Monday, March 15, 2010

Actress Thanks Congress for Strong Circumcision Support

Actress Debra Messing, better known as Grace Adler in the TV sitcom "Will & Grace," told members of Congress last week that circumcision was a key to reducing HIV/AIDs. Messing testified before the House Foreign Affairs Committee on behalf of PSI, a global health organization, after she returned from Zimbabwe which has an aggressive circumcision program.

Here's what Messing told legislators:

"I would like to tell you today about two prevention tools that could make a difference if there is continued investment: male circumcision and HIV testing and counseling.

"First, voluntary adult male circumcision. There is now strong evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by about 60 percent, yet only about one in ten Zimbabwean adult men are circumcised. PSI and its partners run circumcision clinics in Zimbabwe and other countries, with support from PEPFAR and other donors.

"I was invited to observe the procedure, which is free to the client, completely voluntary and according to the young man I spoke with who underwent the procedure, painless. The cost of the procedure at that clinic—including follow-up care and counseling—is about $40 U.S. dollars.
UNAIDS and the World Health Organization have issued guidance stating that male circumcision should be recognized as an important intervention to reduce the risk of heterosexually acquired HIV infection in men.

"Even with no demand creation, the clinic I visited serves upwards of 35 clients per day. It is estimated that if male circumcision is scaled up to reach 80 percent of adult and newborn males in Zimbabwe by 2015, it could avert almost 750,000 adult HIV infections—that equals 40 percent of all new HIV infections that would have occurred otherwise without the intervention—and it could yield total net savings of $3.8 billion U.S. dollars between 2009 and 2025. Male circumcision programs get robust support from the U.S. government in Zimbabwe and other countries, but greater resources would yield greater results."

Zimbabwe does have a massive commitment to circumcise 1.3 million males over the next few years, and the country is beginning efforts to encourage newborn circumcision. In the long run, countries recognize that achieving universal 100% circumcision rates is best obtained by circumcising baby boys before the leave the hospital.

What is ironic to me is that while Messing thanks Congress for its "robust support" for the male circumcision programs in Africa, nobody says anything about America? It's time for government leaders to speak out with just the same passion on the value of circumcising every male in this country.

71 comments:

  1. First of all, she clearly states ADULT VOLUNTARY circumcision. Second of all, she is Jewish who just recently went on public record saying she doesn't think Roman Polanski should go to jail for drugging and raping a 14 year old girl at a party when he was in his 40s(which he admitted to doing) because he was once in the Holocaust and has " been through enough".

    Needless to say, I think she has some biases. She doesn't have the respect she once did after making those comments about Roman Polanski, and many have boycotted her movies.

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  2. Edit: noticed later on infant circumcision was mentioned... still does not change her obvious bias, as has been demonstrated by her opinions on Roman Polanski.

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  3. Ah, Zimbabwe: Life expectancy, 37 (females, 34); Infant morality, 81 deaths/1000 live births; Cholera, 98,741 reported cases, 4,293 deaths as of 10 January 2010, caused by the collapse of the urban water supply, sanitation and garbage collection systems.

    "...before they leave the hospital"? The hospitals are closing. And neonatal circumcision when more (much more) than 8% of those babies will die before they're old enough to have sex?

    This makes Nero's fiddling look like prompt and effective firefighting.

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  4. In Zimbabwe in 2005-06 the HIV rates among men over 20 were: circumcised, 20%; non-circumcised, 19%

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  5. "What is ironic to me is that while Messing thanks Congress for its "robust support" for the male circumcision programs in Africa, nobody says anything about America? It's time for government leaders to speak out with just the same passion on the value of circumcising every male in this country."

    Maybe it's time for you to wake up and smell the roses? The CDC has even said that circumcision would only have a "limited" impact in the US. We don't have an HIV epidemic in this country! Heterosexual HIV transmission is rare here! We have clean water and soap and competent doctors.

    "While studies in Africa have shown that circumcised heterosexual men are as much as 60 percent less likely than their uncircumcised peers to contract HIV from female partners, a new three-year study from the Centers for Disease Control and Prevention (CDC) finds that circumcision does not necessarily prevent transmission among men who have sex with men (MSM) in Western countries, Reuters reports.

    In the study, which was published in the journal AIDS, the CDC examined HIV infection rates among nearly 4,900 men in the United States, Canada and the Netherlands who took part in an HIV vaccine clinical trial. They found no evidence that circumcision affected HIV transmission risk. The agency is considering whether to recommend circumcision to high-risk heterosexual men and whether there is suitable evidence to recommend circumcision for MSM.

    According to Deborah A. Gust, PhD, MPH, and her colleagues at the CDC, many HIV-positive people in Western, developed countries are on HIV regimens that reduce the risk of transmission. Furthermore, circumcision would not affect HIV risk from receptive anal sex, which she says would outweigh any protective value of circumcision during insertive sex.

    Researchers note that, just as other CDC scientists have concluded, circumcision would likely have a “limited” impact on HIV transmission in the United States."

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  6. I wish more influential celebrities and others would publicly come out in favor of routine infant circumcision in the USA and elsewhere...

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  7. Everyone knows the trials were flawed and conducted by biased researchers looking for further grants.

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  8. Everyone knows the trials were flawed and conducted by biased researchers looking for further grants.

    This is obviously an unusual usage of the phrase "everyone knows", meaning something like "some anti-circ conspiracy theorists believe, without any evidence, that ..."

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  9. A study has just come out (Bassler et al,
    JAMA. 2010;303(12):1180-1187) showing that medical trials that are cut short because they seemed to show a benefit (as the three African trials were cut short) are likely to show more than twice as much benefit as those that are not, and to show benefit where there is none. (In the ordinary world, we call it "stopping while you're ahead".)

    It specifically points out that "If reviewers do not note truncation and do not consider early stopping for benefit, meta-analyses will report overestimates of effects." And that is what has happened with a Cochrane Review (normally highly-regarded) after the trials.

    Thus circumcision may offer little protection against HIV, if any.

    Everyone may not know that yet, but eventually everyone will know.

    Oh, and Ben Winkie: if neonatal circumcision becomes universal, the only circumcisions you'll be able to watch and wank over will be those of babies...

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  10. I'm not gay, but I liked Will & Grace. It's great to see Messing involved with a good cause.

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  11. Thank you, Hugh! Here is a report written on www.scientificblogging.com, on March 23rd 2010 on that recent study :

    "Clinical trials ended early due to positive treatment effects likely exaggerate those effects, according to a new review published in JAMA. The authors caution that researchers should resist pressures to end clinical trials early because of the potential risk to patients in the trials.

    The clinical trials reviewed were ended early because of a convincing -- and usually large -- apparent difference between an experimental treatment and an existing standard therapy.

    It usually also allows physicians to prescribe the therapy sooner because it will reach the market earlier. Almost everyone involved benefits from a trial ending early -- doctors, researchers, funding sources, pharmaceutical firms, scientific journals, even reporters -- everyone except the patient, who may end up receiving a therapy on the basis of misleading information about its benefits.

    "Our research shows that in most cases early stopping of clinical trials resulted in misleading estimates of treatment effects. These misleading estimates are likely to result in misguided decisions about the trade-off between risks and benefits of a therapy," says Victor
    Montori, M.D., Mayo Clinic endocrinologist and corresponding author of the study.

    "On average, treatments with no effect would show a reduction in relative risk of almost 30 percent in stopped early trials. Treatments with a true relative risk reduction of 20 percent would show a reduction of over 40 percent."

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  12. There were other problems with the trials that make the science sloppy.

    1) The men were self-selected for the studies, instead of being drawn randomly from the population. This is likely to confound the results, because acquiring HIV is not random, but a product of sexual behavior in a population. Since selecting yourself for a sexual study is itself a kind of sexual behavior, the risk of confounding exists.

