CDC should recommend routine circumcision
Sunday, August 30, 2009
Sunday, August 30, 2009
The Centers for Disease Control and Prevention are weighing a proposal to recommend routine circumcision for all baby boys born in the United States to curb the spread of HIV and other infections. The CDC should ignore the cries of outrage from so-called "intactivists" and recommend the procedure. The evidence shows that the benefits of circumcision outweigh the risks.
This shouldn't even be controversial. Nearly 80 percent of adult American men are already circumcised, and they seem to be getting through life just fine. Studies have shown that circumcision can reduce HIV infection rates for heterosexual men by half. Observational studies have also shown that circumcised men have lower rates of other sexually transmitted diseases (like herpes and syphilis), cancer of the penis and urinary tract infections. What's the problem, again?
Well, the problem centers on the hysterical intactivists, who believe that: A. circumcision is "mutilation"; and that B. baby boys should be able to "decide for themselves," as though families have no right to make decisions about their children's health, treatment and culture. (Not to mention the health and safety of the larger society.)
The CDC should recommend routine circumcision.
I read every reply to this editioral in the SF Chronicle. Not one actually agreed with it, and most forcefully condemned it. It's almost like the Chronicle is secretly an intactivist organisation, and they printed it just for the visceral reaction.
ReplyDeleteMany readers pointed out that in Europe, where circumcision is not especially common, HIV rates are lower than in the U.S. In fact, there doesn't seem to be any correlation between HIV rates and circumcision status when examined over the world: for every correlation cherry picked by circumcision advocates, there's a stubborn counterexample they don't want to talk about.
Sexual practices account for the prevalence of this disease. You don't get HIV like you catch a cold. Circumcised men who repeatedly engage in risky sexual contact where HIV is epidemic can count of getting HIV.
What are your views about "recommend[ing] routine circumcision" for uncircumcised teenagers and adult men? How would you go about achieving those goals? After all, if we are worried about HIV/AIDS, they would be at far more risk than babies.
ReplyDeleteTo respond to "Anonymous" (dated 4:15PM):
ReplyDeleteI read every reply to this editioral in the SF Chronicle. Not one actually agreed with it, and most forcefully condemned it.
I haven't read all of the replies, but looking at some of them I see a lot of familiar names - the same names that appear in many online discussions about circumcision. I don't know whether these individuals use Google Alerts to watch for articles about circumcision, or whether there is an intactivist alert message board where they notify each other. Either way, it has the unfortunate effect of badly skewing the sample in any online resource that allows feedback, making it impossible to judge the reaction of the general public.
Many readers pointed out that in Europe, where circumcision is not especially common, HIV rates are lower than in the U.S.
Yes, this comes up again and again. Those who are unfamiliar with epidemiology often think that this is a persuasive argument. Of course, if we could get reliable results by simply comparing a handful of countries then we could save a lot of time and effort that is spent on expensive studies. But sadly, ecological analyses (as such comparisons are known) are the least reliable of all studies, partly because they're highly susceptible to confounding factors. (Europe and the US, for example, are so different in terms of sexual practices that this is like comparing apples and oranges.)
In fact, there doesn't seem to be any correlation between HIV rates and circumcision status when examined over the world:
It would be interesting to see a source for this. The most exhaustive study that I can think of was Drain's "Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries" (BMC Infect Dis. 2006 Nov 30;6:172).
for every correlation cherry picked by circumcision advocates, there's a stubborn counterexample they don't want to talk about.
If anyone, regardless of their position, relies on correlations in ecological analyses to make their point, then frankly they're so clueless about evidence-based medicine that they're not worth paying attention to. Several ecological studies were published in the late 1980s, but the world has moved on, and many observational studies of much stronger design, and later randomised controlled trials, have been published as well. It's not worth wasting time on such weak evidence now that more rigorous data are available.
And to respond to "Anonymous" of 5:22PM:
What are your views about "recommend[ing] routine circumcision" for uncircumcised teenagers and adult men? How would you go about achieving those goals? After all, if we are worried about HIV/AIDS, they would be at far more risk than babies.
Why are they "at far more risk" than babies? That doesn't make any sense. Babies almost always become teenagers, and then adults. So the risk is surely equal, in time.
if "intactavists" are serious about "choice", they will support free circumcisions offered to all boys and adults males who want it.
ReplyDeleteThey may be surprised just how many choose it, and then their arguments about not doing to babies will seem silly - especially when the adults say "I wish i'd had this done when i was young!"
Thank you all for your comments, pro and con. Jake, as always, you offer a thoughtful rebuttal to the anti-circs who are in total denial about the medical evidence that favors circumcision.
ReplyDeleteI, too, had the same thought as the most recent "Anonymous" poster. If circumcision is an important weapon in the arsenal against HIV, STD, HPV, cancer, and the like for both men and women, then obviously newborn circumcision makes perfect sense. It's easier, less physically traumatic, and less expensive than any teen or adult procedure. But many males remain uncircumcised -- through no fault of their own --and they, too, deserve the protection of circumcision.
