Score one for the foreskin lovers. Their hyperbolic fanatic reaction to earlier reports that the Centers for Disease Control was about to do the sound medical thing -- recommend the universal circumcision of all male newborns in the USA -- seems to have taken a toll on some cowardly bureaucrats at the CDC.
Late last week, the CDC issued a clarification that shows all the signs of "political" intervention into the "health" decisions of this agency. If you read their most recent statement, issued last Thursday, it appears that Rush Limbaugh's accusation on radio that President Obama wants mandatory circumcision so scared political officials in the federal government that the big word now is "voluntary," to wit: "Whatever the content may include, CDC’s final circumcision recommendations will be completely voluntary."
Of course, newborn circumcision was ALWAYS going to be voluntary with the decision left, where it should be, with American parents. While it's medically desirable to have every newborn boy leave the filthy foreskin behind in the hospital, we are not a fascist state that can order that happy event, no matter how beneficial to society as a whole.
The larger question, it seems to me, is whether the CDC retreats from the sound medical evidence in the face of the anti-circumcision movement's effort to put the foreskin on a pedestal. The CDC's recent statement sounds like it was written by politicians in Washington, not Atlanta (where CDC is headquartered), to be all things to all people: "With respect to infant circumcision, it is important to recognize that many options are still being considered in this process, including simply recommending that health-care providers educate parents about the potential benefits and risks to ensure that parents have the information they need to make an informed decision."
This is a classic case of sound science & medicine versus a powerful political lobbying group, now well-funded by a multi-millionnaire, that wants to preserve the foreskin at all costs to public health. I feel sorry for CDC's medical doctors and researchers. They know that all the evidence leads to a recommendation that every male be circumcised, but their hands are being tied by political intervention from the White House and the Department of Health & Human Services and other government bureaucrats who want to keep Rush Limbaugh and the anti-circ lobby "happy."
Throughout his campaign and even into the early days of his presidency, President Obama insisted that "sound science" would not be trampled on by political ideology and expediency. The CDC's call for universal newborn circumcision will be a true test of whether Obama means it. If the CDC does the right medical thing and recommends (not mandates) that all baby boys be clean-cut, then we shall know that Obama meant what he said. Otherwise, it's the same old political interference that we've come to expect from the federal government. Let's hope the CDC doctors have the spine and fortitude to stand up to those who are politicizing an important decision that will protect the health of every male, his partners, and society as a whole.
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I don't understand the problem here. Media reports issued earlier in the week suggested that the CDC were contemplating mandatory circumcision. They issue a clarification. What, exactly, is the problem?
ReplyDeleteJake, the only person I know who said that the CDC was "contemplating mandatory circumcision" was Rush Limbaugh, the conservative talk show host, who said "President Obama" wanted to mandate circumcision for everyone. That's not what the responsible media reported -- their focus was on universal circumcision, a recommendation (not a requirement) that all newborn boys be circumcised for health reasons.
ReplyDeleteThe CDC could NOT mandate circumcision even if it wanted to. This is a distraction from the real issue -- recommending universal circumcision for sound health reasons.
The CDC is under great political pressure to walk away from the medical science. This is an important test of medicine versus politics, Jake.
With respect, PD, I'm not convinced that the evidence warrants a recommendation of universal circumcision. The balance between benefits and risks is changing all the time, as new evidence becomes available, and I certainly think that the evidence is more in favour of circumcision than it was ten years ago, but I don't think that it has reached that point yet.
ReplyDeleteIf you say that the evidence rejects the propaganda of the anti-circumcision lobby, I'll wholeheartedly agree. If you say that the evidence shows that benefits outweigh risks, I'll agree. If you say that the evidence warrants universal circumcision, I'm not sure that I can agree. Show me a parent who chose not to circumcise their son, and I don't think I can honestly say that they made the wrong choice. I just can't bring myself to condemn that choice, and I think calling for universal circumcision is equivalent to doing so.
