Saturday, January 23, 2010

Circumcise Newborns is Most Effective Strategy

Sometimes it just takes a little common sense to do what is right. But it never hurts to have an academic study back up your point of view. Common sense dictates that circumcising baby boys is the most cost-effective way to achieve the benefits of circumcision even if that boy is not likely to engage in sexually risky behavior until later in life. The anti-circ fanatics often rail against newborn circumcision, saying "baby boys don't have sex, don't circumcise them until later in life." Now comes still another study that establishes the obvious -- newborn circumcision is cheaper and safer and less complicated than adult circumcision. So let's do the obvious -- every baby boy should leave that foreskin behind when he comes home with mommy!

Check out this story below, and share your comments.


ScienceDaily (Jan. 21, 2010) — Circumcising newborn boys as a way to prevent HIV infection in later life is more cost-effective than circumcising adult males, finds a new Rwandan study in PLoS Medicine.

It has already been conclusively shown, from three randomized clinical trials in Uganda, Kenya, and South Africa, that adult male circumcision (MC) roughly halves the HIV transmission rate from women to men. Many African countries hit hard by HIV are therefore offering men the procedure as way to control the epidemic. Rwanda is one such country -- about 3% of adults in Rwanda are infected with HIV but only 15% of men are currently circumcised.

But performing the operation in adolescents and adults is linked with a higher risk of complications than circumcising newborns. And the operation is quicker and simpler to perform in newborns. The new study, by Agnes Binagwaho (Rwanda Ministry of Health) and colleagues, therefore set out to compare three different strategies as applied to Rwanda: circumcising newborns (neonates), adolescents, or adults.

The researchers used a technique called "cost-effective analysis," which looks at the balance between the costs of a medical intervention and its benefits. They estimated that each neonatal MC would cost just US$15 whereas each adolescent or adult MC would cost US$59. They found that neonatal MC would in fact save more money than it costs, because the operation is cheap to perform and would prevent HIV infections that are expensive to treat.

The study findings, say the authors, "suggest that Rwanda should be simultaneously scaling up circumcision across a broad range of age groups, with high priority to the very young."

In an expert commentary on the new study, Seth Kalichman (University of Connecticut) says: "The cost-savings of neonatal MC are compelling and suggest that implementation is economically feasible in developing countries hit hardest by HIV/AIDS. Neonatal MC should therefore be considered a priority in comprehensive HIV prevention plans for southern Africa."

17 comments:

  1. Everyone I know who is circumcized and that's like almost everybody is SOOOOOO happy it was done when they were a baby. That's the best time to do it, not when your old and it hurts more. LOL.

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  2. I agree with PD and the first commenter: It's better to be circumcised as a baby. It's cheaper, easier, less painful, safer, and there are some benefits only attained when circumcision is performed in infancy.

    It's really almost not a surgery when performed at that age, because it's so simple and there's no open wound. Isn't it remarkable that nature, or God if you prefer, has made circumcision so easy for us?

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  3. Great comments, Carlos & Anon. I don't know anyone who is circumcised today who says that they would have preferred to have been circumcised as an adult instead of when a baby. In fact, the common reaction is, I'm sure glad that was done back then. As Carlos notes, it's cheaper, easier, less painful, safer, and some obvious medical benefits -- like fewer urinary tract infections (by a 10 to 1 margin) as a baby. So newborn circumcision is a win-win for everybody!

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  4. My son was circumcised at birth. That was 5 years ago. He has never had a problem with his penis. I like it because it's very easy to clean. It only looked a little scary right after he was cut - his poor penis head was red and tender. It healed quick and no complications. We have him pain killers for a few days afterwards and he seemed fine - only a little crying at diaper changes but vaseline on the penis helped it from sticking to his diaper. It looks great now; you can hardly see the scar. I'm glad he was circumcised and would definitely circumcise my future boys at birth also.

    Thanks for the interesting blog. I really like it. Hopefully there are other moms here who can share their experiences with circumcising their boys.

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  5. Thanks, Amy, for your excellent comment. I hope you will encourage other parents of circumcised boys to post their views. So often a blog like this only attracts the anti-circumcision fanatics who get their thrills accusing us of "mutilating" baby boys. Always nice to hear from real people who appreciate the great value of circumcision.

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  6. "almost not a surgery"
    Nonsense! It's much harder to cut a baby's penis accurately (like writing on a balloon, any mistake distorts and expands when it grows larger)

    "...there's no open wound..."
    On some other planet maybe. Look at any video or slide show of a real circumcision and see if you can still say that.

    "Isn't it remarkable that nature, or God if you prefer, has made circumcision so easy for us?"
    If God or nature wanted males to be circumcised we would be born that way. You have the cart before the horse. Humans circumcise (all mammals have a foreskin, but no other mammal circumcises) because it's (relatively) easy for us to do. The operative words are "for us" - it's damned hard for the baby.

