics.4 The RACP Policy Statement reviewed most of the points raised by Morris, including urinary tract infections, STDs, human papillomavirus and carcinomas of the cervix and penis. In each case, after an extensive review of the literature, the RACP reaffirmed that there is no medical indication for routine circumcision. Morris’s view on the reduction of risk of sexual problems is at odds with the article by Darby,9 published in the same issue of the Journal as our article, and is beyond the scope of our study. His claim that circumcision improves appearance is highly subjective and unsubstantiated, and should not be used to justify the surgical removal of tissue that may have a benefit to the individual later in life”

    His deceits:

    Dr. Brian J. Morris, Ph.D. is a biochemist at the University of Sydney.
    He has written a very pro-circumcision page on the Internet.

    His page is full of errors. He frequently misrepresents his sources. Many of his sources are on the CIRP so one should go there and read them to see what they really say.

    For example, Dr. Morris writes”

    “In the light of an increasing volume of medical scientific evidence pointing to the benefits of neonatal circumcision a new policy statement was formulated by a working party of the Australian College of Paediatrics in August 1995 and adopted by the College in May 1996 [6]. In this document medical practitioners are now urged to fully inform parents of the benefits of having their male children circumcised.”

    In reality, the Australian College of Paediatrics states:

    “The College believes informed discussion with parents regarding the possible health benefits of routine male circumcision and the risks associated with the operation are essential. Up-to-date, unbiased written material summarising the evidence in plain English should be widely available to parents.”

    Dr. Morris omitted risks. See

    http://www.cirp.org/library/statements/acp1996/

    Dr. Morris originally had his pages on the departmental board at the U. of Sydney. He was forced to move his pages to the personal pages section because of professional criticism of his diatribe.

    For commentary on Dr. Morris’ work please go here:

    http://www.circumstitions.com/Morris.html

    http://rainforest.parentsplace.com/dialog/get/newcircumcision19/1.html

    The essay “Medical Benefits From Circumcision” by Brian Morris is a case study in misinformation! For example …

    Morris – “In the light of an increasing volume of medical scientific evidence pointing to the benefits of neonatal circumcision a new policy statement was formulated by a working party of the Australian College of Paediatrics in August 1995 and adopted by the College in May 1996. In this document medical practitioners are now urged to fully inform parents of the benefits of having their male children circumcised.”

    Australian College of Paediatrics – “The College believes informed discussion with parents regarding the possible health benefits of routine male circumcision and the risks associated with the operation are essential.”

    The full text can be read at http://www.nocirc.org/position/acp.html

    Morris says that the ACP urged that parents be fully informed of the benefits, but he totally ignores their recommendation that parents also be fully informed of the risks.

    Morris – “Similar recommendations were made recently by the Canadian Paediatric Society who also conducted an evaluation of the literature, although concluded that the benefits and harms were very evenly balanced.”

    Canadian Paediatric Society – “The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed.”

    The full text can be read at http://www.cps.ca/english/statements/FN/fn96-01.htm

    In 1982 the CPS took a position against routine infant circumcision because “there are no valid medical indications for circumcision in the neonatal period.” The CPS did not change their position against RIC in 1996. Morris conveniently ignores the Canadian Paediatric Society’s opposition to routine infant circumcision.

    Morris – “The American College of Pediatrics has moved far closer to an advocacy position …”

    The Department of Pediatrics at Johns Hopkins University has a web page that lists many pediatric organization. There is no organization called the “American College of Pediatrics”. The following are among the many organizations they list – American Academy of Pediatrics, American Pediatric Society, and American Pediatric Surgery Association.

    “Pediatric Points of Interest” compiled by the Department of Pediatrics at Johns Hopkins University
    http://www.med.jhu.edu/peds/neonatology/organ.html#Organizations

    Also “American College of Pediatrics” is not listed in online phone directories.

    Morris has probably confused the American College of Pediatrics with the American Academy of Pediatrics. Assuming that is what he did, let’s look at the statement, “The American Academy of Pediatrics has moved far closer to an advocacy position …”

    The American Academy of Pediatrics (AAP) issued statements on routine infant circumcision in 1971, 1975, 1983, and 1989.

    AAP (1971) – “there are no valid medical indications for circumcision in the neonatal period.”

    AAP (1975) – “there is no absolute medical indication for routine circumcision of the newborn.”

