A fatal irony: Why the “circumcision solution” to the AIDS epidemic in Africa may increase transmission of HIV

‘No, I think readers can read you were clearly alleging that “there is strong evidence…” And I respond by saying, not “strong” enough.’ — you’re still confusing separate issues. “Strong evidence” is about the level of certainty in the benefit, not the magnitude of the benefit vs the risks.

“Judging from the position statements of most respected medical organizations in the world, it’s not high enough…” — again, that’s magnitude vs risk.

‘Will you base your arguments regarding penile cancer on the Christopher Maden study in Washington State, which showed that 37% of the men who get penile cancer, were circumcised at birth?’ — yes. Maden reported: “Relative to men circumcised at birth, the risk for penile cancer was 3.2 times greater among men who were never circumcised”

‘Or the recommendation of the American Cancer Society, which states that circumcision does not prevent penile cancer?’ — Their actual words are: “Circumcision seems to protect against penile cancer when it is done during childhood. Men who were circumcised as children have a lower chance of getting penile cancer than those who were not, but studies looking at this issue have not found the same protective effect if the foreskin is removed as an adult.” http://www.cancer.org/Cancer/PenileCancer/DetailedGuide/penile-cancer-risk-factors

‘Pretty much everyone acknowledges that penile cancer is most likely caused by the HPV virus, which has a vaccine.’ — HPV is one of the major risk factors, yes.

‘How is removing half the skin of someone’s genitals, “no net harm”?’ — removing skin is removing skin. It’s not inherently harmful. It can be harmful, if it increases risk or adversely affects functionality, but to assume it to be harmful is to beg the question.

‘Is it considered no net harm for females? If it is considered harmful for women, why should it not be considered harmful for males?’ — males and females have different anatomy, so it’s illogical to expect identical results.

‘Why would the Swedish Paediatric Society call it “child abuse” and say, “We consider it to be an assault on these boys”’ — it is a mystery to me.

‘Why do Americans, who are circumcised in the majority, consume the most viagra per any population in the world?’ — probably for the same reason that Americans are the largest consumers of pharmaceuticals overall.

‘You’re conflating harm and net harm.’ — no, I’m not. The two concepts are closely related.

‘The former is indisputable of all circumcisions. Circumcision is surgery. Healthy skin is removed. A scar remains.’ — so where is the “indisputable harm” that you mention?

‘Risks of further complications are inherent in the surgery. It is harmful.’ — if risk of future problems is harm, then not circumcising must be harmful. That seems a poor standard.

‘You draw your conclusion on the latter point, that of net harm, which is subjective to the consideration of factors you determine for yourself’ — it’s subjective to an extent, but not exclusively.

‘Please provide specific numeric values so we can understand the decisive, even if close, victory that non-therapeutic child circumcision allegedly provides.’ — would you be kind enough to point me to where I said there was a decisive victory?

‘You are, as you have in the past. Closely related is not the same thing. Harm is an input into net harm’ — so, by showing that the argument that there is inherent harm is flawed, one establishes that the argument of inherent net harm must also be flawed.

‘Again, harm ≠ net harm. I am not making that mistake’ — I understand what you are arguing.

‘Healthy skin is removed. That is harm.’ — no, it is removal of skin.

‘A scar remains. That is harm’ — no, it is a scar.

‘Those harms result from every circumcision. Hence, indisputable.’ — shall we agree that they are indisputable consequences?

‘Please cite where I said otherwise if you intend to ding my argument for this claim.’ — when you said ‘Risks of further complications are inherent in the surgery. It is harmful’, you seemed to be arguing that, because there was a risk of complications, it is harmful. I apologise if I misunderstood.

‘As far as poor standards go, aren’t you citing the risk of problems circumcision may reduce as a reason to support circumcision, as an input into a conclusion that there is no net harm?’ — yes, of course, since ‘net harm’ must inherently take such probabilities into account.

‘Subjective to an extent… My point is that the decision is subjective because some inputs are subjective. I do not draw that conclusion for myself, because I value the various aspects differently (i.e. they are subjective) than you do. You accept that there is subjectivity, so you can’t draw an objective, universal conclusion applicable to all males. Yet, you do that. You say circumcision is not a net harm.’ — yes, I do say that. I agree that one could form a different conclusion. Some conclusions are more reasonable than others.

‘Whatever word you want to use to mean “no net harm”.’ — no net harm can mean net benefit; it can also mean that benefits and harms are equal.

The starting point must be that circumcision creates painful injury. Now how is that injury justifiable?
With regard to ethics, parents are presumed to give “proxy” consent for the circumcision of their child. But what is the basis for them to believe that the child WOULD give informed consent to having part of his penis removed, if he were able to? There should be a valid reason to believe that he would consent to it.

You are saying that having your foreskin removed is like being robbed of monopoly money?
You are, of course, entitled to your opinion. I would guess it runs contrary to the views of the vast majority of the 3 billion men with foreskins.
Your rationalizations contort with more force, with each one. It is getting painful to watch.
It feels more like a denial of harm, and going to tremendous lengths to justify, rather than feeling that no harm was done.
If no harm was done, you would simply be enjoying the benefits of the surgery, and that would be that.
Spraying the internet with tortured logic such as this gives one the impression that all is not well.

Don’t get snotty with me, sister.
You made the comparison with monopoly money. You backed yourself into a corner. I merely mentioned it.

Real money Jake, real money that you worked hard for and saved. Lets say 3 months of rent. You’d be calling the police and filing a report.

‘Or, in context, is surgery removing a healthy, functioning finger harm?’ — again, it depends on the circumstances. It might be a sixth finger that causes the patient distress, for example, in which case it’s dubious to call it harm.

You know very well that he did not mean a birth defect or an anomaly. Do you want a list of body parts that are acceptable for the comparison? Ears (not extra ones), nose (not an extra one), healthy teeth (not extra ones), eyelids (not extra ones), limbs and digits (again, for clarity, not extra ones)
Why do you keep twisting things? Is it because of your bias created by your sexual preference for denuded and scarred male genitals?
To you a denuded and scarred penis is always a net benefit?

Jake, here is a little friendly advice.
If you want to be listened to, don’t obfuscate, deflect, and abstract everything out until no one, including yourself, can tell what you are talking about.
If you don’t want to be personally attacked, stop attacking other people.
Telling the rest of us that we didn’t read your post, or misinterpreted what you had to say, when it was intentionally written in double dutch translated into pig latin, is insulting. I say that, because whenever someone starts to pin you down to something you actually said, you exude the verbal equivalent of the mucous of a hagfish, and slither away, giving yourself the impression that you have eluded your enemies, and lived to obfuscate another day.

Do you want to tell Layla with a straight face that you don’t have a sexual preference which centers on circumcision, or at least an obsession with it which causes you to continuously post in wikipedia, Practical Ethics, Psychology Today, African press, your website, your blog, etc, ad infinitum?

How much credibility do you think that would have here, considering what you have posted, and how many times you have been called on it?
I think James Mac wins the politeness award, by using the term apotemnophiles.
By the way, it is as if you posed for James’ ‘playbook of those promoting circumcision’, until you have turned into self-parody.

Ouch, Layla. You have the courage to say what most of us only think.

‘No need for shame about your fetish Jake, just be up front about it, because it has a lot to do with your diligence on this topic.’ — are you enjoying making these ridiculous accusations, Layla?

‘It’s not an accusation if you are a known member of circ fetish groups.’ — if there is an group which a) I’m a member of, and b) you have proof that every member of said group has such a fetish, then show some evidence. But you can’t. I’m guessing you’re talking about CircList. I’ve seen similar claims made about that group, going back to 2003. I used to be a member of that group, and I’ve never made a secret of that. But in spite of being vilified by intactivists, it wasn’t a fetish group; it was a discussion group about circumcision. A few members seemed to have strange interests in the subject, certainly, but my impression was always that they were in a minority.

