Saturday, February 20, 2010

Circumcision Makes Comeback in Australia

Once upon a time, boys in Australia were as clean-cut as their American cousins. Then the national nannies stepped in to discourage and not pay for this important neonatal procedure. But even during the "bad times" a number of Australian parents opted to circumcise their sons. Now, the growing evidence of the medical benefits of circumcision are reaching parents, despite the reluctance of some in the Australian medical bureaucracy.

Under the headline -- "More boys go under knife as parents opt for kind cut" -- the Sydney Morning Herald reports a resurgence in newborn circumcision in New South Wales. It's still a long ways from American standards, but the good news is that trend is upward. One doctor predicts it will grow quickly to 30% over the next decade.

The headline is also a sign of the change in times. After some used to call circumcision "an unkind cut," how refreshing to see this simple health-giving procedure call what it is: a "kind cut" -- in fact, it's the kindest cut of all a parent can do for a newborn baby boy.

Here's the full story below:


CIRCUMCISION is making a comeback as a new generation of parents arm themselves with medical research to justify their decision.

The rate of circumcision for baby boys in NSW rose from 13 per cent in 1999 to 18 per cent last year, according to Medicare figures.

It's a long way from the 1950s when boys were routinely circumcised but Sydney paediatric surgeon Dr Anthony Dilley predicts the rate will keep rising. This is despite NSW Health banning circumcisions from public hospitals in 2006, except in cases of medical emergency.

"By the time today's baby boys are in kindergarten, it will be 30 per cent," Dr Dilley said.

Dr Dilley said parents were asking for circumcision because they thought it would benefit their child – "to look like dad", be more hygienic and reduce risk of disease – rather than for cultural or religious reasons."My own gut feeling is that there are parents who didn't get it done 20 or 30 years ago because they were bullied out of it," Dr Dilley said. "Most parents now don't stand for being told: 'Don't do it.' They will do their own research."

Proponents of circumcision such as Professor Brian Morris from the University of Sydney school of medical sciences say it is a kind of "surgical vaccine", pointing to studies showing it reduces the incidence of urinary tract infections, sexually transmitted diseases, penile cancer and penile inflammatory disorders, as well as being more hygienic.

It has also been shown to reduce the incidence of cervical cancer in female partners.
"At birth it's a very simple, safe procedure that gives immediate benefit through infancy and continues through life," he said.

The Royal Australian College of Physicians recently softened its opposition towards circumcision. Its 2004 position statement said there was no medical indication for routine neonatal circumcision and that benefits needed to be weighed against a complication rate of 1 to 5 per cent but its interim statement released last year was more nuanced, saying parental choice should be respected.

The college's paediatric and child health policy committee chairman Professor David Forbes said: "We have stepped back and said: 'Yes, there are ethical issues around circumcision but ultimately we have to have a policy that fits with society's practice and acknowledging parents' role in the decision-making process, while recognising the potential benefits and risks'."

But the statement recommends parents should wait until their boys are old enough to make their own decision on circumcision – the subject of a petition by pro-circumcision clinicians led by Professor Morris, who say infancy is best for the procedure.

Royal Australian College of General Practitioners national spokesman Dr Ronald McCoy said he didn't believe there was any reason to circumcise except for a handful of medical indications but agreed the debate was not going away.

"It certainly is a real issue. Parents want to find out what's best for their kids," Dr McCoy said.
General Practice NSW chairman Dr Ken Mackey said circumcision was generally safe but there were still slight risks of infection or deformity of the penis. "As always, fully informed consent is important," he said.

47 comments:

  1. Sorry, but pro-circ articles written by pro-circ owned papers quoting mainly from well known pro-circers doesn't constitute a well rounded article to me. It doesn't even rate as an informative read.
    It is sensationalist crap, nothing more.

    ReplyDelete
  2. This is great news. The anti-circ fanatics have held sway in Oz for too long and boys' health has suffered.

    ReplyDelete
  3. sorry anonymous, but you cant argue with the cold hard facts! the circumcision rate mentioned 18% is only the medicare rate so in reality the rates are higher.

    the 30% projection is already a reality in some states like QLD, having reached a 50% rate in 2008.

    as an Australian i'm very happy about this, it just shows that aussie parents are sensible, intelligent and able to see past all the no-circ emotive rhetoric bullshit and make the right decision for their sons!

    ReplyDelete
  4. sorry anonymous, but you cant argue with the cold hard facts!

    Having participated in the circumcision debate since 2003, I have to say that this statement contradicts my own observations. Everything I've seen indicates that anti-circumcision activists can and do argue with the cold hard facts, and on a regular, ongoing basis. ;-)

    ReplyDelete
  5. "San Diego, California (CNN) -- Antiretroviral drugs that are being used to prolong the lives of patients infected with HIV/AIDS could also be greatly effective in slowing its spread, epidemiologist Brian Williams said.
    The concentration of the virus drops by a factor of 10,000 with antiretroviral treatment, resulting in 25 times the reduction of infectiousness, said Williams, formerly of the World Health Organization and now at the South African Centre for Epidemiological Modelling and Analysis. That means that if more people with HIV received this therapy early, there would be fewer new cases of the disease, he said Saturday at the annual meeting of the American Association for the Advancement of Science.
    "We could effectively stop transmission within five years," Williams said.