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  7. "about 3% of adults in Rwanda are infected with HIV but only 15% of men are currently circumcised."

    According to the National Health and Demographic Survey for Rwanda for 2005 (http://www.measuredhs.com/pubs/pdf/FR183/15Chapter15.pdf p10/17), 3.8% of circumcised men have HIV while only 2.1% of non-circumcised men do. So circumcising the remaining 85% of males in Rwanda could cause the HIV rate to RISE.

    Certainly there is no mandate for applying trials on adult volunteers in three other countries to boy babies in Rwanda - or the US.

    "But performing the operation in adolescents and adults is linked with a higher risk of complications than circumcising newborns."

    If any study has shown this, please give the reference. I don't believe any has. (It would be hard to compare them accurately, because the adults can complain more.)

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  8. According to the National Health and Demographic Survey for Rwanda for 2005 (http://www.measuredhs.com/pubs/pdf/FR183/15Chapter15.pdf p10/17), 3.8% of circumcised men have HIV while only 2.1% of non-circumcised men do. So circumcising the remaining 85% of males in Rwanda could cause the HIV rate to RISE.

    You're making the classic mistake of confusing correlation with causation.

    Here you're presenting an observational study in which there is a slightly higher risk of HIV among circumcised men in Rwanda. But it would be foolish to conclude that circumcision is the cause of that higher rate. Such a conclusion would contradict everything we know, including the majority of the other 40+ observational studies, as well as the more robust randomised controlled trials. All of this evidence tells us that circumcision actually reduces the risk of HIV.

    So the most logical conclusion is that the apparent correlation is the result of confounding. To use a hypothetical example to illustrate, it might be that men in urban areas are more at risk of HIV due to the environment, and there is also a higher circumcision rate in these areas. To remind you, the reason why randomised controlled trials are constructed as they are is to break, through the randomisation process, any pre-existing associations that might act as confounders, to ensure that the results reflect just the effectiveness of the intervention.

    And unless circumcision is actually the cause of the higher risk, there's no rational basis for assuming that introducing widespread circumcision would increase the HIV rate. In fact, doing so would change existing patterns of associations between circumcision and other factors.

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  9. Notice that the news item commits the same "classic mistake" without comment from Jake. (But of course pro-circ studies have always done that - another example of circumcison getting a free ride.) Yes, they broke out the urban men, and indeed, the rate among the non-circumcised was very slightly higher, 5.7% vs 5.0%, nothing like a 60% difference.

    It is indeed possible that circumcision, through unsterile instruments, IS the cause of the higher risk.

    The "40+" studies Jake is so fond of were also subject to confounding. And don't forget that the "robust" RCTs boil down to 73 circumcised men who didn't get HIV who might have, while 327 circumcised men left the study, their HIV status unknown, and confounding factors like HIV status of partners, number of partners, number of sex acts, non-heterosexual and non-sexual transmission are unmeasured and unknown.

    And to the first anonymoust poster, if you'd asked men who were not circumcised, you'd find they (with the odd exception, like Jake before he had it done by his own choice) were SOOOOOOO happy not to be circumcised at all.

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  10. Notice that the news item commits the same "classic mistake" without comment from Jake.

    Please be more specific. What precise mistake has been made in the news item?

    (But of course pro-circ studies have always done that - another example of circumcison getting a free ride.) Yes, they broke out the urban men, and indeed, the rate among the non-circumcised was very slightly higher, 5.7% vs 5.0%, nothing like a 60% difference.

    Urban vs rural was a hypothetical difference that I used to illustrate the concept of confounding. I thought I had made that clear, but obviously not.

    It is indeed possible that circumcision, through unsterile instruments, IS the cause of the higher risk.

    Unlikely, though.

    The "40+" studies Jake is so fond of were also subject to confounding.

    Yes, of course. But when a large number of studies, of different designs and conducted in different environments, give (for the most part) similar results then that is much stronger evidence than a single study.

    And don't forget that the "robust" RCTs boil down to 73 circumcised men who didn't get HIV who might have, while 327 circumcised men left the study, their HIV status unknown,

    So those 327 men would be rather like the 3,000,000,000 men who weren't included in the study at all, then.

    and confounding factors like HIV status of partners, number of partners, number of sex acts, non-heterosexual and non-sexual transmission are unmeasured and unknown.

    What on earth makes you think that these should be confounding factors? Do you have any evidence whatsoever that these should be tied to the randomisation process?

    And to the first anonymoust poster, if you'd asked men who were not circumcised, you'd find they (with the odd exception, like Jake before he had it done by his own choice) were SOOOOOOO happy not to be circumcised at all.

    Actually, studies of circumcision acceptability have shown that a majority of men are willing to be circumcised as adults, which seems inconsistent with your claim.

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  11. Thanks, PD. You do a good service with the blog.

    Amy: Kudos to you, and I'm glad for your son. What you describe sounds normal to me - a little redness and tenderness at first, and maybe a bit of crying at diaper changes until it heals, but it does heal very quickly. Vaseline is often used for the purpose you state.