‘You admit that you find foreskin to be redundant and non-functioning, this goes against science and nature. We know that foreskin is a normal and functioning part of the male genital anatomy.’ — it’s normal, but I’m afraid proposed functions are speculative at best.

‘Until June 2010, the Circlist website (http://www.circlist.com/news.html) inked to a Google discussion group that said:’ — I’ve spent some time searching the Internet and archive.org, but I haven’t been able to confirm that this statement was ever present. It’s not the group description that I remember seeing (my memory is that it was closer to “this is a pro-circumcision list”, followed by a warning that it wasn’t the place to debate infant circumcision).

‘If a uniquely mobile, highly innervated structure near the end of the penis does not have an erogenous function, what was God/evolution thinking?’ — why should every part of the penis have an erogenous function?

I nominate this for the oddest question ever:
“why should every part of the penis have an erogenous function?”
Genitals have erogenous functions. That is their nature. Perhaps your foreskin did not. I would consider my penis less than half a penis, without one.

Sexual effects of circumcision:
On the basis of neuroanatomical science, there should be no doubt that male and female circumcision constitute a serious mutilation, and it is right to regard them as comparable. It may be objectionable to some that I am comparing male and female circumcision in an equal light, but I base my assumption on the same criterion, namely evidence from neuroanatomy.
There are no empirical scientific studies to date that demonstrate that either male or female circumcision is associated with actual loss of sexual pleasure, probably because such parameters are hard to measure scientifically. I have two quite recent studies investigating the sexual effects of female circumcision in Africa, which found no reduction in sexual pleasure or arousal for the circumcised women. That doesn’t mean that western women who had undergone circumcision would provide similar testimony to those circumcised African women, bearing in mind the huge cultural differences. Intuitively, it can be affirmed that a circumcised woman has lost sexual potential for pleasure. Likewise, a circumcised man has lost sexual potential.

Note that the majority of studies (e.g. those listed in Wiki) on the sexual effects of male circumcision are based on THERAPEUTIC (corrective) circumcisions in adults, and so are not relevant to the non-therapeutic circumcision of boys, which almost always removes normal, healthy foreskin. It is disingenuous that Wiki presents these study findings AS IF they had general significance for circumcision. Obviously, they don’t! On examining Wiki’s listed studies, it becomes clear that nearly all the male participants (typically about 90%) were circumcised in response to phimosis or balanitis (conditions known to impair sexual function). Although fairly neutral in terms of circumcision’s sexual effects, the study findings are somewhat troubling, since in spite of their corrective circumcisions, most of the men actually reported no sexual improvement (some even worse) – surely not the hoped for outcome of a corrective operation!
It should be obvious, then, that the sexual outcomes for adult therapeutic circumcisions should not be used at all to promote non-therapeutic infant circumcision.

The remaining studies listed in Wiki on the sexual effects of adult circumcisions focus on those performed in the Sub-Sahara ( by Krieger et al., Kigozi et al. and recently Westercamp et al. The studies report quite positive (or at least neutral), sexual outcomes. Although not based on corrective circumcisions, the cultural complexities of the Sub-Sahara make the sexual outcomes of these African studies virtually impossible to project with any reliability or predictive value onto developed nations, such as the USA (btw, it came as a surprise to me to find even the CDC admitting as much). Some African tribes and communities INSIST on male circumcision for membership and marriage into them, or to be considered respectable. Men desperately needing circumcision would have streamed towards these medicalised trials, in which they were even paid to participate. Cultural motivation and need could easily have affected their testimony on sexual outcomes. Furthermore, there is now in Africa the false presumption that the circumcised penis offers more intrinsic protection against HIV transmission than the uncircumcised penis. Eempirical evidence in Africa contradicts that presumption; the evidence shows that within most African countries investigated, the circumcised men are about equally infected with HIV as the uncircumcised men.
Women having the false conviction (as instilled by the U.S.-subsidised juggernaut steamrollering male circumcision in Africa) that the circumcised penis provides more sexual protection are more likely to respond sexually to circumcised men in a fuller and more committed way than to uncircumcised men, who are now stigmatised. This will obviously improve the reported sexual outcomes for circumcised men.

Finally, those three African studies investigating sexual effects of circumcision have a striking potential conflict of interest: investigators leading them were part of the SAME team recruiting men for circumcision (and thereby gaining rich financial reward)! You will see that associated with the names of Kigozi et al., Krieger et al., and Westercamp et al. (the men who conducted the African studies on the sexual effects of circumcision) are none other than S. Moses, R. Bailey, M.J, Wawer and R.H. Gray. That’s a classic clash of vested interests, if ever there was one. The team investigating the sexual effects of circumcision should be independent from the team which recruits for circumcision.

To Jake:
Hugh wrote: Foreskin is “a uniquely mobile, highly innervated structure near the end” – each element of which strongly suggests an erogenous function.”
Jake replied:
“Not necessarily, no. As an extreme counterexample, the eyeball is highly innervated, but it isn’t particularly erogenous (at least to the touch). The foreskin does have a dense concentration of Meissner’s corpuscles at the tip, but so do the eyelids, to allow them to rapidly detect foreign bodies posing a threat and protect the body before damage is done. It seems perfectly plausible that those of the foreskin have a similar role: to provide an early warning system of damage from twigs and long grasses before humans wore clothing.”

Jake, your reply won’t work or wash! Meissner’s corpuscle nerve receptors, which abound in the foreskin (and other skin areas), do not mediate pain reception, so would not be suitable to alert of physical threats or damage, such as from twigs or grasses. FREE NERVE ENDINGS are much better adapted to warn of physical damage. Meissner’s corpuscles detect subtle touch and vibration. Also, you say that Meissner’s corpuscles allow the body to “to rapidly detect foreign bodies”. No, that isn’t accurate! Meissner’s corpuscles are rapid ADAPTING to stimuli; that doesn’t mean they detect stimuli more rapidly than other receptor types (they don’t). Rapidly adapting is not the same as rapidly detecting.

The mobility of the foreskin permits the Mesissner’s corpuscles to be continually re-stimulated, generating a tingling sensation, which is potentially extremely erotic. They are well adapted to detect texture as well as touch.
I don’t doubt that the eyelid surface has many Meissner’s nerve receptors too (as you say), but this would explain why caressing them is often experienced as sensual. The nipples and lips probably present a good comparison with the foreskin in terms of innervation type.

In summary, the foreskin is potentially highly erogenous. In doubting this, you are flying in the face of neuroanatomists,, such as Ken McGrath (senior lecturer at Auckland university), Ashley Montague, and many others. “Erogenous” is a term that they use to describe the foreskin. The College of Physicians and Surgeons of British Columbia have recently written that the foreskin is “composed of an outer skin and an inner mucosa that is rich in specialized sensory nerve endings and erogenous tissue.” Jake, you are opposed by a lot of “big guns”, who are better qualified than you to discourse on the foreskin!

People who don’t like a particular part of their anatomy (be it foreskin, breasts or inner thighs) are less likely to derive sexual pleasure from them. Or if sexual partners perceive the foreskin as unattractive, this can reflect on the sexual experience of the intact man.
It’s certainly not for you to imply that the foreskin is not important in sexual pleasure. I wonder if there are any bounds to your arrogance.

Jake,
note that I haven’t claimed that Meissner’s corpuscles function exclusively in sex. There is some overlapping in nerve receptor function. I do claim that they are potentially erogenous, having due regard to the fact that sexual perception is subjective. Free Nerve Endings mediate not just pain but touch too, and I’m sure they can play an important part in sexual stimulation also. I should think that all sensory receptors affect sexual pleasure, although not all are equally specialised for this.