    In a 2009 article in The Lancet, Williams and his colleagues at the World Health Organization advocated for broader use of antiretroviral drugs, proposing that everyone over age 15 should be tested annually for HIV, and that anyone who tests positive should begin antiretroviral treatment immediately.

    These ideas have been gaining support worldwide, Williams said. The National Institute of Allergy and Infectious Diseases plans to start a pilot study in New York and Washington, he said. The International Aid Society is doing something similar in British Columbia, and another trial in South Africa will be funded by the French AIDS Research Agency."
    http://www.cnn.com/2010/HEALTH/02/20/hiv.antiretroviral.drugs/index.html?hpt=T2

    ReplyDelete
  6. Yay! Something that could actually work. Hopefully if the transmission has essentially halted people will stop listening to this circumcision crap.

    Just as a question: If, tomorrow, a vaccine came out that cured HIV and prevented people from being able to catch the disease would you still advocate every newborn boy being circumcised?

    ReplyDelete
  7. "A study of HIV transmission between long-term, HIV-serodiscordant heterosexual couples in Africa has found that the chance of transmission is reduced by at least 90% if the HIV-positive partner is on antiretroviral therapy.

    As a comparison, this is better than the efficacy of 100% attempted condom use, which is in the order of 85% (with a high margin of uncertainty).

    There was one transmission from a partner who was taking HIV therapy, however, and presenter Deborah Donnell said that this indicated that the advice to serodiscordant couples that they should maintain safer sex should not change, even when the HIV-positive partner was on treatment.

    The proportion of couples who had unprotected sex actually decreased when the HIV-positive partner started treatment, allaying fears about behaviour change, at least in this population and in the short term.

    The other important finding from this study was that untreated partners with CD4 counts under 200 cells/mm3 were approximately five times more likely to transmit HIV than those with CD4 counts over 350 cells/mm3, strengthening the case for extending antiretroviral (ARV) provision to all people with low CD4 counts."

    http://www.aidsmap.com/en/news/062B2F32-1B29-4CCA-A047-820E21721D9B.asp

    ReplyDelete
  8. "Everything I've seen indicates that anti-circumcision activists can and do argue with the cold hard facts, and on a regular, ongoing basis. ;-)"

    What about these cold hard facts?

    "Late complications of newborn circumcision: a common and avoidable problem

    Journal: Pediatric Surgery International
    Publisher: Springer Berlin / Heidelberg
    ISSN: 0179-0358 (Print) 1437-9813 (Online)
    Category: Original Article
    DOI: 10.1007/s00383-010-2566-9
    Subject Collection: Medicine
    SpringerLink Date: Sunday, February 14, 2010


    Rafael V. Pieretti1 , Allan M. Goldstein2 and Rafael Pieretti-Vanmarcke3

    (1) Section of Pediatric Urology, Massachusetts General Hospital, Boston, USA
    (2) Department of Pediatric Surgery, Massachusetts General Hospital, Boston, USA
    (3) Department of Surgery, Massachusetts General Hospital, Boston, USA
    Accepted: 1 February 2010 Published online: 14 February 2010

    Abstract
    Purpose:

    The purpose of this paper is to study the types of operative and post-operative late complications resulting from newborn circumcisions and to make recommendations to prevent them.

    Methods:

    After obtaining IRB approval, a retrospective review of the late complications resulting from newborn circumcisions treated at the MassGeneral Hospital for Children from January 2003 to December 2007 was undertaken. The source used was the consultation notes and operative reports of affected patients. Additionally, cases seen in the outpatient Pediatric Urology Clinic from April 2007 to April 2008 were reviewed.

    Results:

    A total of 8,967 children were operated during the study period, of which 424 (4.7%) were for complications resulting from previous neonatal circumcision. Penile adhesions, skin bridges, meatal stenosis, redundant foreskin (incomplete circumcision with uncircumcised appearance), recurrent phimosis, buried penis and penile rotation were the most frequent complications. At the outpatient clinic of the Section of Pediatric Urology, 127 boys with concerns following newborn circumcision were evaluated, representing 7.4% of the total volume of cases seen in this clinic."

    Late term complications from circumcision have ALWAYS been underestimated by advocates of circumcision.

    ReplyDelete
  9. Hello, Anon.

    First, I don't understand why you're raising the issue of Pieretti's study. Do you think anti-circumcision activists would be likely to argue with it? Or is this just an attempt at deflection?

    Second, it is unclear why you are drawing attention to the study in the first place. What do you think it proves? The design of the study is such that it cannot estimate the incidence of complications of circumcision, so your assertion that "Late term complications from circumcision have ALWAYS been underestimated by advocates of circumcision" is puzzling.

    ReplyDelete
  10. It's horrible that *any* boys suffer these circumcision complications, especially because all these injuries were unnecessary: not counting birth defects, not a single boy needed a circumcision. Most of them had perfect penises when they were born, and it's reasonble to assume that many will suffer from physical and psychological scars for the rest of their lives, from an operation that did not need to be done, and that was done without their consent.

    ReplyDelete
  11. Kudos to Australians! Circumcision is the best choice. I guess these opponents of circumcision are angry that parents are doing their own research and opting for what's best for their children.

    Jake has already won this debate, but I'm inclined to point out that one of the complications listed by the anonymous individual is [b]redundant foreskin[/b]. How's that horrible if you think circumcision is removing something that's useful?