    2) In at least one study I read, some men who were selected to remain uncircumcised were allowed to switch to the circumcised group. This is unacceptable in a randomized trial. Instead, men who requested transfer should have been disqualified.

    3) Far more men were lost from the study than actually acquired HIV. Unless every dropout is chased down and tested for HIV, the uncertainty from this blunder could undo all the results claimed. It is *not* the same statistically as if these men had never been in the study. See, for example, Prior Probability.

    4) The studies were stopped short, running the risks described above. Only if the decision to stop was made randomly, without peeking at the results, would this be acceptable. But the decision to stop, based on the results seen thus far, ruins the study. They saw what they wanted to see and stopped.

    5) Presumably the men who were circumcised knew which group they were in, and the doctors examining them knew which ones were receiving the treatment - an unavoidable flaw in the study, but one which, nevertheless, would not pass muster for a drug study.

    Far from the gold standard of studies, the African trials are poorly conducted and the results are far from certain.

    There is a need to go back and do these studies properly for making policy in the U.S. To remove the danger of cultural confounding, the studies need to be done on American babies, with true randomization. If, as circumcision advocates claim, circumcision is not an ethical issue and is harmless, then doing such a study should easily get approval from medical authorities.

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  13. aaaaand silence from the pro circumcision advocates. No surprise there...

    Not much they can say, really. Even the researchers themselves bragged about stopping the trial early, because "the results were so convincing."

    "For truncated RCTs having fewer than 500 events, there were large differences in treatment effect size between truncated and nontruncated RCTs (ratio of relative risks < 0.75). The pooled effects of the nontruncated RCTs showed no significant benefit in 39 (62%) of the 63 questions. [***The three circumcision-HIV RCTs put together had a total of 196 events.***]

    "Truncated RCTs were associated with greater effect sizes than RCTs not stopped early," the study authors write. "This difference was independent of the presence of statistical stopping rules and was greatest in smaller studies."

    (http://www.circumstitions.com/news/news36.html#truncated)

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  14. I don't know about "pro-circumcision advocates", but speaking for myself I don't think there's much need to reply. The science is well-established, the facts are proven, and all of the grasping at straws gets a little pitiful as time passes.

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  15. "science" and "facts" based on flawed studies are hardly "science" and "facts".

    The study published in the JAMA clearly shows that RCTs stopped early give misleading results.

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  16. The study published in the JAMA clearly shows that RCTs stopped early give misleading results.

    No, it doesn't. That would be impossible to prove unless you had a perfect study for comparison, and of course such studies don't exist. Think.

    What Bassler et al. showed is that there is a statistical trend for RCTs stopped earlier to show greater benefits than those that are not stopped early.

    But in reality, the results of a study are are not independent of whether it is stopped early. The two are closely related, because studies are usually terminated early if results are seen, and they aren't terminated early if results are not seen. So Bassler's results should not be surprising.

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  17. From the JAMA abstract :

    Objective: To compare the treatment effect from truncated RCTs with that from meta-analyses of RCTs addressing the same question but not stopped early (nontruncated RCTs) and to explore factors associated with overestimates of effect.

    Study Selection: Selected studies were RCTs reported as having stopped early for benefit and matching nontruncated RCTs from systematic reviews. Independent reviewers with medical content expertise, working blinded to trial results, judged the eligibility of the nontruncated RCTs based on their similarity to the truncated RCTs.

    From your comment, it made it appear as if you believed the study was just comparing one RCT that was stopped early to a completely different RCT that was not. The study clearly states that they "match" studies to demonstrate that two matching studies showed different results when one was stopped early and the other not.

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  18. By completely different I mean an unrelated study. IE a pneumonia pill study vs an HIV vaccination study.

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  19. By completely different I meant an unrelated study, obviously I know they are comparing two matching studies and not the same study twice.

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  20. From your comment, it made it appear as if you believed the study was just comparing one RCT that was stopped early to a completely different RCT that was not.

    I'm sorry that you got such an impression, but no, that wasn't what I meant. It's difficult to imagine that a study comparing a mere two studies would even be published.

    The study clearly states that they "match" studies to demonstrate that two matching studies showed different results when one was stopped early and the other not.

    Not exactly, no. They didn't compare pairs of studies. Instead they considered groups of studies that investigated the same research questions, comparing the average(*) results of studies that were stopped early with the average results of studies that were not stopped early.

    Bassler et al. found that studies stopped early reported stronger results than those which were not. I have no argument with that. But what I'm pointing out is that this is precisely what one would expect, since the results of a study directly influence whether it is terminated early or not.

    (*) This is a slight simplification, but meta-analysis techniques do perform what is fundamentally a weighted average. Meta-regression models are more complicated still.

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  21. oops, didn't think the first comment went through.

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  22. Anyone who believes studies can just be stopped half way through when desired results are seen doesn't know how medical trials are supposed to operate. Especially ones that already have so many other confounding factors, as mentioned in previous comments.

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  23. From Medscape:

    "Although randomized controlled trials (RCTs) generally provide credible evidence of treatment effects, multiple problems may emerge when investigators terminate a trial earlier than planned, especially when the decision to terminate the trial is based on the finding of an apparently beneficial treatment effect," write Dirk Bassler, MD, MSc, from McMaster University in Hamilton, Ontario, Canada, and colleagues from the Study of Policy of Interim Truncation 2 Study Group. "Bias may arise because large random fluctuations of the estimated treatment effect can occur, particularly early in the progress of a trial. When investigators stop a trial based on an apparently beneficial treatment effect, their results may therefore provide misleading estimates of the benefit."

    ..."This difference was not affected by the presence of a statistical stopping rule ..."

    "For truncated RCTs having fewer than 500 events, there were large differences in treatment effect size between truncated and nontruncated RCTs (ratio of relative risks < 0.75)."

    The three African trials had a total of 201 events.

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  24. Anyone who believes studies can just be stopped half way through when desired results are seen doesn't know how medical trials are supposed to operate. Especially ones that already have so many other confounding factors, as mentioned in previous comments.

    Well, since many (if not most) trials of more than trivial duration tend to have planned protocols for early termination (based on preliminary results), you appear to be arguing that most of the people who plan studies don't know how to do so. I find that argument a little ... amusing, to say the least.

    The simple fact of the matter is that trials are experiments conducted on living, breathing human beings, and that creates certain ethical obligations for the researchers. If — as in the case of the circumcision/HIV trials — it becomes apparent that there is a protective effect, it is ethically dubious to withhold treatment from those who have volunteered for it.

    So early termination protocols are really just a case of pragmatism. And there's nothing inherently wrong with them: the sample is no less valid than it would have been had the trial run for the full duration.

    Bassler et al. appear to assume that trials that were not terminated early have "correct" results, and based on this assumption they interpret their findings as evidence that early-terminated trials have "incorrect" results. However, this seems to be a shaky assumption: although early-terminated studies have a general bias in one direction, there is also bias in the opposite direction among studies that were not terminated early.

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  25. How is it biased to run a trial it's full duration? That is nonsensical. The duration of the trial is determined before any results are even seen. Stopping after peeking at the results is clearly biased.

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  26. How is it biased to run a trial it's full duration? That is nonsensical. The duration of the trial is determined before any results are even seen. Stopping after peeking at the results is clearly biased.

    Simple. Trials that run to the original planned duration are often those in which a decision was made at an interim stage not to stop early. Since decisions not to stop are usually made if promising results are not seen, this is therefore a source of bias.