You say that “once contact is made, [Meissner’s corpuscles] cease signalling”. But you see, that’s the origin of the “on-off” tingling effect of light stimulation! Meissner’s corpuscles quickly regain the ability to re-fire, as soon as the corpuscle has regained its shape. Moreover, the mobile, rolling nature of the foreskin permits the recruitment of different Meissner’s corpuscles and their subsequent re-stimulation.

Can you not experience sexual pleasure from light touch stimulation of your skin? Don’t you think that tingling is potentially erotic? What nerve receptors are principally involved in that sensation? Aren’t you capriciously undervaluing that sensation in others, and their right to it, by approving infant circumcision?

I said: “Jake, you are opposed by a lot of “big guns”, who are better qualified than you to discourse on the foreskin!’ You replied: “That’s the fallacy of appeal to authority.”
Jake, I think that the conclusions of renowned neuroanatomists have a higher appeal than your opinions, which are not evidence-based. Do you have reason to disagree with, for example, Prof. Ken McGrath (Auckland university), Ashley Montague, and J.R. Taylor? The College of Physicians and Surgeons of British Columbia also seem to have thrown their weight behind the view that the foreskin is erogenous tissue. Do you know of any neuroanatomists who REFUTE that view or claim?

Sorry, there’s a mistake in my post dated June 1, 2012 at 5:17 pm: “but McGrath and Taylor are/were both anatomists” should be “but McGrath and Taylor are/were both pathologists”.

I should also have mentioned Ashley Montagu. He is best known for having been an anthropologist, as you say. However, he was also an anatomist and neuroanatomist(although I think not of the same standing as McGrath and Taylor). You might like to watch the Youtube video “Ashley Montagu on circumcision”, in which he mentions his training.

Jake, would you accept evidence “straight from the horse’s mouth” that Montagu and Ken McGrath are/were anatomists? Here’s the Youtube link for “Ashley Montagu on circumcision”. The relevant part is at 10-30 seconds:
http://www.youtube.com/watch?v=iau_CTRNRr8

As for Ken McGrath, see Youtube video: “Anatomy of the penis: penile and foreskin neurology” (within the first 10 seconds) at:
http://www.youtube.com/watch?v=DD2yW7AaZFw

It’s great to keep an open mind, Jake, but experts in the field of anatomy should be best placed to advise on their field of expertise, neuroanatomy in this case. Of course, if their findings and conclusions are refuted or cast in doubt by other experienced anatomists (or even experts from other fields), then you might be able to produce an informed counter-argument rather than your layman’s opinion, which at least would add something of substance to the discusion.

Jake says: “Now, if you want to discuss whether a particular body part is erogenous in nature, that is of course a question that is outside the field of anatomy”.

No, it isn’t, Jake. Nerve receptors affect the quality of our perceptions, so neuroanatomy is relevant to the discussion on erogeneity. It is true that the interpetation of neural signals (as for example, being “erogenous”) is subjective, variable, and to a large part controllable. The individual person affected is the only authority and arbiter on whether sensation is erogenous or characterised by a different quality. All sensory or tactile nerves are potentially erogenous, although not equally so. Removing nerves leads to loss of sensation and potential loss of pleasure that is very meaningful only to the owner of the body. You can’t evaluate this loss on his behalf. That’s why I called you out for being arrogant.

As for your acccusation of “appeals to authority”, that device is frequently a valuable evidence-based approach, which informs your views as much as mine. Appeal to authority can be the basis for a strong inductive argument. It’s used in our law courts too . Of course, it doesn’t furnish proof.

You appeal to authority every time you cite studies as evidence. For example, your opinion that the particular three African RCTs (alluded to in this forum) present our best form of evidence is only an appeal to the authorities who designed and performed them. And of course, there’s the appeal to the WHO which I think you have made a few times. By the way, I would be happy to accept with due confidence the findings and conclusions of the RCT designers, were the trials not so riddled with confounding factors (which I discussed earlier) and not so inconsistent with other empirical evidence. The inconsistencies have not been duly explained.

You make appeals to authority every time you claim you can weigh up “benefit” against “risk” associated with infant cirucmcision. How do you know that the information you are fed with is reliable or accurate? Appeals to authority! Incidentally, your appeals become less sound in view of the fact that other researchers and authorities dispute them. The book that you intend to publish one day will be riddled with your appeals to authority 0r course.

Your own willingness to empower parents to order the circumcision of their sons is nothing more than an appeal to their authority. It’s actually a very poor appeal, since parents aren’t even close to knowing that circumcision is in their son’s best interests. They’re not informed authorities. The appeal is gratuitous.

To Jake:

Jake said: “I didn’t say that neuroanatomy was completely irrelevant. I said that anatomy cannot answer that question.”

Jake, I emphasise that neither you nor anyone but the owner of the body is in a position to evaluate the foreskin’s significance for that person.
Jake said: “Citing a study by Bailey which provides evidence is not an appeal to authority: the emphasis is not on the greatness of the author, but instead on what evidence is provided.”

I haven’t denied that Bailey has presented “evidence”. What I dispute is what he has presented evidence” OF! He may only have presented evidence that abnormal or impaired foreskin tends to be more conducive to HIV transmission than the circumcised penis is (which we already knew). Would you disagree with that assessment? If so, how do you think that the study results are projectable onto the general population? If you don’t agree with my view, on what basis?

My point is that you are appealing to Baileys’ (in this case) authority NOT on account of his findings (which I don’t dispute), but on your presumption that his study design is reliable. Because there is no reason to be confident that the RCTs’ self-selected men are a good representation of men in the general population, the study is hopelessly flawed from the start in terms of producing reliable results.. You are making a highly dubious appeal to Bailey’s authority as a study designer, though not necessarily as a collector of information.
As an aside, this is also the man who asserted that circumcision is akin to a “surgical vaccine”, despite abundant evidence that it is no such thing. Common sense is an important virtue for a medical study designer.

Jake said: “Do you actually understand what the term [appeal to authority] means? Parents do have the legal authority – in most jurisdictions – to choose circumcision for their sons, but nowhere have I used that as a basis for arguing that they should.”

The fact that parents are granted legal authority to order the unnecessary circumcision of their sons is not in dispute. The point is whether they should have! I repeat:
“parents aren’t even close to knowing that circumcision is in their son’s best interests. They’re not informed authorities…” The appeal is gratuitous in the sense that the legal authority given to them to remove healthy tissue from boys, is (in my opinion) not justifiable. This is very much the topic of this debate. Indeed, the very legality of infant circumcision is being called into question.

Jake says: “my position is that parents should have the right to make any decisions for their children unless such a decision is clearly unreasonable (here I apply the “significant net harm” standard).”

You need to raise your sights a bit, I think! How about: “parents should have the right to authorise non-therapeutic surgery on their children, if there is medical consensus that the proposed surgery is in the best interest of the child”. Your qualifier of “unreasonable” is less scientific than my proposed “medical consensus”. However, if that’s too high for you to aim, then “where there is sound medical evidence” could be substituted. Do you see anything wrong with that?

To Jake:

I said: “I haven’t denied that Bailey has presented “evidence”. What I dispute is what he has presented evidence” OF! He may only have presented evidence that abnormal or impaired foreskin tends to be more conducive to HIV transmission than the circumcised penis is (which we already knew). Would you disagree with that assessment?’
Jake replied: “It wouldn’t make a lot of sense to me, I’m afraid.”

Aren’t you avoiding the question? The question is WHY anyone should have confidence in trial findings (the RCTs) which are based on self-selected participants? We would need to be confident that the trial subjects were a fair representation of the general African population for them to have general predictive value.