    Nonetheless, foreskins have complications as well, including phimosis, balanitis, rashes, urinary tract infections, smegma accumulation, odor, adhesions, injury by zippers, sexual dysfunction, frenulum breve, tearing, cancer, death, STDs including HIV, and so on.

    Conversely, the most common of the rare complications of circumcision is just minor bleeding, which could probably be solved with a styptic pencil in most cases.

    ReplyDelete
  12. Phimosis, Balanitis, Rashes, Zipper injuries, frenulum breve, tearing, STDs are all very treatable or avoidable by current methods. There are many foreskin sparing corrective surgeries (e.g. frenuloplasty, preputioplasty, stretching of the phimotic opening to promote skin-growth). Sexual dysfunction may occur during episodes of phimosis or balanitis, but is more often due to other medical conditions or psychological factors, so it's not reasonable to include that under foreskin ("complications"). Cancer of the penis is exceptionally rare and is usually treatable if caught early.

    Finally, I'm a medical doctor and it pains me to see laymen interpreting these studies. I'd like to mention the HIV studies specifically. We're taught that number needed to treat (NNT) and absolute risk reduction (ARR) are far more important than relative risk reduction (RRR), because RRR is frequently misused to make a study's results seem more significant than they are. Unfortunately, laymen and even science journalists make the mistake of just looking at the results and the RRR and declaring major effects that just aren't useful in the clinical sense. For instance, ARR for the South African trial = 1.8% and NNT = 56. Essentially, this means that 55 people in Africa were circumcised to prevent one case of HIV. Condoms are a much better preventative measure, with no side effects, and are not permanent (like circumcision). These results are made even less significant for the U.S. because the prevalence/incidence of HIV is much lower here than in Africa.

    ReplyDelete
  13. U.S. Incidence of HIV in 2006 through the CDC website is 22.8 per 100,000 or 0.023%. HIV can be avoided easily by most informed individuals. It makes no sense to decide for them that they need to be circumcised long before they know what type of sexual practices in which they will engage. It's like saying to your child, I don't trust you to be intelligent about protecting yourself.

    ReplyDelete
  14. For instance, ARR for the South African trial = 1.8% and NNT = 56. Essentially, this means that 55 people in Africa were circumcised to prevent one case of HIV.

    The mistake you're making, Josh, is to calculate ARR (and, in turn, NNT) from the percentages of infections that occurred during the trial itself. That's a mistake - or at least an extraordinarily conservative estimate - because it assumes that the protective effect lasts only for the duration of the trial.

    A more rational approach is to compute ARR based upon lifetime risk. To do that, we need to estimate lifetime risk, and to do that we need to estimate the lifetime risk in circumcised and uncircumcised men. That's fairly easy to do, though it needs to be calculated for a specific population. To do so, we need: a) the RR, b) the overall risk in that population, and c) the proportion of males who are circumcised in that population.

    That's what makes the RR so much more useful than the ARR within the trial itself.

    ReplyDelete
  15. Strike "that's fairly easy to do." It's that "specific population" part that makes the modeling hard and the predictions shaky. The fact that HIV is rampant in some places while rare in others, with no good explanation after all these years as to why that is so, that makes predictions even within a population unreliable. Extrapolation to other populations must be less certain. Mathematical models can't explain HIV prevalence, so why should anybody put stock in the same models to predict the effect of circumcision?

    ReplyDelete
  16. good~ keep sharing with us, please....I will waiting your up date everyday!! Have a nice day........................................

    ReplyDelete
  17. Jake, you're right. So, I looked it up and someone already did what you suggested:

    Cost-effectiveness of newborn circumcision in reducing lifetime HIV risk among U.S. males.
    http://www.ncbi.nlm.nih.gov/pubmed/20090910

    Essentially, the 1.87% lifetime risk is reduced to 1.57%. Instead of 1 in 53, the lifetime risk is 1 in 64. ARR here is 0.2%. I'm not impressed. And anyway, I shouldn't have brought this side of the issue up, because it really isn't about medicine or statistics.

    We don't look at any other body part this way. We do not excise healthy tissue prophylactically, let alone without the person's consent. When we give vaccines, with the exception of HPV vaccine, it is for diseases that would be difficult to prevent behaviorally without living as a hermit. In the case of HPV vaccine, it is not permanently altering healthy tissue without consent and it is preventing a disease that is far more prevalent than HIV. Furthermore, the HPV types that the vaccine prevents are invisible diseases until cancer has developed. Short of avoiding sex entirely, they cannot be easily avoided behaviorally. HIV is far less prevalent, clusters around specific risk groups, and its sexual transmission is easily avoidable with condoms, monogamy, & not engaging in sex with high risk individuals.

    HIV is a devastating and expensive disease and we need to do everything in our power to curb and eventually eradicate it. However, we need to respect individuals' rights to bodily integrity in the process. Recommending neonatal circumcision or, worse yet, mandating circumcision would be an affront to human rights.

    ReplyDelete
  18. Josh, what you don't understand is that Jake is a gay male who chose to get circumcised as an adult, and now he is a vocal defender of circumcision on the internet without equal. This blog is right in his comfort zone. His role on the internet is strange: without him, the wikipedia article on circumcision would be a hilarious mess of lies, both from the pro and anti sides. He is good with numbers, as long as they support his position. Unfortunately for his reputation there are instances on the web where Jake has taunted men who regret their forced circumcisions, and that's about as much as you'll find out about what makes him tick. Jake will tear apart your post, sentence by sentence, whether it makes sense or not to do so. When cornered, he says "that makes no sense." He also says that when it really doesn't make sense. He clearly enjoys the fight.