Making a choice of this magnitude based on the studies in Africa only is crazy. The studies appeared to be sucessful, however seem to have been conducted in a less than scientific method.
ReplyDeleteFollowing this "study", they indicated that the proceedure did nothing to prevent AIDS transmission from men to women.
More recently, the male to male transmission was proven to not matter the state of the foreskin (absent or not).
What is the real benefit then? AIDS is not the disease that this really prevents. Perhaps better information for both parents and individuals on the risks is more beneficial. Based on this, the CDC is best to tread carefully in recommending this proceedure.
If the CDC were to recommend this based on the loose evidence, perhaps there is hope that they will also take other sloppy scientific evidence to recommend much more medical proceedures to "save" all people. Certainly infants are the perfect candidates for inflicting these saving proceedures as they will not complain, sue, or act out (at the time).
Look out for the fall-out should the CDC recommend such a drastic recommendation.
To respond to Anonymous:
ReplyDeleteMaking a choice of this magnitude based on the studies in Africa only is crazy. The studies appeared to be sucessful, however seem to have been conducted in a less than scientific method.
Nonsense.
Following this "study",
Which one?
they indicated that the proceedure did nothing to prevent AIDS transmission from men to women.
True, though of course if you reduce the probability that a man will be HIV positive, you in turn reduce the probability of transmission.
More recently, the male to male transmission was proven to not matter the state of the foreskin (absent or not).
No, but the evidence in this respect is considerably weaker.
What is the real benefit then? AIDS is not the disease that this really prevents.
You aren't making sense. If you halve the probability of HIV infection, then you've prevented disease. This is basic logic.
Jake, thanks for your thoughtful postings. Yes, we agree: (1) medical evidence rejects the anti-circumcision propaganda; (2) the benefits of circumcision outweighs the minimal risks; and (3) a parent choosing circumcision for his/her son is acting in the best interests of his/her child.
ReplyDeleteIf there is any disagreement at all, I guess it's that you cannot say a parent who chooses NOT to circumcise has mad "a wrong choice." In my view, if we believe (1), (2), & (3) above, then NOT acting in accord with the best medical evidence is WRONG, at least as far as the child's health is concerned. Obviously, parents are free to ignore medical evidence -- a few do with respect to childhood vaccinations -- but that's not necessarily good public policy.
And that's where the call for universal (not mandatory) circumcision comes in. Public health officials should advocate what's in the best interest of all. If circumcision of males protects the male, his partners, and society as a whole, then the CDC (and other health organizations) should embrace it. What parents and others do in light of that will obviously be up to them.
DIFFERENT PERSON THEN OTHER ANONYMOUS USER
ReplyDeleteWhat these studies should tell any good researcher is that this is an area for further research. Nothing more. There are many variables that need to be considered, isolated, and then excluded before real results can be presented. Beyond many of the cultural factors that need to be considered, in the study that found the 60% cut, also advised the freshly cut men to not have sex for 6 weeks, and if they felt like they had to, to use a condom. The uncut guys were given no such advice or restrictions. This alone makes me quite skeptical that we should be making health policy changes because of this study.
Personally I dont the CDC should be making ANY recommendations until they have done a FULL study done within the United States. I dont think the CDC is shaking in their boots over on of the many interest groups out there. I think they are being professionals and seriously considering if this is something they should be doing at all. And yes I think they are also trying to get the sense of Americans opinions, all medical groups tend to, thats why you will see different policy standpoints in different countries even though they are all using the same data.
We are also at a time when were trying to get as much support as possible in revising our health care system, and honestly if this is going to add to the paranoia of peoples fear of government, it should be dropped all together, and start up the discussion again AFTER we have made those changes (hopefully).
I have never really understood the big debate over infant circumcision. I am circumcised, but honestly I know if I really wanted it, I would have gotten it done when I was older anyway. If its true that circumcision will reduce HIV infection rates then bringing that information to good use might mean avoiding the sensitive issue of infant circumcision all together. Instead doctors could influence a new tradition, similar to the phillipeans, where guys get cut when they are older. When a guy turned 18, the American tradition could be thats when he gets circumcised, and thats when he becomes a real man.