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  27. Jake, the recent studies are saying there should never BE a decision to be made at an interim stage. Studies should run their full course, "especially when the decision to terminate the trial is based on the finding of an apparently beneficial treatment effect". EVEN IF there was a bias to run the study to its full duration, at least the results would be more accurate. There is no way to know what the results would have been if the trial had continued, but it is easy to finish the trial and look at what the results were at the interim stage and what they were at the end. Nothing to lose, other than money and time, which seems like a fair trade off when you are talking about people's lives here.

    I also find it nonsensical that you think stopping the trial short to possibly benefit the 1500 or so men that were not circumcised is a somehow better scenario than circumcising hundreds of thousands of men when when the effect of circumcision on HIV may have not even been statistically significant.

    Jake, you are the one reaching for straws. You are repeating the exact OPPOSITE of what professional scientists, researchers and doctors are saying about RCTs. Stopping early when you see a big benefit gives misleading results. Surely you do not think you are more well versed on this topic than those scientists and doctors?

    Repeating the opposite of what the research has shown over and over isn't going to make it any more true.

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  28. Jake, the recent studies are saying there should never BE a decision to be made at an interim stage. Studies should run their full course, "especially when the decision to terminate the trial is based on the finding of an apparently beneficial treatment effect".

    Yes, that's the opinion of Bassler et al., but I don't think agreement with their viewpoint is compulsory, is it?

    I also find it nonsensical that you think stopping the trial short to possibly benefit the 1500 or so men that were not circumcised is a somehow better scenario than circumcising hundreds of thousands of men when when the effect of circumcision on HIV may have not even been statistically significant.

    There's no evidence whatsoever that the effect would not have been statistically significant. That's just wishful thinking, in flat contradiction of the known facts.

    Jake, you are the one reaching for straws. You are repeating the exact OPPOSITE of what professional scientists, researchers and doctors are saying about RCTs.

    More accurately, I'm questioning the conclusions of the authors of one meta-analysis.

    Stopping early when you see a big benefit gives misleading results. Surely you do not think you are more well versed on this topic than those scientists and doctors?

    The protective effect of circumcision against HIV is considered proven by the majority of scientists involved with the issue. Surely you do not think you are more well versed on this topic than those scientists and doctors? :-) Of course, that's precisely what you're doing: applying your own reasoning to the conclusions in published papers, and expressing your own disagreement. And you're perfectly entitled to do that, but appeals to authority seem a bit hypocritical, I'm afraid.

    Repeating the opposite of what the research has shown over and over isn't going to make it any more true.

    What Bassler's research shows is that there is a difference between the results of trials terminated early and those that were not. I'm not disputing that. What I'm disputing is their interpretation, which is unproven.

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  29. "There's no evidence whatsoever that the effect would not have been statistically significant. That's just wishful thinking, in flat contradiction of the known facts."

    When did I say there was? I said the potential for it to not have been statistically significant outweighs the need to stop the trial and circumcise the rest of the uncircumcised men, who were paid adult volunteers of the study. Surely you do not disagree with that? We are, after all, talking about surgery! With hundreds of thousands of men getting circumcised, statistically there ARE going to be botched operations and infections. If those men were receiving a surgery that was not needed, then that is unacceptable. Much more so than asking paid adult volunteers of a study they consented to joining to finish out the duration of the trial before getting circumcised.

    "The protective effect of circumcision against HIV is considered proven by the majority of scientists involved with the issue. Surely you do not think you are more well versed on this topic than those scientists and doctors? :-)"

    The studies have been VERY controversial, among scientists and doctors alike. Here is part of the circumcision policy statement from the BMA- British Medical Association:

    "In relation to circumcision as a prophylactic measure (to reduce the supposed risk of diseases that may be contracted in the future), the BMA warns that there are no agreed "health benefits" in circumcision of children and that doctors **must warn parents that medical opinion is divided.**"

    ..."There is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research. "

    ..."Doctors should ensure that any parents seeking circumcision for their son in the belief that it confers health benefits are fully informed **of the lack of consensus amongst the profession over such benefits**, and how great any potential benefits and harms are."

    These studies are far from being widely accepted, seeing as not one western country is recommending it be done, updating their policy statements after the HIV trials and still not recommending it.

    RACP:

    "Recently there has been renewed debate regarding both the possible health benefits and the ethical concerns relating to routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, and in adults HIV infection and cancer of the penis. The frequency of these conditions, the level of protection offered by circumcision and complication rate of circumcision do not warrant a recommendation of universal circumcision for newborn and infant males in an Australian and New Zealand context."

    Here is a statement from South Africa! They don't even recommend it!


    “After lengthy DISCUSSION on the matter, the Committee RESOLVED that it be conveyed to NOCIRC-SA that, from a medical point of view, there was no medical justification for routine circumcision in males and children."

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  30. When did I say there was? I said the potential for it to not have been statistically significant outweighs the need to stop the trial and circumcise the rest of the uncircumcised men, who were paid adult volunteers of the study. Surely you do not disagree with that?

    I think it would be difficult to get ethical approval for a study that exposed participants to additional risk of HIV for longer than necessary.

    The studies have been VERY controversial, among scientists and doctors alike. Here is part of the circumcision policy statement from the BMA- British Medical Association:

    The BMA do not discuss the scientific literature, do not cite the studies themselves.

    You then go on to quote from the RACP regarding whether or not they recommend universal circumcision. As with your BMA quotes, this is an entirely different question from whether circumcision is protective against HIV, and it can only be assumed that you are attempting to deflect attention from the subject under discussion. I wonder why that is.

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  31. I am not sure exactly what you are getting at, are you insinuating that a policy statement made by the BMA and RACP did not look at the HIV trials before reaching their conclusion? I would find that shocking, especially considering the fact that they mention the "renewed debate" about the health benefits, and about HIV in adults.

    These are not amateur bloggers we are talking about here! They are medical associations! It would be incomprehensible to assume they made these recommendations as early as 2009 without looking at the HIV trials in Africa. The RACP even states "After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed.."

    I suggest you take a look at their pdf policy statement ( I don't know how to link a pdf) if you are interested. There are tons of sources they link of studies they reviewed, pages and pages.

    Trying to convince anyone that medical associations from Western countries did not study and review the HIV trials in Africa because they did not say something to the effect of " After looking at the three RCTs in Africa..." is nonsensical and "grasping for straws"

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  32. Now it is time for my nap. Anyone else feel free to chime in... although talking to Jake is like talking to a brick wall that repeats the same thing over and over and over...

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  33. I am not sure exactly what you are getting at, are you insinuating that a policy statement made by the BMA and RACP did not look at the HIV trials before reaching their conclusion? I would find that shocking, especially considering the fact that they mention the "renewed debate" about the health benefits, and about HIV in adults.

    In the case of the BMA, they did not cite any scientific evidence, and it was not the subject of their statement (which was about the law and ethics), so it is unclear what studies (if any) they examined. In the case of the RACP, their latest statement dates from 2004, which pre-dates the RCTs. Since then they have issued (and later withdrawn) a single page which, again, did not cite any specific evidence.

    These are not amateur bloggers we are talking about here! They are medical associations! It would be incomprehensible to assume they made these recommendations as early as 2009 without looking at the HIV trials in Africa. The RACP even states "After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed.."

    Again, that isn't what we were discussing. The issue that we were discussing is whether circumcision protects against HIV. A separate question is whether all baby boys should be circumcised.

    I suggest you take a look at their pdf policy statement ( I don't know how to link a pdf) if you are interested. There are tons of sources they link of studies they reviewed, pages and pages.

    It's here. You can check the references, if you like, to verify that they don't cite any of the RCTs. However, since it is dated September 2004, and the earliest of the RCTs was published in late 2005, you might want to save yourself the effort.