    ReplyDelete
  19. I just had an Evidence-Based Medicine session today for school. Low and behold, we looked at a RCT that stopped early and showed a beneficial effect. My instructor then handed out this article to show the pitfalls of this course of action.

    Randomized Trials Stopped Early For Benefit
    http://jama.ama-assn.org/cgi/content/abstract/294/17/2203

    I would need to look more closely at the HIV/Circ trials in light of what this paper shows before passing further judgement.

    ReplyDelete
  20. Anon,

    Those are strong claims. I'm going to stay out of analysis of Jake's motives and engage him reasonably and civilly. People on our side of the argument need to approach this subject in such a way if we are to be taken seriously. Thanks for your concern.

    ReplyDelete
  21. Wait for it Josh, Jake is just going to say "There is no way to prevent HIV 100 percent without remaining celibate, so you need to circumcise to get that extra 60 percent reduction!"

    Albeit is a less peppy way.

    ReplyDelete
  22. Queensland and NSW are anomlous. In the rest of Australia, the rates are falling, in some to residual levels. Even in those two states, more than four out of five babies are going home whole.

    'Dr Dilley said parents were asking for circumcision because they thought it would benefit their child – "to look like dad"...."My own gut feeling is that there are parents who didn't get it done 20 or 30 years ago ..." Dr Dilley said.'

    So their sons, the dads of today, are NOT cut, and if they want their sons to look like them, they can just do nothing. How simple!

    "As always, fully informed consent is important," he said.

    And whose penis is it? So who is the only person who should be giving fully informed consent?

    ReplyDelete
  23. To respond to John's post dated March 3, 2010 8:59 PM:

    [Regarding modelling of the HIV prevention benefit for the United States]

    Essentially, the 1.87% lifetime risk is reduced to 1.57%. Instead of 1 in 53, the lifetime risk is 1 in 64. ARR here is 0.2%. I'm not impressed.

    Are you not? That's odd because, you know, HIV is a virus that causes an extremely serious (and ultimately fatal) disease (AIDS). So I find it rather startling that you seem to be saying that prevention of two cases in a thousand is not impressive. If two lives in a thousand are so worthless that saving them is unimpressive, then — I have to ask — how many are needed to impress you?

    And anyway, I shouldn't have brought this side of the issue up, because it really isn't about medicine or statistics.

    Actually, yes, it is. That's exactly what it's about.

    ReplyDelete
  24. First of all, AIDS is not fatal. It's highly treatable with antiretrovirals. It is more a life-altering disease rather than a life-ending disease these days. Regardless, it IS serious, but an HIV diagnosis isn't the same as a fatal stroke or heart attack.

    I think the data is not impressive enough to trump patient autonomy here. You're more interested with big picture and I'm more interested in the impact on the individuals. You're more focused on the cases prevented and I'm more focused on the much larger number of males circumcised without benefit. What we should really be asking ourselves here is, how many sexually transmitted, male HIV infections are we preventing before the age of 18 (when the patient could make a decision himself). Nobody wants to advocate this because they know nobody would CHOOSE to get this operation for HIV prevention in this country if they had a healthy foreskin. The numerous males who wouldn't put themselves at risk with unsafe sexual practices wouldn't see any reason to go under the knife.

    ReplyDelete
  25. Well, if you want to consider circumcision at birth vs at age 18, there are many factors to consider. These include the following:

    (For infant circumcision)

    * Partial prevention of urinary tract infections during infancy and childhood
    * Partial prevention of balanitis & posthitis during infancy and childhood
    * Partial prevention of acquired phimosis during childhood
    * Partial prevention of penile cancer in adulthood (studies suggest that only neonatal circumcision confers this benefit)
    * Partial prevention of HIV and other STDs in the window between the onset of sexual activity and the hypothetical circumcision at age 18

    (For adult circumcision)

    * Greater risk of complications
    * Greater cost
    * Loss of working days
    * Loss of sexual activity during healing period
    * Embarrassment & anxiety before & after
    * Poorer cosmetic outcome due to scarring

    I submit that, when you consider it carefully, neonatal circumcision simply makes more sense than circumcision at age 18. Not only does waiting incur a substantial loss of benefit, but it also carries significant associated cost. As far as I can tell, the only argument for waiting is that he can choose circumcision, but viewed in context, that seems a rather weak argument.

    ReplyDelete
  26. Jake would have a point if all men needed to be circumcised. But most men don't need to be circumcised at any age. He fails to mention the complications of neonatal circumcision, which include

    * Poor cosmetic outcome.
    * Embarrassment and anxiety from scarring.
    * Loss of 1/3 to 1/2 of penile skin.
    * Complications like skin bridges and tags.
    * Risk of serious penile injury.
    * Risk of death.

    If Jake had taken these into account, he wouldn't have made the error of asserting the only argument for waiting is so can choose.

    The benefits of routine neonatal circumcision are tenuous and equivocal. There's no evidence that circumcised men live longer, or better, than intact men, even in countries where it appears that circumcision reduces acquisition of HIV. This is hardly surprising: the overwhelming risk factor for getting STDs is sexual practice, not whether you have a foreskin or not. Similarly, the overwhelming risk factor for cancer of the penis is HPV infection and smoking.