Think about it: the call goes out to recruit African men for circumcision. The operation is to be carried out under optimal medical conditions. The call will obviously attract men who want circumcision for whatever reason. Men with foreskin problems or complaints (e.g. phimosis, balanitis, foreskin infections, cuts, and tears) will probably be most eager to have the corrective surgery, and so their number will be proportionately higher in the trials than they are in the general population.
Based on evidence from adult circumcisions in the USA , for example, somewhere around 90% of U.S. men who get circumcised as adults do so for therapeutic reasons (most commonly phimosis).

Because the three African RCTs did not attempt to prevent such imbalance or disproportion from occurring (i.e prevent the trials from being over-represented by men with foreskin problems), we cannot be confident that the trial results are projectable with any predictive value onto the general population of men. Impaired foreskin is more conducive to HIV infection than normal foreskin, and that was known before the trials.

So, this is the scenario: on arriving at the trials, the male participants were randomized into Intervention and Control arms. Men assigned to the “Control” arm KEPT their defective foreskin (that’s to say, proportionately more men with defective foreskin present in the trials than in the general population). An equal number of men with defective foreskin found themselves assigned to the Intervention arm; but these men LOST their defective foreskin.
Effectively the trials come down to comparing men who have a higher proportion of foreskin problems (in the Control) relative to the general population, versus men free of foreskin (the Intervention). It is not hard to predict what the likely outcome of the unbalanced trial will be, but it will be very limited in value!

Randomised Controlled trials only come close to the “gold standard” if they can be randomised at the population level. These trials were not (admittedly, it would be hard to do so reliably).

Jake,

I found your reply very constructive this time.You can see that there is at least a major potential problem surrounding reliable representation of the subjects in the trials, and Bailey and Gray seem to be cognizant of this. Self-selection is probably potentially the most serious confounding factor of the trials. I admit that it would be very hard to eliminate.
It seems to have largely fallen under the radar of detection for most “intactivists”.

“Severe phimosis” may have been an accepted exclusion from the trials (as it should be), but there are degrees of phimosis, as you know. It is unlikely that many men with moderate foreskin problems were excluded. We just don’t know, but it’s important to know. Recognition of foreskin problems (and the subsequent exclusion of affected subjects) would depend on the medical team, their subjective criteria, and their attentiveness. We cannot know how this potential serious confounding factor (the most serious of all) could have affected the trials.

You say: “If the problems are bad enough for them to be eager for therapeutic circumcision, the men would probably have been excluded from the trial. ”

Really? How bad is “bad enough”? The men would have been eager to have corrective circumcision done in optimal conditions, and to have received payment for taking part as well. That’s a double incentive. Men don’t have to be on their knees from penile problems to go for corrective surgery.

So we have no way of quantifying how useful circumcision is to reduce HIV based on those trials. I would agree that the trials indicate at least SOME protective effect, if predicated on nothing else that that a significant minority of men DO have foreskin problems at some time, particularly men from third-world countries. The usefulness of circumcision on a population level probably relates to the frequency of foreskin problems. However, the risk of complications may be very much higher than the utilitarian benefit. The RCT study design lacks the subtlety to provide quantifiable information.

Most foreskin problems are correctable less invasively than by circumcision.

I recognize how many opponents deal with me. That doesn’t mean I have to engage in the same. There’s a difference between attacking the argument and attacking the man. Good people can have bad opinions. I can think of proven exemptions to the first part of that, but I’m not interested in guilt-by-association because a) it’s wrong and b) it could ensnare any of us at some unsuspecting point in the future. No, thanks. I don’t wish to be discredited for someone else’s sins, so I need my integrity.

As for the latter part, too late. My parents already mutilated me. I haven’t forgiven them yet, and I don’t expect to do so. I possess what feels like more than my fair share of anger about it, but the vitriol I have would be directed solely at them, were I interested in doing so. They are responsible for what they did to me. The larger societal push for circumcision that’s existed for over a century enabled them, of course, and I condemn that, too. It’s what I’m working to end to protect current and future children from the same violation. If I encounter a situation in which being an ass is helpful, I believe it can be an effective tool to do so. An example of someone who could do this is the late Christopher Hitchens when he spoke on this topic. But very few of us are a Hitchens. I am not. Being a poor facsimile is just a hack way to be a jerk. Ultimately, I’d rather win the debate than try to explain how superior I am, personally, for holding the superior position in the debate. Regardless of their being wrong on this issue, the person typing on the keyboard on the other side of these tubes is still a person first.

To Jake:

I said: “”Severe phimosis” may have been an accepted exclusion from the trials (as it should be), but there are degrees of phimosis, as you know. It is unlikely that many men with moderate foreskin problems were excluded. We just don’t know, but it’s important to know.”

Jake replied: “I wouldn’t entirely agree. We don’t have all the data, but we do have enough to place an upper limit on the number. In “Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya”, Kreiger et al state: “Of the 1,332 uncircumcised men, 9 (0.7%) had symptoms or signs of balanitis during follow-up, including 1 man who had both balanitis and phimosis. None of these findings were detected by physical examination among the circumcised men.”

That’s not a particularly relevant observation! We don’t know from when they had those conditions. I’m interested in the foreskin conditions they entered the trial with. Secondly, those are only two of the conditions I mentioned that could increase foreskin’s predisposition to contract HIV (and HPV). What about STDs and foreskin tears?

Note that many of the men were recruited form STD clinics (see “Study design and methods”). Foreskin impairment or abnormality in the uncircumcised participants might explain the extraordinary finding that so many of them experienced substantially IMPROVED sexual function during the course of the 2-year trial (the uncircumcsed men’s sexual dysfunction decreased from 25.9% down to 5.8% at month 24). This suggests that many may have entered the trial with foreskin problems, which were subsequently cleared up e.g. by the medical team. The study designers (Bailey, Krieger et al.) omit to discuss this apparent anomaly.

It is obvious that the trial designers haven’t taken this potentially huge confounding factor of foreskin abnormalities affectig the RCTs (all of them) seriously enough. I suggest (with some supporting evidence) that having a foreskin condition of whatever type is the primary motive for adult circumcision. Men with foreskin conditions would be over-represented (by self-selection) in all of the RCTs relative to the general population.

Of course, vested interest on the part of the trial designers (financial and professional) is that the trials should display a positive effect for circumcision both in terms of health and sexual function.

Exclusion criteria for participation in the trial of Krieger et al. “included foreskin covering less than half the glans, a condition that might unduly increase surgical risks, or a medical indication for circumcision.” Well, that’s not good enough! Recall that recruitment sources for the trial included STD clinics. We have no evidence of the number excluded from the trials on account of detected foreskin problems.

Conclusion: the RCTs are quite possibly little more than a medical hoax.

How many Wimps does it take to circumcise a baby?

Three — One to hold him down, one to cut his dick, and one to tell him lies.

(repost)

‘No, Jake, we have no data that allow us to know or put an upper bound on who entered the trials with foreskin conditions (which would have made the particiapnts more susceptible to HIV infection than men in the general population)’ — yes, we do: we know the number of men who had these conditions during the trials. Unless you wish to argue that these conditions spontaneously resolved as soon as they entered the trials, the number of men with these conditions will not have been greater when they entered the trials.

‘I think we can easily conclude this matter: Is there documented evidence that the trial participants had their penis medically examined before being included in the trials?’ — yes, there is. See the 2nd paragraph of the ‘Methods’ section of Bailey et al.

‘A medical check could be done in les than two minutes per man. A check is important, since the men were self-selected. At its simplest level, it would include a visual check for each man followed by random foreskin and penile swabs (e.g. for one in 5 men). The swabs would then undergo laboratory analysis for common STDs’ — it seems reasonable to suppose that the baseline STD statistics presented in Bailey’s Table 1 were gathered in this way, don’t you think?

‘The 0.7% of men who were identified as having phimosis and balanitis during follow-up(incidentally, a figure that looks surprisingly low!) does NOT represent the true level of those conditions.’ — here you’re grasping at straws again.