Avoiding this stupid debate might save more lives, there would be no grey area because the guy does it himself, and no drama to deal with and the CDC could more confidently make these kind of recommendations.
What these studies should tell any good researcher is that this is an area for further research. Nothing more. There are many variables that need to be considered, isolated, and then excluded before real results can be presented. Beyond many of the cultural factors that need to be considered, in the study that found the 60% cut, also advised the freshly cut men to not have sex for 6 weeks, and if they felt like they had to, to use a condom. The uncut guys were given no such advice or restrictions. This alone makes me quite skeptical that we should be making health policy changes because of this study.
ReplyDeleteOne would certainly expect to see greater incidence of HIV among the control group during the healing period. If this alone could explain the results, we would expect to see a different rate of HIV infection in the first 3 months, and then equal rates thereafter.
When we examine Auvert's Table 3 (link), what we actually find is that there is indeed a greater difference in the first 3 months (relative risk of 0.23). However, the protective effect continues through later time periods: relative risks of 0.46, 0.43, and 0.40 are apparent here.
Similar results are found in the other 2 trials.
Well I am not saying the difference could explain away the whole study. I am saying that if you have a guy who wants to have sex with his wife, but is told by those researches that he has to use a condom while it heals, he will use a condom. And if a guy is willing to get circumcised to reduce his chance of infection, its likely he would go to the far less extreme step of using a condom after he got use to using them.
ReplyDeleteHow much could this have effected the whole study? One one can really say, but more research needs to be done to show that. Everyone keeps going back to these same three studies, and honestly if circ could for sure reduce rates of HIV infection then the CDC should tell people about it. But we should not be making big changes in public health policy, not until we have done research in our own country, under conditions that are less debatable.
Well I am not saying the difference could explain away the whole study. I am saying that if you have a guy who wants to have sex with his wife, but is told by those researches that he has to use a condom while it heals, he will use a condom. And if a guy is willing to get circumcised to reduce his chance of infection, its likely he would go to the far less extreme step of using a condom after he got use to using them.
ReplyDeleteThis is pretty basic epidemiology: if you suspect that you might have another variable (or variables) that might explain the results, you record that variable and incorporate it into a regression model. And happily, that's what Auvert et al. did, reporting: "When controlling for behavioural factors, including sexual behaviour that increased slightly in the intervention group, condom use, and health-seeking behaviour, the protection was of 61% (95% CI: 34%–77%)."
Interesting, I did not realize that, thank you. Although that still was only one example I was giving to a larger problem.
ReplyDeleteThe reason I feel more research should be done is because I have lingering doubt:
How is it that the United States as the highest rates of infant circ in the western world(besides Israel) yet we still also have some of the highest rates of HIV infection? Or how some uncircumcised European countries have some of the lowest rates?
I have other questions, but I am interested in what you think about this first.
How is it that the United States as the highest rates of infant circ in the western world(besides Israel) yet we still also have some of the highest rates of HIV infection? Or how some uncircumcised European countries have some of the lowest rates?
ReplyDeleteAs with many diseases, HIV has multiple risk factors. It isn't terribly meaningful to compare countries because they usually differ in terms of several of these factors, making it impossible to isolate the effect of just one (in this case, lack of circumcision).
When we examine the literature, we find that there is evidence of differences in sexual behaviour, with higher risk behaviour being more common in the US than in European countries:
"More US (16%) than UK (4%) women reported additional acts (other than in the last 5 days) of unprotected sex during the cycle in which they sought EC." Blanchard K, et al. Differences between emergency contraception users in the United States and the United Kingdom. J Am Med Womens Assoc. 2002 Fall;57(4):200-3, 214.