    Circumcision advocates always overplay the benefits and downplay the risks: they have to. With 100 million U.S. men circumcised at a cost of about 10 billion dollars, and no evidence that they live longer or better, there's something else going on besides medical benevolence.

    ReplyDelete
  27. To respond to anon:

    Jake would have a point if all men needed to be circumcised. But most men don't need to be circumcised at any age.

    True, but that isn't the point. The question is whether they would benefit, not whether it is actually necessary.

    He fails to mention the complications of neonatal circumcision, which include

    * Poor cosmetic outcome.
    * Embarrassment and anxiety from scarring.


    These are possible (and somewhat more likely) with adult circumcision, so it is unclear why they are presented as complications of neonatal circumcision, specifically.

    * Loss of 1/3 to 1/2 of penile skin.

    I wouldn't regard the removal of skin as a complication of circumcision: it is, after all, the intent!

    * Complications like skin bridges and tags.

    These are certainly risks, albeit minor.

    * Risk of serious penile injury.
    * Risk of death.


    These are risks, though the probability is very small. Risks are somewhat greater in adulthood.

    If Jake had taken these into account, he wouldn't have made the error of asserting the only argument for waiting is so can choose.

    I did, in fact, take these into account.

    The benefits of routine neonatal circumcision are tenuous and equivocal. There's no evidence that circumcised men live longer, or better, than intact men,

    Oh?

    even in countries where it appears that circumcision reduces acquisition of HIV.

    Nonsensical: there's no evidence that the protective effect of circumcision depends on the country.

    This is hardly surprising: the overwhelming risk factor for getting STDs is sexual practice, not whether you have a foreskin or not. Similarly, the overwhelming risk factor for cancer of the penis is HPV infection and smoking.

    In both cases, of course, there are multiple risk factors, and among these is circumcision. It's not clear why you're trying to suggest otherwise.

    Circumcision advocates always overplay the benefits and downplay the risks: they have to. With 100 million U.S. men circumcised at a cost of about 10 billion dollars, and no evidence that they live longer or better, there's something else going on besides medical benevolence.

    As a rule of thumb, if a person starts to speculate about the motives of those who hold a different point of view, he's probably losing the argument. :-)

    ReplyDelete
  28. Jake: I wouldn't regard the removal of skin as a complication of circumcision: it is, after all, the intent!

    Really? Given a second chance, Jake might want to revise that, even if this statement reveals what he really thinks. If the intent is simply to remove skin, I think that definitely means the person whose skin is being removed should have some say-so in the matter.

    Jake: Oh?

    Yes. In the case of circumcision, there are no studies that I'm aware of that show intact men live fewer years and have more health problems than circumcised men. The protective effect of circumcision of course doesn't depend on country, but it does depend on culture and sexual practice. But it's interesting that HIV incidence is correlated with geography more than with circumcision status.

    Jake: These are possible (and somewhat more likely) with adult circumcision, so it is unclear why they are presented as complications of neonatal circumcision, specifically.

    What? Adult circumcision is voluntary. Men who decide to get circumcised can't complain about poor cosmetic outcome and scarring, knowing that the former is possible and the latter is certain.

    Jake: As a rule of thumb, if a person starts to speculate about the motives of those who hold a different point of view, he's probably losing the argument. :-)

    Of course I wasn't speculating about anybody's motives - just that medical reasons alone do not explain the push to circumcise. Even circumcisers admit that! It's amusing that Jake misses the irony of his statement, which involves his own speculation.

    ReplyDelete
  29. Jake, you admit that we aren't talking about necessity here, only benefit. I will allow advocates of neonatal circumcision all the benefit they claim and I still find it lacking versus personal autonomy & right to bodily integrity. Also, I find your comparisons of adult versus infant circumcision to be completely one-sided. You list only the purported benefits of infant circumcision. UTIs are highly treatable and only a small minority lead to severe kidney issues. There is also concern that studies on the subject were skewed because they did not exclude premature babies which are more prone to UTIs and obviously won't be circumcised due to their precarious situation. Balanitis, posthitis, and phimosis are treatable without surgery in all but a small number of cases. Many operations exist that can spare the foreskin in treating the few recalcitrant cases of phimosis. Look to England for the humane way of treating such conditions. Penile cancer is extremely rare. You list only the detriments of adult circumcision. I'll allow you STD prevention, even if studies show unequivocal results outside of HIV. STDs are also prevented by a number of less invasive techniques and can be adopted by those who choose to expose themselves. Again, STDs are in an entirely different category than infectious diseases that are vaccinated against.

    I wonder where you get your facts about adult circumcision's supposedly worse outcomes. It's obvious when you think about it that adult circumcision is far more easy to perform accurately (larger operating area, foreskin is not still adherent to the glans, etc). I small inaccuracy in infant circumcision is amplified by the very small area on which the surgeon operates.

    Also, I feel that your easy dismissal of personal choice is troublesome. The fact that you don't consider penile function and the impact of skin loss is also dismissing one of the primary concerns. Losing all that penile skin & possibly the frenulum seems like a moot point to you when it self-evidently HAS to change the mechanics and experience of sex.

    ReplyDelete
  30. Jake: I wouldn't regard the removal of skin as a complication of circumcision: it is, after all, the intent!