    The AAP reiterated their 1975 position again in 1983.

    AAP (1989) – “Newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained.”

    The full text can be read at http://www.aap.org/policy/02624.html

    While it may be “technically” correct to say that the AAP has “moved closer to” an advocacy position, the statement by Morris is misleading because the AAP has *not* taken an advocacy position in favor of routine infant circumcision. A more correct statement would be, “The American Academy of Pediatrics has softened its opposition to routine intact circumcision.” Softening one’s opposition to a policy is not the same thing as advocating that policy.

    Later in the article Morris again misrepresents the position of the American Academy of Pediatrics (AAP).

    Morris – “The trend not to circumcise started in the mid to late 1970s, after the American Academy of Paediatrics Committee for the Newborn stated, in 1971, that there are ‘no valid medical indications for circumcision’. In 1975 this was modified to ‘no absolute valid … ‘, which remained in the 1983 statement, but in 1989 it changed significantly to ‘New evidence has suggested possible medical benefits …’”

    The sentence that Morris quotes from the 1989 AAP report is in the introduction, not the conclusion. The conclusion of the report states clearly that there are both potential medical benefits and risks. Morris does not mention the disadvantages and risk of infant
    circumcision. He leaves the impression that the AAP only mentions benefits.

    AAP – “Newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained.”

    Actual statements by Aust Ped societies:

    Australasian Association of Paediatric Surgeons. Guidelines for Circumcision. http://www.cirp.org/library/statements/aaps/

    “The Australasian Association of Paediatric Surgeons does not support the routine circumcision of male neonates, infants or children in Australia. It is considered to be inappropriate and unnecessary as a routine to remove the prepuce, based on the current evidence available.”

    “We do not support the removal of a normal part of the body, unless there are definite indications to justify the complications and risks which may arise. In particular, we are opposed to male children being subjected to a procedure, which had they been old enough to consider the advantages and disadvantages, may well have opted to reject the operation and retain their prepuce.”

    “Neonatal male circumcision has no medical indication. It is a traumatic procedure performed without anaesthesia to remove a normal functional and protective prepuce. At birth, the prepuce has not separated from the underlying glans and must be forcibly torn apart to deliver the glans, prior to removal of the prepuce distal to the coronal groove.”

    AMA (Aust):

    The AMA will discourage circumcision of baby boys in line with the Australian College of Paediatrics’ Position Statement on Routine Circumcision of Normal Male Infants and Boys.

    The statement, released in June and supported by the AMA’s November Federal Council meeting, includes: The Australian College of Paediatrics should continue to discourage the practice of circumcision in newborns.

    Now if you think this man has any credibility–you need to think again.

  89. micheleinmichigan says:

    As a mom who routinely consults with pediatric specialists regarding therapy, tests and surgeries for my son, the truly disconcerting thing when meeting a new specialist is trying to figure out whether I’m dealing with a Dr. Gorski/Dr Hall type or a Dr Tuteur type. The first can offer a senescent summary of risk and benefit, possible complications and long term effects.

    The second, well I always come out of her post feeling kind of worried and then her comments tell me she wasn’t really saying what her post seemed to say. How does that method play out in the doctor’s office?

    When we adopted our son at age 2 he was not circumcised. Our Ped gave us the standard run down of information basically saying it wasn’t needed, but it wasn’t harmful. The HIV research came out shortly after, but like Harriet’s post said, it’s still not a clear recommendation in the U.S.

    My son is 5 now. The thing I end up thinking is this. Because we know my son will need several future surgeries, I want to be able to tell him each time that this surgery is necessary or will offer him a noticeable benefit. Based on the run down in Harriet’s article and other online reading, I find it hard to do that with a circumcision surgery.

  90. edgar says:

    ““I have some wonderful photographs of a group of Masai boys in their early teens that I met in Kenya in 1989 dressed in their dark circumcision robes, with white feathers as headwear, and white painted facial decoration that stood out against their very black skin.
    Each wore a pendant that was the razor blade used for their own circumcision. The ceremony that they had gone through is a special part of their tribal culture and was very important to these boys, who were proud to show that they were now ‘men’. In other cultures it is associated with preparation for marriage and as a sign of entry into manhood.”

    I don’t really see the problem with this, and I don’t understand why you included it? That would fit the criteria of ‘consenting adult(s)’ would it not?