"In comparison with that of Britain, the US population has greater variability in sexual behavior, less tolerant opinions about sexual behavior, and a higher STD prevalence and lower condom usage among men." Michael RT, et al. Private sexual behavior, public opinion, and public health policy related to sexually transmitted diseases: a US-British comparison. Am J Public Health. 1998 May;88(5):749-54
"Annual abortion rates (per 1000 women aged 15-44) are 5.6 in the Netherlands, 13 in Britain and 28 in the USA" Drife JO. Contraceptive problems in the developed world. Br Med Bull. 1993 Jan;49(1):17-26
"Of the 4 country/gender groups, US males were at the highest risk, while Swedish men had a low-risk behavior profile. Fewer differences were found between the women." -- Weinberg MS, et al. AIDS risk reduction strategies among United States and Swedish heterosexual university students. Arch Sex Behav. 1998 Aug;27(4):385-401.
"Among countries of the 'developed world', the teenage birth rate in the UK is second only to that in the USA. The UK rate is nearly five times that in the Netherlands, over three times that in France and over twice that in Germany" -- Contraception in teenagers. Drug Ther Bull. 2002 Dec;40(12):92-5
"In 1998, 42 health professionals and graduate students from the US traveled to Europe to study successful approaches to adolescent sex behavior adopted by Germany, France, and the Netherlands. The main lesson learned was that the policies of these countries are based on research not ideology and accept adolescent sex behavior as normal and healthy. The countries fund sex education and reproductive health services for adolescents, including contraception and abortion services. Rather than leading to promiscuity, as compared to the US this policy has resulted in a higher average age at first intercourse, fewer sex partners, longer waits between partners, and reduced numbers of abortion." -- Brick P. How does Europe do it? Fam Life Matters. 1999 Winter;(36):3
So really comparing the US and European nations is like comparing apples and oranges. They're too dissimilar to be able to isolate the impact of circumcision. Please remember that the effect of circumcision is relative: it reduces the risk in comparison to what it might otherwise have been. It doesn't eliminate risk altogether, and lack of circumcision doesn't create risk where it would have been nonexistent.
Interesting, its kind of what I thought. But that is one of the reason why I doubt these studies when being applied to the United States.
ReplyDelete"So really comparing the US and European nations is like comparing apples and oranges. They're too dissimilar to be able to isolate the impact of circumcision."
Africa is very different from the United States. They have many culture, social, and gender issues that are different then the U.S.. HIV does not have the same risk factors in these two regions.
How can we take results from a study that may have worked in parts of Africa and then use it to back a public health policy change by the CDC in the United States?
Shouldn't the next step be doing new studies within problem areas inside the United States?
Africa is very different from the United States. They have many culture, social, and gender issues that are different then the U.S.. HIV does not have the same risk factors in these two regions.
ReplyDeleteThe HIV virus doesn't have a passport. It doesn't understand about country borders. A biological mechanism that increases (or reduces) the risk in one place has the same effect in another. So many risk factors are common to all countries, although levels of exposure to these factors can vary greatly from place to place.
How can we take results from a study that may have worked in parts of Africa and then use it to back a public health policy change by the CDC in the United States?
Biological mechanisms don't vary by country, as noted, and this is confirmed by the fact that results were so consistent between the three trials in Kenya, Uganda, and South Africa. It's rational to assume that the degree of protection will be similar everywhere, just as we don't need to test the theory of gravity in every possible location to be confident that it will work.
However, the most significant difference between countries is the absolute risk of HIV. This, in turn, affects the absolute risk reduction attainable through circumcision. And, when weighing the risks and benefits, it is important to weigh the magnitude against each other. Consequently what may be an imperative in countries with very high HIV rates may be less compelling in countries with very low HIV rates.
Shouldn't the next step be doing new studies within problem areas inside the United States?
There's no need. The fact that circumcision is effective is well established.