‘The only way to know is if the participants’ penises had been checked and any conditions documented. ‘ — you don’t think that it might have been noted during the genital examinations at months 1, 3, 6, 12, 18 and 24, then?

‘Do you really believe that Bailey knew the total number of participants affected by genital ulcerations? Just how?’ — his Table 1 presents baseline results for HSV-2, syphilis, T vaginalis, gonorrhoea, chlamydia, and chancroid.

‘We’re going round in circles here. Kindly present evidence that the penis of participants had been EXAMINED before those men were included in the trial.’ — as I already pointed out, it’s stated in paragraph 2 of the ‘methods’ section.

‘Provide documented evidence that only 0.7% of the participants had balanitis amd phimosis (no more appeals to authority please!)’ — I’m not making any appeals to authority. I’m just applying basic logic. To argue that significantly more men had balanitis or phimosis before the trial began implies that these conditions spontaneously resolved when they entered the trial. Not only is that unlikely but, if it occurred, it would eliminate the confounding that you believe occurred.

‘Is there documented evidence that all the Control men had their foreskins medically checked at those times?’ — it’s clearly stated that the men “underwent a genital examination” at these times, yes.

‘Re. Bailey’s RCT, regrettably, my subscription to the Lancet has expired, and I can’t access the information today or tomorrow. Would you like to email me a copy of Bailey’s trial (I don’t have it any more), or alternatively, copy and paste his Table 1with the information, including the methodology, on the forum so everyone can know what you refer to?’ — you don’t need a subscription. All you need to do is to complete the free registration.

As an intellectual, I’m also a pedant. I understand these gutter tactics. I’ve been both a direct and indirect recipient of such tactics. I don’t share your belief that they are acceptable or effective in a debate just because they are deployed by some advocates who I oppose.

To God says:
Circumcision is only one action mandated in your Torah. The Torah also commands to stone to death adulterers, Sabbath-breakers, idol worshipers and rebellious teenagers, amongst other offences (e.g. see Deut. 21) . If the Torah is God’s revealed word, will you also demand your religious right to carry out those other commandments too, or do you prefer to treat the Torah like a buffet, picking and choosing what you want from it?

Btw, you might want to read St. Paul’s letter to the Galatians some time. It shows that circumcision is not a Christan rite, and not only do you NOT need to circumcise any more, but you don’t need to continue to stone anyone to death either.

To God says:

Good question! I love buffets, especially as a metaphor for religion. That way, I can enjoy myself, and even without harming anyone else.

‘You don’t seem to grasp how bias or confounding of self-selection of participants could have impinged on the RCT findings. … It is reasonable to conjecture that men who are aware that they have foreskin problems are more likely to enrol in a circumcision programme or trial (performed under optimal medical conditions) than men who have normal and healthy foreskin.’ — I understand your theory. But, as I’ve shown, it’s not supported by the evidence. The evidence shows a fairly low prevalence of balanitis and phimosis — the two most common foreskin problems, and baseline STI rates that are more or less typical for the region. This is not what one would expect if your hypothesis were correct.

Now, my experience of discussing studies (any studies) is that one can always find an unanswerable question, something that wasn’t measured, and say this might be a cause of confounding. One has to judge how likely it is. In this instance, yes, it’s possible that men with minor foreskin cuts and tears were more likely to enrol in the studies. But for that hypothesis to be true, it would be necessary for men with these minor complaints to preferentially enrol in the studies, while (according to the available evidence) men with STIs, phimosis, and balanitis were no more likely to enrol. That seems implausible given the hypothesis that such men would be likely to enrol to obtain a free circumcision to treat a preexisting problem. Possible, I guess, but given the evidence one has to regard it as extremely unlikely.

To Jake:
You say that “the evidence shows a fairly low prevalence of balanitis and phimosis — the two most common foreskin problems, and baseline STI rates that are more or less typical for the region. This is not what one would expect if your hypothesis were correct.”

The evidence shows nothing of the sort! The only RCT to mention balanitis meaningfully is the one by Krieger et al. I cite their study:
“Of the 1,332 uncircumcised men, 9 (0.7%) had symptoms or signs of balanitis during follow-up, including 1 man who had both balanitis and phimosis.”
So there is no indication of the number of men who suffered from phimosis (only a combination of phimosis and balanitis). Moreover, there are varying degrees of both phimosis and balanitis, and there are other possible and common penile infections, which are not documented. Because Krieger was comparing sexual pleasure, he should have carefully documented the incidences of phimosis following sound protocol. Phimosis needs to be assessed by an expert. The question I have is why Krieger et al. failed to do so. Recall, they also recruited from STI clinics.

Without having evidence of a protocol (establishing methodology and the training of the investigators taking the genital exams) having been duly followed, we can’t be sure if we even know the total number of balanitis cases (it’s doubtful the figure is relaible). Regarding the RCT of Krieger et al., it is striking that the sexual pleasure of the uncircumcised men seems to have greatly improved in the course of the two-year trial, which would be consistent with the men having entered the trial with foreskin problems, including pain, and then having these problems resolved (medically) during the trials. Since the trial design withheld from us the necessary information to rationalise this “oddity”, we can’t be sure what it is based upon.

Re. Bailey’s RCT, the incidence of STIs is tabulated in Table 1 (as you said). STIs are not a very good indicator of motivation to elect circumcision, unless men are aware they are infected, since STIs can be latent. In Bailey’s RCT, as many as 28% of the participants had genital Herpes simplex 2 (a very high proportion, certainly much higher than usually found in the USA). It would be useful to know its incidence in the general population (in Kisumu).

In the RCT of Gray et al., pre-existent STIs are recorded, but only by the men’s self reporting, so they may be an under-estimate. In Table 2 (“enrolment characteristics”) of the RCT, it is recorded that in the year prior to the RCT, 7% of the participants reported having had genital ulcer disease, 3.5% reported having had urethral discharge, and 6% reported dysuria. So, in total, up to about 16.5% reported some penile problem that could be related to the foreskin (and those don’t indicate the total number of possible penile infections). Those figures are high enough to urge comparison with a random sample of the general male population. Moreover, a careful penile analysis (following documented protocol) of the RCT participants was in order. With regard to phimosis, all we know is that Gray et al. excluded from the trial men with “severe phimosis”. Gray doesn’t even inform us as to how many men were excluded for severe phimosis. So, Gray fails us by 1) not providing reliable documented evidence of the incidences of phimosis and STIs in his participants and 2) by not informing us of their incidences in the general population.

If just ONE of the RCTs had followed sound protocol, we would be able to make an assessment of the trials’ epidemiological usefulness.

‘I’m not sure where your last comment ended up.’ — yes, the blog software seems to place new comments at random, as far as I can tell. It’s a nuisance.

‘You ask “why document cases of phimosis only when they coincided with a case of balanitis?” But that’s the study’s flaw not mine’ — no, it’s a question: why would they do that? The most obvious answer is that there’s no reason to do so. Consequently, the most reasonable interpretation is that there was only one case of phimosis.

‘(NB. Doesn’t Brian Morris estimate that 10% of men have it? I estimate it at about 1%).’ — over a lifetime, yes, but one would expect a two-year sample to be much smaller.

‘Whether or not penile conditions are picked up and documented depends on the competence of the medical team and their protocol to follow. The men couldn’t ask or require to be circumcised, since that would defeat the object of the RCT (some men were excluded for doing that).’ — the participants are not responsible for the study. They could do whatever they liked, and it is reasonable to suppose that they took advantage of the free medical care given to them. The notion that they made a deliberate choice to enter the study in order to get treatment and then failed to mention medical problems during the period in which they received free medical care seems rather implausible.