    Really? Given a second chance, Jake might want to revise that, even if this statement reveals what he really thinks. If the intent is simply to remove skin, I think that definitely means the person whose skin is being removed should have some say-so in the matter.


    I'm sorry to disappoint, but I don't intend to revise it. Of course the intent of circumcision is to remove skin: are you seriously suggesting that anyone performs circumcision with the intention of leaving the foreskin? That seems completely absurd. Circumcision is defined as the removal of the foreskin.

    Jake: Oh?

    Yes. In the case of circumcision, there are no studies that I'm aware of that show intact men live fewer years and have more health problems than circumcised men.


    Remarkable. I have perhaps 1,000 papers in my personal collection, and I would guess that probably two thirds of these indicate that uncircumcised males have more health problems than circumcised males. Common sense alone would suggest that certain of these health problems (cancers and AIDS in particular) will translate into shorter lifespans, on average.

    What? Adult circumcision is voluntary. Men who decide to get circumcised can't complain about poor cosmetic outcome and scarring, knowing that the former is possible and the latter is certain.

    I'm afraid you're being unrealistic. I assure you that some men who decide to get circumcised can and do complain about poor cosmetic outcomes, including scarring.

    ReplyDelete
  31. Jake, you admit that we aren't talking about necessity here, only benefit. I will allow advocates of neonatal circumcision all the benefit they claim and I still find it lacking versus personal autonomy & right to bodily integrity.

    That's fair enough. You're entitled to reach your own conclusions.

    Also, I find your comparisons of adult versus infant circumcision to be completely one-sided. You list only the purported benefits of infant circumcision. UTIs are highly treatable and only a small minority lead to severe kidney issues. There is also concern that studies on the subject were skewed because they did not exclude premature babies which are more prone to UTIs and obviously won't be circumcised due to their precarious situation.

    That's probably a valid criticism of some studies, but not others. For example, in Nayir's randomised controlled trial, circumcision was performed as a result of random assignment, hence it would be nonsensical to claim that the results were due to prematurity. In fact the sheer variety of different designs of study, and the range of different settings, is strong evidence that the protective effect is real and not a product of confounding.

    Balanitis, posthitis, and phimosis are treatable without surgery in all but a small number of cases. Many operations exist that can spare the foreskin in treating the few recalcitrant cases of phimosis. Look to England for the humane way of treating such conditions.

    Sorry, you've missed the point. The question isn't how to go about treating the conditions once they arise, but how many cases might be avoided through early circumcision. Incidentally, I only have to look out of my window to see England. :-)

    Penile cancer is extremely rare.

    Yes, about 1 in 600 to 1 in 900. On the other hand, it can be fairly devastating when it does occur.

    You list only the detriments of adult circumcision. I'll allow you STD prevention, even if studies show unequivocal results outside of HIV. STDs are also prevented by a number of less invasive techniques and can be adopted by those who choose to expose themselves. Again, STDs are in an entirely different category than infectious diseases that are vaccinated against.

    Again, I think you're missing the point.

    I wonder where you get your facts about adult circumcision's supposedly worse outcomes. It's obvious when you think about it that adult circumcision is far more easy to perform accurately (larger operating area, foreskin is not still adherent to the glans, etc). I small inaccuracy in infant circumcision is amplified by the very small area on which the surgeon operates.

    Infants are extremely good at rapid healing (and they have fewer erections to strain the wound), and the fact that they grow so much tends to even out any perfections.

    Also, I feel that your easy dismissal of personal choice is troublesome. The fact that you don't consider penile function and the impact of skin loss is also dismissing one of the primary concerns. Losing all that penile skin & possibly the frenulum seems like a moot point to you when it self-evidently HAS to change the mechanics and experience of sex.

    Ah, that sounds like a testable hypothesis. We could test it, for example, by examining studies of adult men to see whether they report harm or benefit from adult circumcision. If your hypothesis is correct, then most or all studies ought to report harm...

    ReplyDelete
  32. Jake: I'm sorry to disappoint, but I don't intend to revise it. Of course the intent of circumcision is to remove skin: are you seriously suggesting that anyone performs circumcision with the intention of leaving the foreskin? That seems completely absurd. Circumcision is defined as the removal of the foreskin.

    One would think the intent of circumcision is to prevent some future health problems, and removing skin is the necessary tactic, the procedure needed to achieve the intent. But you've turned the reasoning on its head. I'm not disappointed, but rather expected your response. Others may see, as I have, your mistake, even while you don't.

    Common sense 100 years ago, when circumcision came onto the medical scene in England and the U.S., was that circumcision prevented a long list of diseases, and the medical literature from that time is just as convincing as the literature today. Until I see the neonatal randomized controlled studies on longevity, I'm afraid I don't buy your common sense either.

    ReplyDelete
  33. One would think the intent of circumcision is to prevent some future health problems, and removing skin is the necessary tactic, the procedure needed to achieve the intent.

    I think we're talking at cross purposes here. I'm not talking about why circumcision is performed in the first place. I'm talking about what the surgeon intends to do during the circumcision. I would have thought that was obvious from the question I posed (which, incidentally, you haven't answered): "are you seriously suggesting that anyone performs circumcision with the intention of leaving the foreskin?"

    ReplyDelete
  34. Jake: I think we're talking at cross purposes here.