    Trying to convince anyone that medical associations from Western countries did not study and review the HIV trials in Africa because they did not say something to the effect of " After looking at the three RCTs in Africa..." is nonsensical and "grasping for straws"

    But you think it is perfectly reasonable to claim that policy statements constitute rejection of the RCTs when those statements a) do not mention the RCTs, b) do not cite the RCTs, and c) were published before the RCTs?

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  34. RACP 08-27-2009- revised policy statement on circumcision:

    "Recently there has been renewed debate regarding both the possible health benefits and the ethical concerns relating to routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, and in adults HIV infection and cancer of the penis. The frequency of these conditions, the level of protection offered by circumcision and complication rate of circumcision do not warrant a recommendation of universal circumcision for newborn and infant males in an Australian and New Zealand context.

    After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed..."


    SOUTH AFRICAN MEDICAL JOURNAL, Volume 98, Number 10: Pages 781-782,
    October 2008.

    "The 2003 Cochrane review5 of observational studies of MC effectiveness concluded that there was insufficient evidence to support it as an anti-HIV intervention. Three randomised controlled trials (RCTs) from South Africa, Kenya and Uganda in 2006 - 2007 show a protective effect of MC. However, Garenne6 has subsequently shown from observational data that there is considerable heterogeneity of the effect of MC across 14 African countries. Despite the South African RCT showing a protective effect, he reports for the nine South African provinces that **‘there is no evidence that HIV transmission over the period 1994 - 2004 was slower in those provinces with higher levels of circumcision’.** Interestingly, in both Kenya and Uganda, where two of the RCTs were done, a protective effect of MC was observed, but a **harmful effect was observed in Cameroon, Lesotho and Malawi. The other eight countries showed no significant effect of MC.**

    These somewhat discordant findings are difficult to interpret. While RCTs are theoretically strong designs, **it is conceivable that their findings are not generalisable beyond their settings.** Furthermore, there have been **no trials of neonatal MC**. **Study flaws such as inability to obtain double blinding, and loss to follow-up in RCTs, may effectively degrade their quality to that of observational studies.**

    Meanwhile other disturbing findings referred to by Sidler et al. are emerging, including the reported higher risk for women partners of circumcised HIV positive men, disinhibition, urological complications, relatively small effect sizes of MC at the population level, and relative cost-inefficiency of MC.

    Given the epidemiological uncertainties and the economic, cultural, ethical and logistical barriers, it seems neither justified nor practicable to roll out MC as a mass anti-HIV/AIDS intervention. "

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  35. RACP 08-27-2009- revised policy statement on circumcision:

    That would be the single page document that I mentioned. As I mentioned, it was later withdrawn, and as I recall it didn't cite the RCTs specifically. However, far from supporting your claim, the very passage you quote suggests that they agree that circumcision is protective: "The most important conditions where some benefit may result from circumcision ... in adults HIV infection ..."

    SOUTH AFRICAN MEDICAL JOURNAL, Volume 98, Number 10: Pages 781-782,
    October 2008.


    I don't understand why you're quoting at great length from and highlighting particular passages from an obscure opinion piece written by a humanities student. But I'll comment anyway:

    Despite the South African RCT showing a protective effect, he reports for the nine South African provinces that **‘there is no evidence that HIV transmission over the period 1994 - 2004 was slower in those provinces with higher levels of circumcision’.** Interestingly, in both Kenya and Uganda, where two of the RCTs were done, a protective effect of MC was observed, but a **harmful effect was observed in Cameroon, Lesotho and Malawi. The other eight countries showed no significant effect of MC.**

    Observational studies are less reliable, so it would be foolish to expect them to be reliably consistent, wouldn't it?

    These somewhat discordant findings are difficult to interpret. While RCTs are theoretically strong designs, **it is conceivable that their findings are not generalisable beyond their settings.**

    I don't understand why you've highlighted this claim. Myers didn't offer any supporting evidence for it.

    Furthermore, there have been **no trials of neonatal MC**.

    Nope. There haven't been trials of people who only have sex on Thursdays, either.

    **Study flaws such as inability to obtain double blinding, and loss to follow-up in RCTs, may effectively degrade their quality to that of observational studies.**

    That's a hell of a stretch, and again, it's completely unsupported.

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  36. obscure opinion piece? It is on the South African Medical Journal website, hardly obscure.

    "That's a hell of a stretch, and again, it's completely unsupported."

    Unsupported? Oh, I didn't realize that the men who had half of the skin of their penis surgically removed whilst under anesthesia didn't know they were being circumcised....interesting indeed.

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  37. obscure opinion piece? It is on the South African Medical Journal website, hardly obscure.

    Perhaps you're unaware of this, but most journals have websites, and in general their published articles can be found via said websites.

    Unsupported? Oh, I didn't realize that the men who had half of the skin of their penis surgically removed whilst under anesthesia didn't know they were being circumcised....interesting indeed.

    To remind you, the claim we're discussing is Myers' argument that "flaws ... may effectively degrade their quality to that of observational studies". They did not offer any support for this claim.

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  38. "Nope. There haven't been trials of people who only have sex on Thursdays, either."

    That is a completely illogical argument.

    Studies done on adult women undergoing double mastectomy surgery has proven it to be an extremely safe and effective way of preventing breast cancer. Don't know of any studies about operations done on Thursdays though...hmm... guess its OK and safe to start doing them on babies then!

    It's the same argument. Removing breasts has shown to be incredible effective in reducing the chance of breast cancer by up to 99 percent in women. It has also been shown to be very safe with few complications. Should that then just be extrapolated to infants? without doing any kind of research or study?

    No one knows whether or not circumcising infants has any benefit on HIV. Is the scarring worse when done on neonates? Does forcibly separating the foreskin that is fused to the glans make a difference?

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  39. "Nope. There haven't been trials of people who only have sex on Thursdays, either."

    That is a completely illogical argument.

    Studies done on adult women undergoing double mastectomy surgery has proven it to be an extremely safe and effective way of preventing breast cancer. Don't know of any studies about operations done on Thursdays though...hmm... guess its OK and safe to start doing them on babies then!

    It's the same argument. Removing breasts has shown to be incredible effective in reducing the chance of breast cancer by up to 99 percent in women. It has also been shown to be very safe with few complications. Should that then just be extrapolated to infants? without doing any kind of research or study?

    No one knows whether or not circumcising infants has any benefit on HIV. Is the scarring worse when done on neonates? Does forcibly separating the foreskin that is fused to the glans make a difference?

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  40. Studies done on adult women undergoing double mastectomy surgery has proven it to be an extremely safe and effective way of preventing breast cancer. Don't know of any studies about operations done on Thursdays though...hmm... guess its OK and safe to start doing them on babies then!

    It's the same argument. Removing breasts has shown to be incredible effective in reducing the chance of breast cancer by up to 99 percent in women. It has also been shown to be very safe with few complications. Should that then just be extrapolated to infants? without doing any kind of research or study?


    The obvious questions are:

    1) Is there any existing data that may help? For example, do we have data showing that age alters (or does not alter) the protective effect of mastectomy? Do we have data showing a relationship (or lack thereof) between mastectomy complications and age? Do we have data showing a relationship between surgical complications in general and age?

    2) Is there a likely mechanism which would create a difference between the two?

    Finally, I should note that science cannot answer whether it is OK to perform mastectomy on infants. That's an ethical question, and science is by definition value-free.

    No one knows whether or not circumcising infants has any benefit on HIV. Is the scarring worse when done on neonates? Does forcibly separating the foreskin that is fused to the glans make a difference?

    We don't know, but fortunately we can make some educated guesses. And, as I pointed out, there haven't been trials of people who only have sex on Thursdays, but we're able to apply some common sense.