‘You have eyes like a hawk, I think!’ — I wish! As things are, I’m just a pedant.

‘It’s useful to know (for HIV infection susceptibility), but since many men aren’t aware that they have HSV-2, it’s unlikely that its occurrence would motivate many men to be circumcised’ — I agree (though I have to wonder why you raised the issue).

‘How about documented foreskin cuts and tears, and foreskin inflammation and infections? How did they compare to the general population?’ — I don’t have that data. Given the failure of your hypothesis to predict the low prevalence of phimosis and balanitis, and the rates of STIs, I would be surprised if these were greater than in the general population of that area.

‘How about the most obvious answer being that Krieger et al. knew that a significant number of phimosis cases would blow his trial out of the water?’ — feel free to assume deviousness on the part of the authors, but I thought this was a serious conversation, and took part accordingly.

‘When you can produce clear evidence that there was just one case of phimosis among the thousands of men in Krieger’s trial, that may be your crowning achievement. There is nothing in Krieger’s study that indicates your view.’ — except a rational reading of what the paper actually said.

‘Even if they had mentioned it, there is no reason for you to believe that Krieger et al. would have documented it. Where’s the protocol you base your opinion on (what does it instruct investigators to document)? And why was there a need for the men to reveal more than they were asked to? ‘ — it clearly states that ‘All participants were provided free medical treatment throughout their 24 months of follow-up.’

‘The more men with foreskin problems entering the trials, the better the result for the study designers and investigators.’ — Sigh. If your argument is little more than an elaborate unsupported claim of deviousness on the part of the researchers, then let’s stop here. I find such ridiculous claims to be a tedious waste of time.

To Jake:
I asked you what the investigators’ protocol instructed them to document in the trials. You answered:
“it clearly states that ‘All participants were provided free medical treatment throughout their 24 months of follow-up.’ I’m afraid your answer doesn’t pertain to my question.
But not to worry! Your answer WOULD be in context with why the uncircumcised men may have experienced better sex as the RCT progressed, don’t you think?

the RCTs are a hoax, funny stuff!

your left hook knocked him for a loop. he’s out for the count.

‘First, ” a standardized medical history and physical examination, plus a personal interview to obtain sociodemographic and health information” doesn’t imply any genital examination!’ — as I’ve already pointed out, however, the study states elsewhere that a genital examination took place.

‘Furthermore, there is no proper documentation of genital conditions. If you are trying to convince yourself that the only genital conditions for the thousands of participants (many recruited from STD clinics) was just 7 cases of balanitis and one case of phimosis, then just remain in the cloud cuckoo land you inhabit.’ — a number of STIs were present as well, but there’s absolutely no evidence of the overinflated number of foreskin-related problems that you theorise. I wonder why you’re clinging on to this theory in the face of the evidence.

‘Because documented evidence is lacking. We need to have it’ — I agree, there are questions which cannot be answered with presently available information, but as I noted previously, it’s always possible to think of such questions with any study. Consequently we have to ask how likely is your hypothesis given the information which we have, and the information which we do have flatly contradicts it. Thus, the most sensible approach is to tentatively reject your hypothesis unless and until evidence comes along supporting it.

‘I apply my criticism to all the RCTs, not just Krieger’s.’ — while it’s possible that two RCTs attracted undue numbers of men with foreskin-related problems while the other did not, the recruitment methods were sufficiently similar that this seems unlikely. To speculate, without evidence, that there might have been some unknown and unexplained difference between the RCTs that would just happen to mean that the other two were susceptible to confounding, seems unlikely at best. There comes a point at which scepticism turns into irrationality, and I think that point has passed. Your arguments are analogous to that of a man determined to reject the laws of thermodynamics, who protests that they haven’t been shown to apply on a particular desert island in the South Pacific, and thus until we spend large amounts of money travelling to that location and performing expensive experiments there, the laws must be considered flawed. One is very much aware that, if such an experiment were to be conducted, he’d then select another desert island. And so on. One must draw sensible conclusions from the preponderance of evidence.

‘Whether or not there was an “overinflated number of foreskin-related problems” would also have to be determined on the basis of a non-selected, randomised Control taken from the general population.’ — the fact that there were so few cases of balanitis and phimosis, plus about the same number of STI cases as might be expected, counts against the idea.

‘Note also that the RCT results are not consistent with “within African country” observational (ecological) findings investigating the incidences of HIV infection in the circumcised and uncircumcised male populations’ — actually, quite the reverse is true. To use numbers from Weiss et al (Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis), which obtained data from a systematic review of observational studies in sub-Saharan Africa, 21 of 27 studies found results consistent with a protective effect. Had the situation been otherwise, of course, the RCTs would never have been conducted: it wouldn’t make any sense to perform a trial if most of the available evidence indicated that it wouldn’t work.

To Jake (1 of 2):

Jake says: “To speculate, without evidence, that there might have been some unknown and unexplained difference between the RCTs that would just happen to mean that the other two were susceptible to confounding, seems unlikely at best.”

Jake, if you think that “the other two” produced documented evidence of a comprehensive genital exam of the participants following protocol, you have singularly failed to come up with the evidence. Bailey et al. (the exception) documented their evidence of STI infections in the participants. However, there is no documentation of other genital abnormalities. So, importnat evidence is lacking, as I have to keep pointing out. I started this discussion itemising important conditions that should have been investigated. To repeat:
“Men with foreskin problems or complaints (e.g. phimosis, balanitis, foreskin infections, cuts, and tears) will probably be most eager to have the corrective surgery, and so their number will be proportionately higher in the trials than they are in the general population.”
So STIs don’t feature there (since many men don’t know they have them, and there is no proven causative relationship between STIs and foreskin). They are probably one of the least important motivators for elective circumcision. So, your argument is not persuasive that STI documentation provides evidence that the men’s self-selection did not introduce bias into the RCTs. It is important to document STIs, because common STDs can predispose to HIV infection.

NONE of the RCTs investigated any foreskin abnormalities following a protocol that you have evidence of! Protocol is fundamental to climical science. Even the Krieger et al. study doesn’t document balanitis or phimosis with evidence of any methodology followed. There is no indication of the total number of phimosis cases, just one case of “both balanitis and phimosis”. Who was responsible for documenting the 9 cases of balanitis – maybe a part-time nurse? Did the balanitis affect the glans or just the foreskin (or both)? Somehow, you interpret the term there was “one man with both balanitis and phimosis” as meaning that the total number of phimosis cases was just one. The evidence doesn’t imply that! I think Brian Morris would fall out of his chair if you were to convey to him evidence from the RCT that phimosis was that rare.

Jake, if you can’t understand the importance of PROTOCOL in clinical investigations, you’re already out of your depth.
Actually, I’ve been too charitable or generous with the RCTs! Self-selection bias in the RCTs may not just be caused by the presence of foreskin abnormalities. High-risk sexual behaviours in uncircumcised men led to believe that circumcision offers protection is another plausible self-selection bias, which might make them (even) less representative of the general population. So what was clearly needed was a random sample of the general population (say just 300-500 men) to undergo a full documented genital exam. Really, these men (or another random population sample) should be questioned on their sexuality according to established protocol too. The same procedure should be applied to RCT participants. Then there would have been a proper associated randomized population Control.

While on the subject of “Control”, it is worth pointing out that the RCTs lacked a proper Control; participants assigned to Control and Intervention arms are normally supposed to be given an identical set of instructions. The RCT Intervention arm absolutely had to abstain from unprotected sex until wound healing. Moreover, ethical principles could bias support in favour of the circumcised trial men (who were genitally wounded). All these factors combine to make a randomised population Control essential in the interests of reliability and predictability.