Since the U.S. government and some foundations (like the Gates Foundation) are spending millions of dollars to circumcise adult Africans, I see no reason why we cannot have a "free" or "minimal co-pay" procedure to circumcise America's teens and adults. At a minimum, health insurance (including Medicaid for the poor and disadvantaged) should cover the procedure without all the redtape that some men say is required today. But this is no way negates the value of newborn circumcision which, after all, is a long-term investment in good public health.
In response to Jake:
ReplyDeleteYour analysis falls just short of a conclusion, about where you accuse others of being clueless.
What you are saying is that effect of "confounders" in ecological studies swamps the results of the observational and controlled studies. Whatever effect circumcision might have can't be detected by simply examining where circumcision and HIV occur, but this makes the controlled studies practically useless outside their domain, since they can't be applied to other places. If these studies were statistically powerful, they would *agree* with the observations of where circumision and HIV occur. For example, the smallpox and polio vaccines work everywhere, all the time, not just in one country and not another, depending on "confounders."
The observation that HIV rates are lower in Europe is relevant. As you suggest, however, we don't really need to mount a study about this. Sexual practices rule the HIV equation. Again, Jake: if you are having risky sexual contact where HIV is epidemic, you can count on getting infected, foreskin or cut, sooner or later. Circumcising every man woman and child won't stop this epidemic.
John Kuehne, Ph.D.
To respond to John Kuehne:
ReplyDeleteWhat you are saying is that effect of "confounders" in ecological studies swamps the results of the observational and controlled studies.
Not quite. I'm saying that susceptibility to confounding factors is one of several weaknesses that contribute to the low reliability of ecological studies. And that means that ecological studies are, as a rule of thumb, less likely to find accurate results.
Whatever effect circumcision might have can't be detected by simply examining where circumcision and HIV occur, but this makes the controlled studies practically useless outside their domain, since they can't be applied to other places.
That doesn't make any sense.
If these studies were statistically powerful, they would *agree* with the observations of where circumision and HIV occur.
What you're saying, to put it another way, is "if more reliable studies had some property or other, they'd agree with the results of less reliable studies". This, of course, is completely backwards: when comparing two measurements, you generally place more trust in the most reliable, not the least.
For example, the smallpox and polio vaccines work everywhere, all the time, not just in one country and not another, depending on "confounders."
There is no evidence that circumcision only works in one country and not another. It's important to clearly distinguish between apparent and actual effects. The actual effect of circumcision is due to its biological mechanism, and is (according to all available evidence, as well as basic logic) independent of country. The apparent effect (or not) is a product of both the actual effect and the strengths and weaknesses of the measurement - that is, the study methodology.
The observation that HIV rates are lower in Europe is relevant. As you suggest, however, we don't really need to mount a study about this. Sexual practices rule the HIV equation.
Undoubtedly so.
Again, Jake: if you are having risky sexual contact where HIV is epidemic, you can count on getting infected, foreskin or cut, sooner or later.
I think you're overstating your case here. Even in such a situation, HIV isn't inevitable, though it is likely.
Circumcising every man woman and child won't stop this epidemic.
Universal circumcision wouldn't stop the epidemic, no, but it would probably make a dent, and maybe a substantial one (please note that I'm not endorsing a call for universal circumcision, just commenting on what the consequences might be). On balance, the evidence suggests that circumcising women will not make any difference at all.
Jake, I think you are understating the case about sexual contact. It's the primary mode of transmission in most of the world. The controlled studies from Africa are really rather sobering, and not good news at all. What they say is that about half the men spared HIV infection in the first two year period will become infected in the next two year period. That is, the numbers coming out of these studies are not an absolute lifetime risk reduction, but a percentage *rate*. Your personal chances of acquiring HIV - assuming your sexual practices don't change - are only delayed, and not by many years, if you are circumcised. To extrapolate these finding via mathematics models to a large population is impossible. Those pesky confounders: cultural effects would totally swamp the effect of circumcision. When HIV sweeps the Amish community, I'll eat my words. In the meantime, HIV will continue to grow, with or without circumcision, regardless of what you think! Take that to the bank.
ReplyDelete-John
Jake, I think you are understating the case about sexual contact. It's the primary mode of transmission in most of the world.
ReplyDeleteNo argument from me, John.
The controlled studies from Africa are really rather sobering, and not good news at all. What they say is that about half the men spared HIV infection in the first two year period will become infected in the next two year period.
No, they don't.
That is, the numbers coming out of these studies are not an absolute lifetime risk reduction, but a percentage *rate*.
Of course. Risk reduction is inherently relative to the risk prior to its reduction.
Your personal chances of acquiring HIV - assuming your sexual practices don't change - are only delayed, and not by many years, if you are circumcised.
That would only be so if HIV infection were inevitable. That is, if a person's lifetime risk of HIV infection was 100%. But - thankfully - that isn't the case, and the lifetime risk of HIV is just the sum of the risk of HIV in every year of a person's life. So if you halve the risk per year, you in turn halve the risk over a lifetime.
To extrapolate these finding via mathematics models to a large population is impossible. Those pesky confounders: cultural effects would totally swamp the effect of circumcision.