    We have data in the form of observational studies that indicate that infant circumcision is protective. (This isn't the same standard as RCTs, but it is still evidence.) We know from RCTs that circumcision in adults protects against HIV, and we know that infant circumcision and adult circumcision are extremely similar. While there are some differences, the similarities are greater (both remove the foreskin).

    The most rational conclusion, then, seems to be that infant circumcision protects against HIV. It is possible that it doesn't, but the balance of evidence seems not to support that idea.

    So, as always, we have to make an intelligent choice. Do we use common sense and the best data currently available to us, or do we conduct a further RCT? Given that such an RCT would take approx. 20 years to conduct (from birth to sexual active age), how many HIV infections would that risk?

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  41. "We don't know, but fortunately we can make some educated guesses. And, as I pointed out, there haven't been trials of people who only have sex on Thursdays, but we're able to apply some common sense.

    We have data in the form of observational studies that indicate that infant circumcision is protective. (This isn't the same standard as RCTs, but it is still evidence.) We know from RCTs that circumcision in adults protects against HIV, and we know that infant circumcision and adult circumcision are extremely similar. While there are some differences, the similarities are greater (both remove the foreskin).

    The most rational conclusion, then, seems to be that infant circumcision protects against HIV. It is possible that it doesn't, but the balance of evidence seems not to support that idea.

    So, as always, we have to make an intelligent choice. Do we use common sense and the best data currently available to us, or do we conduct a further RCT? Given that such an RCT would take approx. 20 years to conduct (from birth to sexual active age), how many HIV infections would that risk?"

    Like you said, there are differences. If the scarring on infants is greater or the possibility of skin bridges and skin tags is increased when circumcision is performed on infants then that is something that needs to be taken into consideration. Skin bridges, extra scar tissue, and skin tags could potentially harbor more bacteria and increase the risk of HIV, or make it a wash. We don't know.

    The risk of a man getting HIV through vaginal intercourse is exceedingly rare in the United States. In Australia it was shown that a man has a lifetime risk of .02 percent, or 0002 of getting HIV if he did not inject drugs or have sex with men, and the main modes of transmission of HIV are the same in the US and Australia. A 20 year study wouldn't put those men in that great of a risk. On average, males do not become sexually active until 15 or 16, and they should be using condoms, which are more effective at preventing HIV anyway.

    I think it is safe to assume that if there were health organizations and campaigns and doctors and scientists convincing parents and men that they should get circumcised specifically on a Thursday, people would expect some kind of study and explanation as to why this is the case. Especially if no study had ever been done on circumcisions performed on Thursdays. Do you not agree?

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  42. Like you said, there are differences. If the scarring on infants is greater or the possibility of skin bridges and skin tags is increased when circumcision is performed on infants then that is something that needs to be taken into consideration. Skin bridges, extra scar tissue, and skin tags could potentially harbor more bacteria and increase the risk of HIV, or make it a wash. We don't know.

    We can't be 100% certain but, as I said, the preponderance of evidence is clearly that infant circumcision is protective.

    The risk of a man getting HIV through vaginal intercourse is exceedingly rare in the United States. In Australia it was shown that a man has a lifetime risk of .02 percent, or 0002 of getting HIV if he did not inject drugs or have sex with men, and the main modes of transmission of HIV are the same in the US and Australia. A 20 year study wouldn't put those men in that great of a risk. On average, males do not become sexually active until 15 or 16, and they should be using condoms, which are more effective at preventing HIV anyway.

    There's a recent CDC study giving data for the US. It suggests that circumcision reduces the lifetime risk from 1.87% by 16% (that is, to about 1.57%).

    But, of course, that's for a country with relatively low HIV rates, where the case for prophylactic circumcision is weaker than in many developed nations, for example, where HIV rates are much higher. And delaying circumcision programmes while waiting for the results of a 20-year RCT could cost a lot of lives - one estimate is that circumcision programmes could prevent 5.7 million HIV cases in sub-Saharan Africa in that time.

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  43. Of course, any adult in Africa could get circumcised during that 20 year period. From my understanding, the vast majority of little boys with HIV in Africa contracted it through their mother, in which case circumcision wouldn't benefit them.

    Even waiting until they are a teenager, since the glans and foreskin should have naturally seperated by that time, and the penis should be almost its adult size.

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  44. ""For truncated RCTs having fewer than 500 events, there were large differences in treatment effect size between truncated and nontruncated RCTs (ratio of relative risks < 0.75). The pooled effects of the nontruncated RCTs showed no significant benefit in 39 (62%) of the 63 questions. [***The three circumcision-HIV RCTs put together had a total of 196 events.***]"

    My error, actually 201 events. Still way too few.

    "one estimate is that circumcision programmes could prevent 5.7 million HIV cases in sub-Saharan Africa in that time."

    Sure, based on a total of 73 HIV seroconversions that didn't happen in less than two years in the three trials. That's a scale-up factor of 78,000! And one of the authors of the estimate is B Auvert, an author of one of the three trials. It's a very small and close-knit group that is doing all the pushing for circumcision.

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  45. Amazing signal to noise ratio Hugh7!

    It would be just fascinating to find out why Jake got cut as an adult, and why he is such a crusader for neonatal circumcision, while pretending to be 'neutral' about it in Wikipedia (way to go Jake!)

    Jake, just think of the money you could make writing a book about your adult circ! It would easily pay for your amateur circumcision reference library. Dude, go for it!

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  46. I'm guessing he got cut because he thought it would lower his risk of contracting HIV, probably before study after study after study came out showing that being circumcised does not lower the risk for men who have sex with men.

    Now he has to justify his surgery. That's my guess.

    Note: I am pro gay rights and have nothing against homosexuality, so that is not the angle I am getting at.

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  47. I see the subject of your posts now appears to be myself, rather than circumcision, Anonymous. This being so, may I assume that our discussion is complete?

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  48. Oh poor Jake! I thought your discussion was done a long time ago in the Wikipedia circumcision discussion where you make fun of men who regret their forced circumcisions. Seems like you're a pro at turning the discussion from the question at hand when it suits you.

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  49. To return to my question, is that a 'yes'?

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  50. Why not answer ours? What's the obsession with cutting babies penises? Why not let them have the same basic human right you had and ever girl has in the united states and let them decide what they want to do with their own body?

    You're proof that adult men can and
    do decide to get circumcised as an adult if they so wish.

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  51. Why not answer ours? What's the obsession with cutting babies penises?

    Amusingly, that's actually the first time that question has been asked in this thread, so in effect you're refusing to answer my question while, at the same time, demanding to know why I haven't answered a question that hadn't been posed.

    Why not let them have the same basic human right you had and ever girl has in the united states and let them decide what they want to do with their own body?

    It doesn't have much to do with human rights, but yes, not circumcising infants is always an option. Personally, since I hold a pro-parental choice position, I'm supportive of those who choose not to circumcise infants as well as those who choose to circumcise.

    I have to say, though, that I find it rather bizarre to see this "choice" presented as such a wonderful thing. Is it the cost of the surgery that makes this choice so attractive? Or the time taken off work or education? Is it the period of abstinence from all forms of sexual activity? Is it the anxiety about the surgery? Is it the embarrassment factor? Is it the greater risk of complications?

    I merely ask because, you know, if I had to decide between this "choice" and having it done for me, as a baby, with no recollection of it, the latter sounds awfully compelling.

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  52. Because that "choice" is not one that most men would choose. If it held huge benefits within the United States, and a large number of men with foreskins were getting circumcised- much larger than the number of men with foreskins choosing to remain intact- you might have a point.