But even though statistically Americans generally take part in more risky sexual behavior, if circumcision reduced infection rates by up to 60%, wouldn't that be somewhat reflective data collected on infection rates between the US and Europe? From what you said, safe sex practices are a far more effective and important factor, as they, (not circumcision rates) show a more meaningful reduction in HIV rates. Seeing as this is true, shouldn't we be focusing our energy and money on sexual education campaigns, instead of universally applying a procedure to alter the after effects of the problem instead of the problem itself?
ReplyDeleteFurther if the useful application of circumcision as a tool to fight HIV is relative to the risk factors for individuals, isn't it sloppy to apply one policy stance to the entire country when there are many different communities, within the United States that do not all have the same risk levels?
Shouldn't the next step be doing new studies within problem areas inside the United States?
ReplyDeleteThere's no need. The fact that circumcision is effective is well established.
One small correction: ineffective. For example, Mor et al. found no significant protective effect in nearly 60,000 men attending SF STI clinics over ten years (who ought to be canaries in a mine for any such effect).
One small correction: ineffective. For example, Mor et al. found no significant protective effect in nearly 60,000 men attending SF STI clinics over ten years (who ought to be canaries in a mine for any such effect).
ReplyDeleteNo, I said "effective" and I meant "effective". It would be foolish to rely on an observational study such as that of Mor et al., which is inherently susceptible to confounding, when three randomised controlled trials are available.
But even though statistically Americans generally take part in more risky sexual behavior, if circumcision reduced infection rates by up to 60%, wouldn't that be somewhat reflective data collected on infection rates between the US and Europe?
ReplyDeleteShort answer: it depends.
Slightly longer answer: let's assume, for the sake of argument, that the prevalence of circumcision is 100% in the US and 0% in Europe (the actual figures are probably about 80% and 10%). If this is so and everything else is equal, then we might expect rates to be 0.6x that in the US. But we know that everything else is not equal: we know that high-risk behaviour is more common in the US. How much does that increase the overall risk? If it's exactly 1.7x (that is, 1/0.6), then it would cancel out the effect of circumcision. If it's more, then there would be greater risk.
1.7x is roughly comparable to using condoms 80% of the time vs using condoms 90% of the time.
From what you said, safe sex practices are a far more effective and important factor, as they, (not circumcision rates) show a more meaningful reduction in HIV rates.
I would say that both are effective, and they are not mutually exclusive.
Seeing as this is true, shouldn't we be focusing our energy and money on sexual education campaigns, instead of universally applying a procedure to alter the after effects of the problem instead of the problem itself?
I don't agree with universal circumcision. Please see my comments in the third post in this thread.
"I don't agree with universal circumcision. Please see my comments in the third post in this thread."
ReplyDeleteThen what do you see is the proper thing to do?
Then what do you see is the proper thing to do?
ReplyDeleteI favour informed parental choice (and, where appropriate, individual choice for older patients). So I favour making the choice available to all parents (including the poor via Medicaid programmes), and making reliable information available to inform that choice.
Well why not just promote informed choice for boys, and young men, instead of babies? Like were getting push back because there are groups that dont agree with infant circ.
ReplyDeleteMost "circed countries" dont circ in infancy and they seem to go along just fine. The Philippines being a great example of this.
Who cares when it happens? I think if circ could make a difference, why not retool the message to being a truly informed consent, that way anti-circers would have absolutely no ground to stand on.
I support anyone's right to prefer and choose circumcision for HIMSELF. I do not support anyone's effort to shove their religious, political, pseudo-scientific, or sexual /aesthetic preferences down my throat.
ReplyDeleteI can tell you from direct experience that circumcision does NOT prevent HIV or STD's.
NO ONE, let me repeat that, NO ONE, has the right to amputate another person's healthy genitalia without their informed, adult consent. If someone wants a cosmetic circumcision, then he can choose it for himself when he is 18.
BTW, I was raised as a Jew; I completely support right of Israel to exist. I just find the ideas of a covenant with god, a divine origin for the bible, and religion itself to be ridiculous.