    No, I'm pointing out your circular logic about "intent" and "circumcision," which you repeat again in your next question:

    Jake: "are you seriously suggesting that anyone performs circumcision with the intention of leaving the foreskin?"

    Actually, I'm seriously suggesting that performing circumcision without consent of the person who is being operated upon is ethically far more complicated than you or your "mandatory circumcision" friends want to admit. I am hardly expecting to convince a man who got cut as an adult, and who has 1000 articles in his library, 2/3 of which presumably support circumcision, that there are any ethical problems with neonatal circumcision!

    ReplyDelete
  35. No, I'm pointing out your circular logic about "intent" and "circumcision," which you repeat again in your next question:

    Which, once again, you haven't answered. :-)

    ReplyDelete
  36. Jake, I appreciate your sanity on this discussion. It's refreshing to have an intelligent debate, especially when the two of us are so firmly entrenched in our opinions.

    "You list only the detriments of adult circumcision. I'll allow you STD prevention, even if studies show unequivocal results outside of HIV. STDs are also prevented by a number of less invasive techniques and can be adopted by those who choose to expose themselves. Again, STDs are in an entirely different category than infectious diseases that are vaccinated against.

    Again, I think you're missing the point."

    How am I missing the point here? I see how we were arguing on two different levels with penile cancer, UTIs, etc. With this, I'm arguing that exposing oneself to sexually transmitted HIV is only an issue for a certain segment of people who put themselves in that position and that there are other methods of prevention that aren't so permanent. I think that's a valid point here.

    Also, while I appreciate you addressing many of my points, you sort of glazed over my point that those arguing for circumcision seem to present the argument as, "Well it prevents all these things and clearly people still have working penises afterwards. Therefore, other than the small number of surgical complications, this is a no lose situation."

    I think that's disingenuous, demeans personal choice, and dismisses the importance of sexuality and bodily integrity. Of course when you frame the argument as a no lose situation, the general public will readily jump on board, especially when they don't know what they may be missing by not having their complete anatomy.



    PS

    I wrote a paper for med school that discusses such issues. I'd be interested in your take on it. Could I e-mail it your way?

    ReplyDelete
  37. How am I missing the point here? I see how we were arguing on two different levels with penile cancer, UTIs, etc. With this, I'm arguing that exposing oneself to sexually transmitted HIV is only an issue for a certain segment of people who put themselves in that position and that there are other methods of prevention that aren't so permanent. I think that's a valid point here.

    At least from my perspective, the point is the comparison between adult and infant circumcision: what are the pros and cons of each, statistically speaking? I'm not sure why it's relevant to talk about other methods of prevention, because we're not talking about infant circumcision vs other methods of prevention, we're talking about infant circumcision vs later.

    Also, while there are higher and lower risk groups, STDs are potentially an issue for anyone who chooses to have sexual intercourse, and that's most of the adult population.

    Also, while I appreciate you addressing many of my points, you sort of glazed over my point that those arguing for circumcision seem to present the argument as, "Well it prevents all these things and clearly people still have working penises afterwards. Therefore, other than the small number of surgical complications, this is a no lose situation."

    I don't know. I can't speak for anyone else; I can only speak for my own views, and I don't argue for circumcision but rather for parental choice. That said, if you intended to summarise my views I'd find that an oversimplification. I'd say it's more like this: "Well, there is a certain amount of risk involved, which is small but real. On the other hand, there are several medical benefits which appear to outweigh the risks."

    I think that's disingenuous, demeans personal choice, and dismisses the importance of sexuality and bodily integrity. ...

    I don't think it dismisses the importance of sexuality at all. If there were convincing evidence of sexual harm then that could need to be treated as a risk. And if the probability of harm and/or the magnitude of damage were high then risks might be much more substantial. But the evidence indicates that circumcision isn't harmful, sexually.

    (continued)

    ReplyDelete
  38. (continued)

    As for personal choice, I think it's important, but it's not the only consideration. And I think that many people would frown upon making harmful decisions for a child for the sole purpose of preserving his right to choose. For example, would it be acceptable to deny a child an education so that he can decide, at age 18, whether to be educated or not (it's irreversible, after all)? What about vaccinations? Yes, I know that there are differences between these and circumcision, but I'm just using them to illustrate my point.

    I think that maybe an abstract concept of "choice" is probably fairly non-productive. Maybe it would be more useful to talk about what happens when a person exercises that choice. If he "chooses" his existing state, then there's no cost. The issue arises when he chooses something other than his existing state. If he was uncircumcised and chooses to be circumcised, he has certain costs (I'm using the word in a broad sense, including financial as well as other meanings). He might resent not having been circumcised as an infant, which is an additional cost. If he was circumcised and wants to be uncircumcised, he might choose foreskin restoration (which again carries certain costs), or he might not. Again, he might resent having been circumcised as an infant.

    As for bodily integrity, I don't think it is violated in a meaningful way by circumcision.

    PS ... I wrote a paper for med school that discusses such issues. I'd be interested in your take on it. Could I e-mail it your way?

    Sure, but I'd rather not post my email address here as I get enough spam already! If you post a message containing your email address to my blog, I'll pick up the message through the moderation system & will contact you privately that way.

    ReplyDelete
  39. ..."But circumcision may not make much difference in transmission among men in Western countries for a number of reasons, according to Deborah A. Gust and her colleagues at the

    CDC.