    With the exception of North Korea, adult intact men that choose to get circumcised are in the vast minority, even in the United States. The number wanting to get circumcised for non immediate medical need is even smaller- ie if they do not have phismosis or some other condition of the foreskin. Very few men think that prophylactic circumcision is worth the risks, or the loss of foreskin.

    THAT is why it is a violation of human rights. If given the choice, statistically, they would not choose it for themselves, and most never have to.

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  53. Because that "choice" is not one that most men would choose. If it held huge benefits within the United States, and a large number of men with foreskins were getting circumcised- much larger than the number of men with foreskins choosing to remain intact- you might have a point.

    With the exception of North Korea, adult intact men that choose to get circumcised are in the vast minority, even in the United States. The number wanting to get circumcised for non immediate medical need is even smaller- ie if they do not have phismosis or some other condition of the foreskin. Very few men think that prophylactic circumcision is worth the risks, or the loss of foreskin.


    There are some obvious problems with that argument.

    First of all, it's impossible to know how many uncircumcised men choose to remain uncircumcised. The reason for this is that it is often difficult to distinguish between choosing not to do something and not making a choice at all (perhaps not even thinking about it, or perhaps finding the obstacles too much).

    So we can't use statistics (or, in your case, what appears to be guesswork) on the proportion of adults that actually do get circumcised to infer that the remainder have chosen not to do so.

    A second problem with your argument is that it is circular. I've already shown that there are considerable obstacles to adult circumcision, so again it doesn't make a lot of sense to infer the number who'd like to be circumcised from those who actually do get circumcised. It's like noting that less than 1% of the world's population are millionaires, and concluding that most people would rather not be. More realistically, if it were easier to become a millionaire, it's likely that more people would do so.

    Fortunately, we have better data available. Studies have been performed in which adult men were asked whether they'd like to be circumcised. A review of thirteen such studies (in 2007) found that, on average, 65% of men were willing to become circumcised.

    It seems to me that there are actually a total of six useful categories:

    a) men circumcised at birth who are contented
    b) men circumcised at birth who don't care
    c) men circumcised at birth who would rather not be
    d) men not circumcised at birth who are contented
    e) men not circumcised at birth who don't care
    f) men not circumcised at birth who would rather be circumcised

    Now, men in group (a) benefit from infant circumcision.

    Group (b) have no resentment from being circumcised, which makes them neutral in this respect. (If we were considering other pros and cons as well, we'd point out that they enjoy the medical benefits of circumcision, but let's keep this analysis simple.)

    Group (c) do resent being circumcised, but they have the option of foreskin restoration (yes, I know, it's not quite the same, but neither is adult circumcision the same as infant circumcision).

    Group (d) benefit from not being circumcised.

    Group (e) are effectively neutral in this respect.

    Group (f) are harmed by not being circumcised at birth. This group has the option of adult circumcision, which isn't quite the same thing as infant circumcision (heavier scarring, fewer medical benefits, etc), but is perhaps close enough.

    Precious few statistics are available to give us information about the relative proportions of the various groups. However, I should point to Schlossberger et al., who reported: "Circumcised boys scored higher on satisfaction items than did uncircumcised boys, (t(15.65) = -3.96, p less than 0.001)."

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  54. " It's like noting that less than 1% of the world's population are millionaires, and concluding that most people would rather not be. More realistically, if it were easier to become a millionaire, it's likely that more people would do so."

    Of course. No amount of wishful thinking or praying or hoping can make the vast majority become millionaires. If a man wants a circumcision badly enough, he can get one in most cases. As an adult, there is no law prohibiting them from getting circumcised. Men have even circumcised themselves. This is obviously different than wanting to become a millionaire, wanting and wishing doesn't help.

    "Fortunately, we have better data available. Studies have been performed in which adult men were asked whether they'd like to be circumcised. A review of thirteen such studies (in 2007) found that, on average, 65% of men were willing to become circumcised."

    What I understood from that study is that these were all men in Africa. Africans are understandably extremely desperate to find any cure or risk reduction for the HIV/AIDS virus. It has ravaged their country. The majority of people in that country are uneducated, and it was a widespread belief at one point that having sex with virgins would cure them of AIDS. Thus mass raping of babies and children ensued. Thousands were convinced that eating dirt would cure them of aids, and many also believed in injecting themselves with lizard blood would cure the virus.

    Not surprisingly, there is a growing belief among African men that circumcision provides them with an immunity to HIV. (http://allafrica.com/stories/200807311102.html)Therefore, I do not find it surprising at all that African men are flocking to get circumcised, they don't have the resources to do research themselves and often rely on word of mouth.

    Speaking in a US and western world context, uncircumcised men are not flocking to get circumcised. Anesthesia carries risks, as does the operation itself, and given the minuscule benefits that a man living in the United States would receive getting circumcised, I don't blame them. As far as I know, no large study has every produced results of 100 percent of the men being satisfied with their circumcision. It would be naive of anyone to assume that every man that gets a circumcision has increased pleasure, and that none of the circumcisions resulted in decreased pleasure and satisfaction. It would be just as naive to assume every man had decreased pleasure after their circumcision. Point is, you don't know which category you will fall into until it's too late. Ben Affleck even said he hated his circumcision, and there is a lot of other anecdotal evidence showing that many men had decreased sexual satisfaction after circumcision. Needless to say, the possibility of decreased pleasure is not a risk many men would be willing to take for a non immediate medical necessity, and since it is their body, that should be a choice they make for themselves.

    "...(perhaps not even thinking about it, or perhaps finding the obstacles too much)."

    Right. Many men consider the foreskin a normal body part, and have no desire to remove it. I don't know of any women who think about whether or not they should remove their clitoral hood, but that is not a legitimate reason for doing it in infancy.

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  55. Of course. No amount of wishful thinking or praying or hoping can make the vast majority become millionaires. If a man wants a circumcision badly enough, he can get one in most cases.

    Indeed. In both cases it requires a certain amount of determination to succeed in achieving one's goals in spite of the many obstacles in the way.

    What I understood from that study is that these were all men in Africa.

    Indeed. Was the title ("Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: a review") a clue?

    But the location of the studies is, of course, not really terribly relevant. Examination of the literature shows similar results in India, Dominican Republic, and the United States.

    As far as I know, no large study has every produced results of 100 percent of the men being satisfied with their circumcision.

    That is true; rates are typically in the range between 95% and 100%.

    It would be naive of anyone to assume that every man that gets a circumcision has increased pleasure, and that none of the circumcisions resulted in decreased pleasure and satisfaction. It would be just as naive to assume every man had decreased pleasure after their circumcision.

    Statistical evidence suggests that the most probable outcome is no change in sexual sensation. However, some men do report changes; increased sensation seems slightly more likely than decreased sensation.

    Ben Affleck even said he hated his circumcision

    Are we having a serious conversation here, or discussing anecdotes about random celebrities?

    and there is a lot of other anecdotal evidence showing that many men had decreased sexual satisfaction after circumcision.

    That's the thing about anecdotes: you can gather them to prove whatever point you want to make. For that reason it is better to rely upon scientific evidence.

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  56. 71 out of 133 men is no where near a large enough sample to accurately represent the majority of men in the United States. Even if every homosexual man in the United States wanted to get circumcised, that would still not be the majority, since estimates put the rate of homosexuality at about 10 percent of the population.

    Since it was asked in a "what if" it reduced their risk of HIV (which studies in the United States have not shown for MSM) and showed a correlation with the belief that it lowered the risk of penile cancer (which even the American Cancer Society disputes) I would guess that number to be exponentially lower once informed of those two things.

    Cherry picking studies from a gay parade that asked 133 men whether or not they might consider circumcision is hardly reliable, and certainly not representative of the majority of men in the United States. Especially given the "what if" scenario of the question.