    Hugh7: The skin of the penis remains stuck together during and after neonatal circumcision without requiring stitches, so I stand by my statement that there is no open wound in the circumcision of an infant.

    It is among the earliest and safest surgical procedures that I know of, healing is amazingly rapid, and there is usually virtually no blood loss, so I'll also stand by my statement that it's so minor that it's barely even a surgery.

    I don't need to watch a video. I bet I know which video you want me to watch. I used to be one of the people like you telling others to watch a video. No medical procedure is pretty, but most of the circumcisions I've seen weren't so bad.

    And as for what nature or God wants, if the foreskin were as important as opponents say, wouldn't nature or God have made it much more difficult to remove?

    One thing that distinguishes humans from other mammals is our great reliance upon learning, and this allows some of us to adapt and improve much faster than the slow, random evolution of DNA would allow. Circumcision is a meme, and it's a rather successful meme that allows us to remove the foreskin faster than it could evolve away by selection processes and random mutations.

    Anyway, as for your claims concerning rates of HIV in Rwanda, you're making irresponsible, unscientific claims about a deadly infectious disease. If you really cared about HIV rates, you wouldn't pick and choose statistics based on personal bias.

    If there were any truth in the radical views of the opponents of circumcision, they wouldn't need to always resort to outright lies, speculation, or pseudoscience. That's certainly not helping anyone to make an informed decision, is it? Come on, Hugh7.

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  12. And don't forget that the "robust" RCTs boil down to 73 circumcised men who didn't get HIV who might have, while 327 circumcised men left the study, their HIV status unknown,

    So those 327 men would be rather like the 3,000,000,000 men who weren't included in the study at all, then.Only if they left the study regardless of their HIV status - but they were encouraged to find that out at a clinic nearby.

    I bet I know which video you want me to watch.How about this one, from that well-known hotbed of Intactivism, Stanford University? http://newborns.stanford.edu/Gomco.html (Gomco™ clamp) or this one? http://newborns.stanford.edu/Mogen.html (Mogen™)

    if the foreskin were as important as opponents say, wouldn't nature or God have made it much more difficult to remove?It's no harder to remove than an eyelid. Easier, actually, since you don't have to run a blunt probe under the eyelid first to separate it from the eyeball. I don't think Nature ever gave any thought to the possibility that anyone might want to remove it. But back to reality, if it were anything like as dangerous as circumcisionist say, it would have evolved away billennia ago.

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  13. Here is the fallacy of "correlation implies causation" (but it isn't even correlation) right in the article we're discussing: "Here, 3% of the adult population is infected with HIV but only 15% of men are circumcised — worldwide, about 30% of men are circumcised."

    PS: if the foreskin was meant to be removed, why doesn't it have perforations?

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  14. Hugh, I think the article was saying there's a lot of potential for circumcision to help to reduce the risk of HIV infection there. It's not using the figures to claim that the low circumcision rate caused the high HIV rate, though it could be the case based on what is known about HIV transmission.

    But your comment about perforations was very funny.

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  15. Not just babies. All men should be circumcised, whether they want to or not. There is no sight more beautiful that the permanently exposed glans, looking up at you, so

    helpless, vulnerable, and totally exposed

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  16. As the unwilling owner of a dried-out cut penis, I can only too well testify that sex is a less than fulfilling experience for both of us, After 30 to 50 minutes of thrusting, I get numb, and she is sore even with copious amounts of lubricant. As a result we have not had intercourse for more than 4 years, but I am trying to restore what little tissue I still have, so that I may be able to resume. Because of this, and that I don’t have the moral right to modify a natural baby’s body, our son is intact, and at 26 years of age has had no problems with his penis.

    Penile cancer can affect both cut and uncut men but only at an advanced age. I’m sure most men would be happy to have 60 years of great sex, and take that risk. A better precaution is avoiding tobacco.

    To Amy: Whether your son will still love you when he realises that his penis is not as sensitive as it should be, and that his partner needs to use an artificial lubricant to make intercourse pleasurable for HER, only time will tell. His penis may look ok now but when it enlarges at puberty there will be little or no loose skin.

    As far as God in concerned, circumcision was rejected by Christians nearly 2000 years ago, see Letters to Romans and Corinthians.

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  17. Several women want the law on male circumcision to ensure that the practice is compulsory.

    Susan Akello from Orom sub-county says government should pass a legislation that will compel all men to be circumcised and those who refuse be punished.

    Jane Adokorach, a self styled women activist agrees with Akello. Adokorach says women should deny sexual rights to men who are not circumcised. She also proposes a law that will include punitive measures for men who refuse to be circumcised. She says this reduces the rate of infection for men and transfer of the disease to their spouses.



    Read more: http://ugandaradionetwork.com/a/story.php?s=33903#ixzz1Y9HgjBya

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