Jake said: “Your arguments are analogous to that of a man determined to reject the laws of thermodynamics, who protests that they haven’t been shown to apply on a particular desert island..”
Thank you for the jaded analogy, but your description reveals that you confuse established proof of scientific laws with unproven, highly conflicting, and shaky evidence! As for your accusation that I think laws may change from place to place, let me give you some food for thought then: Within the United States, Blacks have about the same circumcision rate as Whites (several investigations indicate this). But Blacks have a far higher rate of heterosexually transmitted HIV. Is that in line with your scientific model?

NB. 2 of 2 to follow!

Fake says to psandz:
June 7, 2012 at 8:36 pm
I said there’s little purpose in wasting further time on a debate that’s clearly going around in circles.

REPLY: It’s going in circles because you’re running around in circles like a chicken with its ____ cut off.

Replying to Tony, June 2, 2012 at 2:16 pm:

‘You’ve said your position is that non-therapeutic circumcision is not a net harm. You hadn’t previously said that your standard revolves around “significant net harm” rather than “no net harm”, that I’m aware of’ — I think you may have misunderstood, Tony. Both statements are correct. My ethical standard is that parental choices are acceptable if they would not result in non-trivial net harm. (Trivial net harms, such as giving a child a poor but not actually dangerous diet, don’t warrant intervention by society, in my opinion.) My view is that circumcision is not a net harm. Since it’s not a net harm, it’s obviously not a significant net harm.

‘That was my initial reaction. But I stopped and thought and realized you hadn’t said that’ — okay. You seemed to think there was a contradiction of some kind. I apologise for misunderstanding your reaction as possible misunderstanding (if you see what I mean).

‘But it’s not a good position.’ — I wouldn’t expect you to agree with it. You and I clearly have radically different notions of what is ethical. You place a huge amount of emphasis on autonomy, and you’re willing to sacrifice what may be best in the average case; I’m more interested in what’s best on average. You view subjectivity as an argument against making decisions; I see nothing wrong with forming a model of subjective values and reasoning from that. You frequently talk about principles that apply to genital cutting; I generally talk about principles with a much broader scope. Let’s be frank: we think very differently.

‘Significant is a subjective term. Non-trivial is a subjective term. They fail to clarify’ — I agree: they’re not perfect. But if you average subjective views, the result is usually good enough, and for better or worse, lots of laws in democracies are built on the average of subjective views. When a net harm is really significant, most people tend to agree on that. Vanishingly few people would agree, for example, with chopping off a child’s legs in the absence of immediate need.

You all are too kind to give the Lying Waskell the benefit of the doubt. There’s not a sincere bone in the Waskell’s body.

Your idealism is admirable; in a street fight, I kick the bastards in the nuts.

Just go to law school, and get it out of your system.
Do you talk like that to the people you work with? Your love? Your family? There are so many disclaimers and caveats, it gives me a headache. It doesn’t benefit any human communication.

“that’s the fallacy of appeal to authority”
Sort of like when you lean on those African studies like a pair of artificial limbs?
Sort of like when you say, “The great and powerful WHO has spoken”?
Sort of like when you present Morris as evidence?

“Dr. Waskell’s Cure-All for the Foreskin–Relieves All Diseases Known to Man”

Replying to Hugh7, May 31, 2012 at 11:07 pm:

‘I cut and pasted the message from the Circlist Google disussion group before Google closed it and it moved to http://groups.yahoo.com/group/Inter-Circ/‘ — I can’t comment on that, but I was able to confirm that, between about 2007 and 2010, the CircList website contained those words. (See my post of May 31, 2012 at 10:41 am). Incidentally, you’re incorrect in stating that CircList moved to Inter-Circ. They’re separate. CircList closed down in June 2010. Inter-Circ was created five years previously, as you can see from the link you provided.

‘I didn’t say “every part”, but “a uniquely mobile, highly innervated structure near the end” – each element of which strongly suggests an erogenous function.’ — not necessarily, no. As an extreme counterexample, the eyeball is highly innervated, but it isn’t particularly erogenous (at least to the touch). The foreskin does have a dense concentration of Meissner’s corpuscles at the tip, but so do the eyelids, to allow them to rapidly detect foreign bodies posing a threat and protect the body before damage is done. It seems perfectly plausible that those of the foreskin have a similar role: to provide an early warning system of damage from twigs and long grasses before humans wore clothing.

‘Circlist is still going at http://www.circlist.com/‘ — that’s the CircList web site, not the CircList discussion group (which closed in 2010).

‘If CircList was distinct, few woud have noticed, so intimately were they connected, and Inter-Circ seamlessly took its place as the fetishist arm.’ — nonsense.

‘Would Jakew’s foreskin blink when dust got under it (until he had it cut off)?’ — of course not.

‘On the “twigs and long grasses before humans wore clothing”, he’s channelling the 19th C lung-doctor Paul Remondino: http://www.circumstitions.com/Remondino.html Not the most reliable or desirable source: http://www.circumstitions.com/Remondino.html#rape‘ — I’m afraid your argument is incomprehensible. How am I “channelling”?

Jake says, in reply to Hugh: “You’ve noted that there are vague similarities between Remondino’s argument that “In those days…”

It seems likely that pro-circumcision advocates like Morris and Schoen have bandied about the same gratuitous nonsense that arose from the likes of Remondino.
Calling it “channelled” is Hugh’s tongue in cheek, which I found quie amusing (to be frank), and well-deserved too, since their analysis is so banal and baseless.

“what was God/evolution thinking?” and why has it continued for 120 million years on almost every mammal?
We don’t circumcise dogs or cats or girls. Why would we circumcise boys? Why are there ethical implications with pets and girls, but not boys? Perhaps that is a better question.

‘I can work within your incorrect context of Monopoly money. Assume you didn’t want to dispose of it. You want to play Monopoly tonight with a friend. You discover someone has taken all the money from the game. Are you harmed?’ — yes, but the harm is because of the consequences (reduced entertainment potential), not an inherent property of loss as you seemed to be arguing previously.

‘The circumstance is that you’re begging the questions you want to answer by building the bizarre scenarios necessary to extrapolate back from your conclusion.’ — which is exactly what you’re doing, by deliberately choosing examples of loss that also happen to involve associated reduction in functionality.

‘I can narrow this down to the relevant question: You accept as fact that circumcision creates a wound. Is a wound evidence of a harm to the individual from circumcision? (i.e. a harm, not net harm)’ — no, I don’t think it’s inherently harmful.

Jake wrote: “no, it is removal of skin”

And that is harm by any definition. At birth, we have exactly the right amount of skin, not too tight and not too loose. The genitalia is no exception. Removal of that skin is harm because it leaves us with a deficit of skin.

“no, it is a scar.”

A scar is evidence of past injury or harm depending on whether it was accidental or maleviolent. Circumcision is maleviolent.

“shall we agree that they are indisputable consequences?”

Yes, indeed indisputable. Consequences? Are you trying to play word games?

“when you said ‘Risks of further complications are inherent in the surgery. It is harmful’, you seemed to be arguing that, because there was a risk of complications, it is harmful.”

The risk is a warning of inherent harm whether it happens or not. Since the genitals are reduced in all cases, there is harm in all cases.

“I do not draw that conclusion for myself, because I value the various aspects differently (i.e. they are subjective) than you do.”

Yes, you chose circumcision for yourself

Tony, since there is no sound evidence at all that non-therapeutic circumcision is associated with net health benefit, your position is correct. Any of the alleged benefits of circumcision can be acquired simply and less invasively than by circumcision. The onus is therefore on the medical profession to justify why the removal of healthy foreskin from a minor is NOT harmful. Circumcision inflicts injury. Jake’s position is untenable.
The Hippocratic oath says: “First, do no harm”. Since this is the first principle, circumcisers should first have evidence that circumcsion is NOT harmful, or that it carries benefit that outweighs the painful injury that they inflict. Without this evidence, circumcision has no more medical standing than a ritual. Parents are not in a position of knowledge to order doctors to make unnecessary medical interventions, since there is no medical consensus that the intervention is beneficial.
The same criterion should be applied to removal of healthy foreskin as to the removal of any other healthy tissue. And of course the law should protect boys equally to girls.