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  57. 71 out of 133 men is no where near a large enough sample to accurately represent the majority of men in the United States. Even if every homosexual man in the United States wanted to get circumcised, that would still not be the majority, since estimates put the rate of homosexuality at about 10 percent of the population.

    Since it asked in a "what if" fashion in the connection with the belief that it reduced their risk of HIV (which studies in the United States have not shown for MSM) and the belief that is reduced their chance of penile cancer (which even the American Cancer Society disputes) I would guess that number to be exponentially lower once informed of those two things.

    Cherry picking a study that showed 71 out of 133 men might choose circumcision if they thought it lowered their HIV risk (which it has not shown to do) is hardly a reliable and representable study.

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  58. Since it asked in a "what if" fashion in the connection with the belief that it reduced their risk of HIV (which studies in the United States have not shown for MSM)

    On the contrary, several US studies have found that circumcision reduces the risk of HIV. See, for example, Kreiss and Hopkins, Buchbinder et al, Warner et al., or Reisen et al.

    Having said this, the evidence is not as consistent as it is for heterosexual males, and it is not yet conclusive.

    and the belief that is reduced their chance of penile cancer (which even the American Cancer Society disputes)

    "Circumcision is the removal of all (or a part) of the foreskin. This procedure is most often done in infants but it can be done later in life. Circumcision seems to protect against penile cancer when it is done shortly after birth. Men who were circumcised as babies have a lower chance of getting penile cancer than those who were not." ACS

    Cherry picking a study that showed 71 out of 133 men might choose circumcision if they thought it lowered their HIV risk (which it has not shown to do) is hardly a reliable and representable study.

    Then I look forward to the study/studies that you will present. Alternatively, if you are unable to find such studies, I trust you will be courteous enough to withdraw your accusation of cherry-picking, and you will agree that the studies I present represent the best available evidence.

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  59. Jake has brought up this "foreskin restoration" twice now, as if this myth can somehow mitigate the damage done to men who resent their forced circumcisions.

    The first hit on Google is a commercial site - 4restore.com - that sells some stainless steel contraption. A quick look at their photos of "success" stories shows the whole site to be a fraud! Some of these photographs are just lifted straight from other internet sources showing intact penises from anti-circumcision sites!

    Yeah, when your "after" photo is an intact penis, the results look pretty darn good.

    Jake, you call "foreskin restoration" a choice. There's no proof, medical or otherwise, that men can "restore" their foreskins. Myths and lies do make a choice.

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  60. I presented my evidence as anecdotal. Surely you are not implying you think that over 50 percent of intact men in the United States are getting circumcised?

    From the ACP website

    "Circumcision reduces the risk of penile cancer if it is done shortly after birth, *but removing the foreskin later (as an adult) does not lower this risk.* Adult men can lower their risk of penile cancer by avoiding things that are known to raise the risk of penile cancer."

    Since the study you linked and the one we are discussing is clearly in reference to adults, and the adults were basing their decision partly on the thought it would reduce their chance of getting penile cancer... you get the idea.

    ACP further says it does not recommend circumcision for purely medical reasons, and penile cancer is extremely rare, affecting 1 in 100,000 men. I don't think anyone would argue that circumcising 100,000 babies to prevent one case of cancer is cost effective or rational.

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  61. Jake has brought up this "foreskin restoration" twice now, as if this myth can somehow mitigate the damage done to men who resent their forced circumcisions. [...] Jake, you call "foreskin restoration" a choice. There's no proof, medical or otherwise, that men can "restore" their foreskins. Myths and lies do make a choice.

    I have neither proof nor personal experience indicating that it can be done; however I am quite convinced by sites such as norm.org that it is possible. You must form your own conclusions.

    I presented my evidence as anecdotal. Surely you are not implying you think that over 50 percent of intact men in the United States are getting circumcised?

    Not at all, but I think I've supplied sufficient evidence to indicate that a significant proportion of uncircumcised men are willing to be circumcised. Since we're discussing how men feel rather than what they do, the number who actually do get circumcised doesn't interest me as much as the number who'd be willing to do so.

    Since the study you linked and the one we are discussing is clearly in reference to adults, and the adults were basing their decision partly on the thought it would reduce their chance of getting penile cancer... you get the idea.

    You're quite right: the ACS appear to believe that adult circumcision does not reduce the risk. Quite why they should believe this is unclear; a major confounding factor in almost every study to date is that phimosis is the most common reason for adult circumcision, and phimosis is itself a risk factor for penile cancer. This fact was noted by Brinton et al. in (as I recall) 1992.

    ACP further says it does not recommend circumcision for purely medical reasons, and penile cancer is extremely rare, affecting 1 in 100,000 men. I don't think anyone would argue that circumcising 100,000 babies to prevent one case of cancer is cost effective or rational.

    I don't think anyone would argue that either, but you're using the wrong figures. The 1 in 100,000 figure is the annual incidence, which is not appropriate for comparison with circumcision. Since circumcision lasts for a lifetime, the appropriate figure is the lifetime risk, which is estimated as between 1 in 1,400 and 1 in 600. For the sake of argument, let's say 1 in 1,000.

    Now, would anyone argue for circumcising 1,000 babies to prevent one case of penile cancer? Maybe, maybe not. With the risk of complications at about 1 in 500, that's about 2 complications per case prevented, and penile cancer is likely more serious than the complications themselves, so it might be worthwhile.

    However, this analysis is necessarily incomplete, and borders on meaningless. Does it make sense to compare all complications with a single benefit? Of course not. A meaningful comparison would have to recognise that there are multiple benefits, as well as multiple risks, and it is important to weigh all of these against each other.

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  62. "However, this analysis is necessarily incomplete, and borders on meaningless. Does it make sense to compare all complications with a single benefit? Of course not. A meaningful comparison would have to recognise that there are multiple benefits, as well as multiple risks, and it is important to weigh all of these against each other."

    I agree completely. I disagree, however, that a person shouldn't have the right to weigh the risks and benefits for themselves. Some may think hassle of washing their foreskin is worth the circumcision alone, others may view that as nonsensical as removing the ear lobes for easier cleaning.

    Times change, studies change, science changes. Who knows if/what benefits the foreskin might be shown to have. Or if a vaccine for AIDS/HIV is discovered in 15 years. The majority of benefits of circumcision are benefits that affect an adult, and an adult should make those decisions.

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  63. "A meaningful comparison would have to recognise that there are multiple benefits, as well as multiple risks, and it is important to weigh all of these against each other."

    I agree. The person whom the penis belongs to should be the one weighing the risks and benefits for their own body.

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  64. Times change, studies change, science changes. Who knows if/what benefits the foreskin might be shown to have. Or if a vaccine for AIDS/HIV is discovered in 15 years. The majority of benefits of circumcision are benefits that affect an adult, and an adult should make those decisions.

    Okay. You've made your position clear, and you're obviously convinced of its merit. That's fine. I don't share your view that only an adult can make the choice for himself; I think it's a perfectly legitimate choice for parents to make on behalf of their son. If I were in such a position, I'd personally choose to circumcise, but please understand that I'm not saying that other choices are wrong or in any way invalid.

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  65. Jake wrote:
    "I have to say, though, that I find it rather bizarre to see this "choice" presented as such a wonderful thing. Is it the cost of the surgery that makes this choice so attractive? Or the time taken off work or education? Is it the period of abstinence from all forms of sexual activity? Is it the anxiety about the surgery? Is it the embarrassment factor? Is it the greater risk of complications?

    I merely ask because, you know, if I had to decide between this "choice" and having it done for me, as a baby, with no recollection of it, the latter sounds awfully compelling."