Actually, if one were to introduce circumcision into a country with previously low circumcision rates, and measured HIV incidence before and after, then it's questionable whether there would be any significant confounding, because you're comparing like with like. The differences between two different countries are likely to be far greater than the difference between one country and itself a short span of time later.
When HIV sweeps the Amish community, I'll eat my words. In the meantime, HIV will continue to grow, with or without circumcision, regardless of what you think! Take that to the bank.
Okay, John. Thanks for the mature discussion! :-)
I have to admit I got more than a little lost in the back and forth between you two scientists, but happy to facilitate the debate!
ReplyDeleteOne thing is certain about the report of the CDC and universal circumcision is that it has sparked lots of healthy debate across the country. Let's all agree that's a good thing IF we can keep the nasty nonsense to a minimum. Given the hysteria, as the Chronicle calls it, of the foreskin lovers, that could be tough. Calling people "mutilators" for circumcising their sons is hardly a good way to start a debate! LMAO.
. . .urging the Centers for Disease Control to stick to its original position that now is the time for all American newborns to be circumcised.
ReplyDeleteSince the U.S. government and some foundations (like the Gates Foundation) are spending millions of dollars to circumcise adult Africans, I see no reason why we cannot have a "free" or "minimal co-pay" procedure to circumcise America's teens and adults. At a minimum, health insurance (including Medicaid for the poor and disadvantaged) should cover the procedure without all the redtape that some men say is required today.
OK, so at a minimum, you'd advocate that teen and adult circumcisions be provided free or at minimal cost without red tape. But, do you really think that would result in most of the 21% of American adults who are estiumated to be uncircumcised to choose to get circumcisions? Since you are arguing that all newborns should be circumcised, are you settling for a target of less than 100% of adult and teen males getting circumcised as well? If not, how would you suggest that the CDC encourage a greater uptake among older males? What is the minimum target that you think that the CDC should consider acceptable?
Every year 5+ million children die from malaria, and tens of millions suffer untold agony and shortend lives. But until recently the world spent more on erectile dysfunction drugs than malaria research (thanks to Mr. Gates for evening that out, at least temporarily).
ReplyDeleteA dozen kinds of tropical parasites infect tens to hundreds of millions of people, causing blindness, organ damage, and death, and many can be cured for just a few dollars per person. Yet, the death continues. I bet that 5 in 1000 Amerians can name one of these parasitic diseases.
The biggest health threat to hundreds of millions of people is simply the water they drink. For just a few dollars per year per person, clean drinking water is possible with modern filter technology. But it doesn't happen.
Tuberculosis is spreading like fire. Sick people get the drugs for a few months, stop taking them, and then relapse with drug resistant strains, spreading death at every cough.
HIV is just one player in the cocktail of death. It mostly provides a large number of immune deficient hosts for malaria, TB, and dozens of parasites, who then infect otherwise healthly people.
In the West, HIV is a disease of choice. People choose to have risky sex, to inject drugs. But in parts of Kenya a girl's first sexual experience is likely to be rape.
The U.S. frenzy to circumcize the world is a cynical thing. Sex sells, and that's the charm of HIV and circumcision for Americans. It gets newspaper headlines. It gets blogs with childish attitudes about foreskin and sex. It gets advocacy groups for and against circumcision. Nobody wants to see another picture of a child dying of malaria!
Optimistic mathematical modeling suggests that it will take decades of mass cirucmcision to prevent a few million infections, during which time malaria and TB will have killed numbers that boggle the mind (see The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa, by Williams et al.) The key word in that title is "Potential" for many reasons I have already discussed: what an HIV epidemilogist calls a "confounder", i.e. something he doesn't understand and can't control that screws up his precious model, is the ground truth that controls what will really happen. Just wait: HIV will rage forever unless something like a vaccine can be discovered. And even then, would a world that cares more about a limp penis than malaria do anything?
Circumcision is the least thing we can do, as in the least effective. I bet Christian missionaries in Africa will save more lives than circumcision ever will. In the U.S., where people choose, in essence, to get HIV, circumcision won't do anything. 4/5 U.S. males are already cut. The study here is already done and the results are out, fools.
Mass circumcision is the new AIDS denialist propaganda.
John Kuehne, Ph.D.
Provoking, the hysteria didn't arise from Intactivists, it arose from red-blood Murricans who were afraid that the Garmint was going to take their right to choose away from them - just as you do. There was even talk of "circumcision panels".
ReplyDeleteInteresting, the US right wing thinks the right not to circumcise is more important than the right not to be circumcised.
But still, there was also a groundswell of opinion from people previously unknown to the movement, that neonatal circumcision is a human rights abuse.
And it's inspired a new bumpersticker -
You can take my foreskin
from my cold, dead hand!
"if "intactavists" are serious about "choice", they will support free circumcisions offered to all boys and adults males who want it."
ReplyDeleteThat's about as logical as the same statement would be with "pro-choicers" "abortions" and "girls and adult females" substituted. (Or piercings, tattoos, etc.) Since when did the hapless taxpayer have to fund everything that anybody chooses?
Most pro-choicers ARE in favor of government funding abortions.
DeleteThe evidence is in all boys should be circumcised.
ReplyDeleteLinda