    One factor could be the fact that many HIV-positive people in developed countries are on powerful HIV drugs that reduce the chances of transmission, and may outweigh any effects of circumcision. In addition, Gust and her colleagues point out, circumcision would not affect HIV risk from receptive anal sex -- and that, again, could outweigh any protective effect of circumcision during insertive sex.

    The findings are based on data from 4,889 men who took part in an HIV vaccine trial begun in 1998; 86 percent had been circumcised. During the three-year study, 7 percent of the men became HIV-positive.

    When the researchers accounted for other factors -- including demographics, and HIV risk factors like drug use and having unprotected sex -- circumcision showed no effect on the odds of HIV transmission. They say that future studies, with larger samples of uncircumcised men, should continue to look at the question of circumcision and HIV transmission among men who have sex with men.

    The researchers also note, however, that other CDC scientists have concluded, based on their own studies, that circumcision would likely have only a "limited" impact on HIV transmission in the U.S."

    ReplyDelete
  40. Jake's analysis of "choice" is strained. Wouldn't it be simpler to note that men who were circumcised as infants had no voice in that decision - which can't be undone - but men who were not cut as infants can make the decision to get circumcised? Throwing in the issue of cost just serves to muddy the water, and makes an unconvincing argument even weaker.

    It's really a stretch to suggest the "foreskin restoration", whatever that is, somehow preserves "choice", or is a choice. Absurd.

    ReplyDelete
  41. Jake's analysis of "choice" is strained. Wouldn't it be simpler to note that men who were circumcised as infants had no voice in that decision - which can't be undone - but men who were not cut as infants can make the decision to get circumcised?

    As I said, I think that's that's too simplistic.

    Throwing in the issue of cost just serves to muddy the water, and makes an unconvincing argument even weaker.

    As I explained, I used the word "cost" in a very broad sense, which did not simply mean financial costs but also other negative effects that are considered in our decision making, such as those outlined in my post dated March 9, 2010 5:46 AM.

    It's really a stretch to suggest the "foreskin restoration", whatever that is, somehow preserves "choice", or is a choice. Absurd.

    Of course it's a choice; don't be so absurd.

    ReplyDelete
  42. "As for bodily integrity, I don't think it is violated in a meaningful way by circumcision."

    I think this is what it comes down to, ultimately. I'm not sure if this is just a belief or if the point can be argued successfully with facts & ethical principles. Regardless, that sentence is what this argument is really about, I think.

    Jake. Sent my e-mail to your blog. I don't expect to change your mind, but I'm just curious what your takes on the topics I discuss are.

    ReplyDelete
  43. Jake: Of course it's a choice; don't be so absurd.

    Huh? You can't get back something that was surgically removed. This "foreskin restoration" can't somehow reverse circumcision. Your statement about "foreskin restoration" just makes your analysis of choice even sillier.

    ReplyDelete
  44. "Well, there is a certain amount of risk involved, which is small but real. On the other hand, there are several medical benefits which appear to outweigh the risks."

    I didn't mean to oversimplify, and my summary was crude, I'll admit. I would still argue that the above argument completely omits a discussion about the role the foreskin plays, sexually and otherwise. If we're removing something, at the base of the discussion needs to be, "What is it there for and what happens if its removed." I feel that, in general, most of those who advocate circumcision as a viable option and the populace in general give this topic short shrift, if it's mentioned at all.

    "But the evidence indicates that circumcision isn't harmful, sexually.

    I would argue against this conclusion, but you'll need to read my paper to understand why.

    ReplyDelete
  45. i'm a circumcised 15 year old and i'm sick of all the crap from anti circumcision activists with their garbage like it leaves phsycological scars. i dont remember a thing from being circumcised. i don't know where they get that from. at least when your circumcised you dont have to worry about infections and diseases and having a smelly penis!

    ReplyDelete
  46. Spoken like a truly ignorant fool. Yep, that's what this sort of vitriol opinion, disguised as an article, does to people. Makes them think that circumcision makes them impervious to health problems like HIV. Real progress, right there.

    Can you please explain why the US has the highest western country rate of HIV/AIDS, when it has the highest western country rate of infact circumcision? A slightly glaring hole in your ridiculously pro-mutilation bullshit.

    ReplyDelete
  47. "Josh" wrote March 10, 2010 1:55 PM in response to Jake's comment:

    "I wonder where you get your facts about adult circumcision's supposedly worse outcomes."

    Where did he get his "facts" from?

    Jake underwent non-therapeutic circumcision for sexual reasons. Unfortunately for him his longed for circumcision was botched. Since then the obsessive thought has been preying on his mind, as he himself admitted elsewhere, that if he had only been circumcised as an infant he would not suffer from unsightly penile scarring whilst still being blessed with the "tightly clean-cut penis, he desired.
    For this reason he spends his entire life propagating circumcision of unconsenting minors

    Being a former Circlist member- a website run by avowed fetishists, who find circumcisions of adults AND children- both the procedure itself and the result thereof-sexually exciting and featuring a variety of material Circlist members find sexually exciting including nude pictures of male genitalia of children- having subjected himself to circumcision as a supposed "sexual act" and being psychologically challenged by the poor cosmetic outcome of his fetish-motivated foreskin-removal Jake's motives behind his ongoing war against the foreskin are sexual and selfish rather than factual or disinterested in nature.

    ReplyDelete