    That's a great argument, IF a man chooses to have himself circumcised. All of those "disadvantages' mean nothing if he chooses not to be circumcised because he wants to keep his foreskin - as most men do.

    "I think it's a perfectly legitimate choice for parents to make on behalf of their son. If I were in such a position, I'd personally choose to circumcise, but please understand that I'm not saying that other choices are wrong or in any way invalid."

    So they might as well toss a coin? Their decision impacts on them minimally, if at all. It impacts on him almost 100%.

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  66. That's a great argument, IF a man chooses to have himself circumcised. All of those "disadvantages' mean nothing if he chooses not to be circumcised because he wants to keep his foreskin - as most men do.

    First, what proof do you have that most men choose not to be circumcised? (As I've pointed out above, the actual adult circumcision rate would not constitute proof since it would not be possible to distinguish between a choice not to be circumcised and it never having been considered.) Second (assuming that you can answer the first question), what proof do you have that most men choose not to be circumcised for that particular reason (and not, say, because of the obstacles I outlined)?

    So they might as well toss a coin? Their decision impacts on them minimally, if at all. It impacts on him almost 100%.

    Exactly 100%, surely? :-)

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  67. There is NO serious scientific evidence that circumcision or non-circumcision has anything to do with the spread of HIV/AIDS. Debra Messing is an actress, not a scientist - she has no expertise in this field and her opinions on this topic are irrelevant.

    "First, what proof do you have that most men choose not to be circumcised? " What proof do you have that most "intact" men would voluntarily choose to be circumcised? Circumcision is an ancient and somewhat barbaric religious practice and hence has no place in a scientific discussion . One might as well bring up the Earth being flat and only 6000 years old.

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  68. There is NO serious scientific evidence that circumcision or non-circumcision has anything to do with the spread of HIV/AIDS.

    "The efficacy of male circumcision in reducing female to male transmission of HIV has been proven beyond reasonable doubt." — World Health Organisation (source)

    "First, what proof do you have that most men choose not to be circumcised? " What proof do you have that most "intact" men would voluntarily choose to be circumcised?

    Actually, it is customary in a debate for a person to be asked to substantiate his own claims. It is more unorthodox to ask a different participate in debate to substantiate a claim that he hasn't made. Nevertheless, I have actually supplied such evidence in this thread, in my posts dated April 6, 2010 6:40 AM and April 6, 2010 1:13 PM.

    Circumcision is an ancient and somewhat barbaric religious practice and hence has no place in a scientific discussion . One might as well bring up the Earth being flat and only 6000 years old.

    That doesn't make a lot of sense. The notions that the Earth is flat and young are ideas (and since they're scientifically testable ones, and thus fall within the scope of scientific investigation, there's no reason why scientific discussions shouldn't include them — scientific discussions often involve incorrect hypotheses).

    But circumcision isn't just an idea: it's a real, verifiable change to the human body. And it doesn't make much sense to say that the effects of such a change are beyond the scope of scientific investigation just because the change is sometimes performed for religious reasons. One might as well say that nutrition isn't a valid field of scientific investigation because feasts form a part of many religious traditions.

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  69. Intact men often choose circumcision, if not for themselves, for their son(s). It is done for religious, ritual, medical and aesthetic reasons. Each is valid in its own way for those who do it, and at worst, no harm is truly done. Methods are sometimes medical, sometimes seemingly crude, and styles (outcomes) vary as a result. There are many medical benefits of circumcision, though few of them are absolute, but rather like many choices in life, they merely reduce genuine risks. An awful lot of people are unhappy with some aspect of their appearance or bodies, obviously most not of their own choosing. A medically required or opted circ beyond birth costs at least ten times as much as a neonatal one, so because there are likely (from figures one often sees) about ten percent of boys and men who need a circ or want one later, we pay about the same cost of doing all for the benefit of doing those few later. In a nation (world) where the citizens were truly free, parents would be trusted and enabled for their choice in this matter, and their sons would endure and prosper as men and boys typically do, with crooked teeth or a broken heart or sometimes missing limbs. Great harm is done by obsessive, neglectful, emotionally and physically abusive parents and guardians. Those who choose to (lovingly) circumcise or (lovingly) leave their sons intact are acting safely within that comfort zone often called "none of our business." In that spirit, may we always advise and never impose.
    PS... A common surgery done to kids these days is to "correct" protruding ears... because of teasing or bullying. Hardly medically necessary, and only hopefully worthwhile... and thankfully none of my business!

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  70. the owner of this blog is seriously disturbed.

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  71. Nature Really Likes Male Circumcisions

    Way down under in Melbourne, Australia is the story of a tightly done male adult circumcision of the ultimate kind. You’ll never believe the story … or will you?

    Around 17 years ago, I became aware that circumcision was of interest to me. How to go about it ? What an embarrassment, how to sneak into a Doctor cost etc. I became more and more frustrated, as I knew I wanted it done. Australia is a hot climate too and I wanted a slick model penis, not a sock, at half mast. I had learnt from school that I was bisexual, I would use the odd opportunity to check out and occasionally talk another classmate into pulling down his pants and letting me give him oral sex. Both circumcised and uncircumcised, although I didn’t know what circumcision was then, I was only ten ! We start pretty early in Australia !

    Anyway back to circumcision. I became more and more, frustrated and there didn’t seem to be a way of resolving the issue. Then I had a bereavement in the family. If I couldn’t solve this simple problem… It was a question of honor.
    So what I did may surprise many. I am an everyday kind of bloke, a family now, job and the rest of it. So don’t be too shocked. Where there is a will there is a way.

    I had been researching on the net at the time and I was reading and seeing pics of tribal and African circumcisions. There are great stories of the Tuli in the Philippines and also teens putting their penis on a log with a piece of twine and the elder slicing off the foreskin, high and tight, leaving a terrific red patched scar.

    I decided after much viewing and research that this is what I wanted. I was a bit far from the Philippines and Africa, so this is what happened.

    One long weekend when there was a Public holiday, I decided to have a go myself. This is not for the faint hearted.

    On the Friday night, I did the usual, a few beers then came home. I opened a bottle of white wine and proceeded to watch an x-rated video. Of course with a long ring barked cock or two. After a while I was ready. A bit of popper amyl and I was more or less ready to have a go. At circumcision.

    I knew the skin would be sensitive, so I had purchased from an adult store, delay spray. This I think had lidocaine like when you get Suntan mozzie burns cream from the supermarket only stronger. I applied it to my foreskin until the end of my cock felt number, than usual. Another drink and some poppers, a look at the tightly taut scarred cocks on the TV screen and it was time. Time to join the rest of my male brothers on the planet with a permanently forever nude glans and a stripped pointed helmety penis. Intention purple glans to always lead the way, from that night on or else.

    I sized and drew a line working out where to cut and checked this out numerous times. Another drink, more amyl and an inspection of the video playing and I was ready.
    I took a very sharp pair a medium size sewing scissors and sat down. Carefully lining them up, I very slowly, and I mean really really slowly, put them through the line on the foreskin I had drawn. I had already pulled the foreskin as hard as I ever could in front of my glans.

    Slowly but surely I got the job done. Everything dropped back behind my glans and my foreskin lay on a tissue. A dream come true. I couldn’t believe my absolute relief and satisfaction.

    All this time later nearly two decades on, I am still happy. A couple a days later, I consulted a friendly doctor and some stitches were added on the quiet to complete the job.
    Result is I have a very tightly circumcised penis, with absolutely no frenulum or foreskin.

    The absolute tightest male circumcision possible, for myself and any partner I should choose, whether it be female or male. Amazingly there is no two tone scar and the circumcision join is one color and height. No different levels of skin height or misalignment.

    Nature really does like circumcisions.

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