  91. Robert Samson says:

    “I don’t really see the problem with this, and I don’t understand why you included it? That would fit the criteria of ‘consenting adult(s)’ would it not?”

    I also agree that any adult stupid enough to get circumcised should be allowed to, it was posted to show that BM is hardly disinterested or academic about circumcision–he certainly has some unusual non-academic interests (hobby) in promoting circumcision.

  92. joep says:

    @BillyJoel

    You bring up the vaccination comparison again but that is one that just doesn’t stick for many reasons which have been listed here. It is common enough that Dr. Forbes (who is head of the RACP group that reviews this issue) noted as part of a recent editorial:

    http://www.6minutes.com.au/articles/z1/view.asp?id=498029

    The option of delaying the decision to circumcise is one way of dealing with the ethical and potential legal issues of undertaking an elective procedure on a minor. The procedure is not to be equated with vaccination, either in its delivery or in its effectiveness.

    The two just shouldn’t be compared.

  93. Robert Samson says:

    Returning to an often posted, but never answered s question..

    Can anyone provide a scientifically credible reason for infant circumcision?

    I realize that it is a troubling question for the scientifically illiterate and circumcisers, but it still is a crucial question that demands an answer.

    Is ANY poster here (Amy?) willing to try to provide an answer?

    If so, it would provide an interesting diversion to the usual nonsense being posted here?

  94. Xero says:

    That’s right Dr. Tuteur, and so is The Globe and Mail:

    Circumcision health benefit virtually nil, study finds

    http://www.theglobeandmail.com/life/health/circumcision-health-benefit-virtually-nil-study-finds/article1427972/

    Outside the bubble of cultural acceptance in the United States, there is a clear consensus that newborn circumcision is not medically indicated.

    Now, will you answer my questions, Dr. Tuteur?

    http://www.sciencebasedmedicine.org/?p=3310#comment-39428

  95. Robert Samson says:

    Haven’t you yet realized that Dr. Tuteur does NOT “answer” questions (ESPECIALLY science-related questions). She only throws out more and more worthless OPINIONS or OPINION sites.

    “Circumcise or not? Parents, you’re on your own. Two medical journals take disparate stances within just one week”

    WHICH one of these provides ANY scientifically credible information? AND which one provides medical rubbish? In essence, which one deserves my attention and time?

    Please advise.

  96. Hugh7 says:

    “Routine” is a wonderfully slippery word, and it would add to clarity if it were not used in the context of non-therapeutic circumcision.

    In common parlance, it means “as a matter of course, without further thought”. If anyone said “Babies are routinely circumcised in X hospital”, you would suppose that parents have to take some action to make sure they are not. This was the case in many US hospitals a few decades ago, but hardly anyone would advocate that today.

    So to use it to mean “without medical indication, but with parents’ informed consent” creates ambiguity.

    Prof. Brian Morris has never seen a reason for circumcising he does not like, up to and including
    “The prepuce can become entrapped in zippers, leading to swelling and scarring. This is painful and traumatic. ‘The Bathroom splatter’ of uncircumcised males can be a source of annoyance.”
    (“Why circumcision is a biomedical imperative for the 21st century” BioEssays 29:1147–1158, p1153 – this paper acknowledges The Gilgal Society, a circumfetish organisation)

    It should go without saying that the circumcised glans can also become entrapped in zippers (and it is more sensitive to pain), and that the bathroom splatter of circumcised males can also be a source of annoyance.

    He also says “Recurrent UTIs occur in 19% of uncircumcised boys, but in none of the circumcised.(61)” (ibid, p1151) which sounds frighteningly common, but you have to go to the source to find that the “19%” amounted to FIVE intact boys out of 26 with recurrent UTIs, out of 36 whose circumcision status was known (the 10 known to be circumcised didn’t have recurrent UTIs, hence “none”), out of 68 boys with any UTI (but the circumcistion status of the other 32 was unknown), out of nearly 75,000 children altogether! (543 of the girls had UTIs, 75 recurrent.) This is, to say the least, selective, and it is typical of his method of arguing.

    He has also described himself as “the expert reviewer for the RACP” and was publicly corrected by the chair of the RACP’s Paediatrics & Child Health Policy & Advocacy Committee: “Professor Morris … is not a member of the RACP and is not and has not been engaged as a reviewer for the College.”

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