So even though the American Cancer Society does not recommend circumcision to prevent penile cancer, you are all for it, for cancer prevention, even though it is almost certainly preventable with Gardasil or another HPV vaccine?
Why?
No one is talking about results of genital surgery, when discussing the sexism inherent. They are talking about ethics.
Ethically, it is the same issue. Do you have difficulty grasping that the owner of the body should ethically be the one who decides which healthy body parts to keep?

How would you feel, if someone strapped you down, and took a random body part against your will?
Can you understand it from that point of view?
Can you understand how, because of your singular views, this might not be a problem for you personally, but may be a problem for a large number of other people?
Can you understand that for most people, this is not considered ethical behavior, because the person having the part removed cannot consent?

To reply to eshu21’s comment of May 26, 2012 at 10:05 pm:

‘Exactly where do these numbers you propose come from? Are the numbers of circumcision deaths and penile cancer reflected in non-circumcising countries such as Great Britain and Australia? Where are the data to support your “Now, in the uncircumcised group, we should expect twice the number of penile cancer cases”’ — it was a conservative estimate that I made some time ago. The best evidence is: Larke NL, Thomas SL, dos Santos Silva I, Weiss HA. Male circumcision and penile cancer: a systematic review and meta-analysis. Cancer Causes Control. 2011 Aug;22(8):1097-110

‘Further, your statement “For example, HPV (a sexually transmitted infection) is a risk factor for penile cancer, and the US has relatively poor sex education and consequent levels of condom usage than many European countries, which would suggest greater risk of HPV.” is certainly not proved; please see Male Circumcision and Serologically Determined Human Papillomavirus Infection in a Birth Cohort, Nigel Dickson, Department of Preventive and Social Medicine, University of Otago Medical School, P.O. Box 913, Dunedin, New Zealand’ — Sorry, I don’t understand why you’re citing this study. It’s not a study of penile cancer, so it cannot be relevant to my statement that HPV is a risk factor for penile cancer. It’s a study of a New Zealand cohort, so it doesn’t establish anything about US sex education or condom usage.

In reply to James Mac May 27 2012 @ 07:43

It’s especially peculiar considering there is a very good vaccine available for both boys and girls but yet here we see the promotion of a potential HPV reduction as one of the important ‘benefits’. This is part in parcel with circumcision promotion and promoters. Purported benefits can almost always be realized with more efficient, less invasive, and/or safer prophylaxis or treatments, to the promoters thought that doesn’t matter.

Frank:
The male HPV vaccine was recommended by the CDC routinely for all boys (aged 11 to 12) and young men in October 2011. Circumcision is redundant.

I will read through the study you cite as the basis for your figures Jake, but note that it is a meta-analysis of other studies, each of which needs to be evaluated on its own merits. Some older studies of penile cancer in the past have been slipshod, not taking into account factors such as the relative ages of the participants, and other risk factors such as smoking. It is obvious why I cite the New Zealand study; Dickson was clearly demonstrating no significantly greater likelihood of HPV among intact men (you declared HPV to be a risk factor for penile cancer). Therefore similar rates of HPV (if the association is true) between cut and intact men would be the basis for non-circumcising Europe’s equivalent rates of penile cancer to circumcising USA. Your statement was implying that America would have far lower rates of penile cancer (due to widespread circumcision), if only its health care system was better. Dickson’s study makes it clear there may be other explanations.

Jake Wrote: “it was a conservative estimate that I made some time ago.”

And you, a computer programmer has the qualifications to make medical judgments? ? ?

” is certainly not proved”

How is it that 80% of sexually active American males are circumcised and also an estimated 70% have been infected with HPV? That clearly doesn’t speak for the efficacy of male circumcision as an effective intervention.

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‘It’s curious that I’ve never known anyone who has known a man who died of penile cancer. I’ve conducted public polls with this question and have never found a single one.’ — I can’t comment on the methodology of polls you may or may not have performed.

‘But, you make the jump that penile cancer is fatal in your calculations’ — I’ve assumed that it’s fatal in 5% of cases. The American Cancer Society give 5-year survival rates from 11 to 85%, depending on the nature of the cancer (http://www.cancer.org/Cancer/PenileCancer/DetailedGuide/penile-cancer-survival-rates)

‘That figure is not a “given.” Four separate studies by four separate authors in four distinct time frames quantify the death rate at 1:7,000 or 7+ times your claim.’ — and, as I’ve pointed out, these are dubious estimates.

‘In medical research, 3 studies that find essentially the same thing establish the research as fact’ — what utter nonsense!

‘Do you have 3 (or more) research projects that back your claim of 1:500,000?’ — These are large series showing 1 death in 566,000 circumcisions (Speert), no deaths in 100,000 boys (Wiswell), and no deaths in 500,000 circumcisions.

This is a reply to Frank OHara’s comment of May 27, 2012 at 1:32 am:

‘In 1979, Robert Leon Baker found that 229 infants died as a result of their circumcisions’ — this was just an estimate based on the “16 per 90,000” figure he listed. While he doesn’t cite a source for that figure, it’s obviously taken from Gairdner’s “Fate of the Foreskin”, which was taken from older children in Britain and hence was inflated due to use of general anaesthesia.

‘Ten years later, another study was done that found the same number of deaths.’ — two estimates using the same source data will produce the same answer.

‘Then in 1998, Bollinger again found about the same number of deaths’ — and he calculated on the assumption that differences between male and female infant mortality rates were due to circumcision!

This is a reply to James Mac’s comment dated May 27, 2012 at 8:02 am:

‘Jake, in your own mind, at what point would the number of infant deaths at the hands of circumcisers reach a morally-unacceptable threshold? You’re clearly comfortable with a small number of deaths each year, but at what number would it become unacceptable?’ — difficult question. As a minimum, there would have to be a net increase in deaths for it to be unacceptable; that is, the number of deaths caused by circumcision would have to be at least equal to the number of deaths prevented by circumcision. I might be willing to allow the figure to climb very slightly higher than that, but I’d have to give that further thought.

‘I say zero boys harmed and zero boys killed due to unnecessary circumcision surgery is the only acceptable number.’ — sometimes accepting a small risk in the immediate term reduces the overall risk in the longer term.

Even if circumcision offers protection against HIV (or other STDs) in Africa, this finding alone does not justify promoting male circumcision in other countries, such as developed ones. National health policy or strategy is ALWAYS formuated on the basis of internal evidence of efficacy, i.e. within the country targeted. At most, the findings from the three African RCTs could be useful if they corroborated national evidence of circumcision efficacy.

Despite over 30 years of the HIV pandemic, there is no resonable evidence that circumcision offers any protection against STDs in any developed nation. In European countries, the men are at least 90% uncircumcised, promiscuous, and with a cavalier attitude to sexual protection, yet HIV has spread VERY slowly in their indigenous heterosexual populations. Most cases of heterossexual HIV infection in Europe are seen in immigrants from the Sub-Sahara (see online “WHO HIV/AIDs Europe.pdf”, which details how HIV has spread in Europe).

Furthermore, the fact that there is so much inconsistency in findings even within Africa as to the usefulness of circumcision must lead us to treat the three RCTs with some skepticism. I refer to the USAID report of 2009 (“Levels and spread of HIV”), alluded to above, which investigated 18 Sub-Saharan (or third-world) countries for HIV incidence against male circumcision status. USAID researchers found that in TEN of those countries, the CIRCUMCISED men actually had more HIV than the uncircumcised. That many “anomalies” would surely not be expected if circumcision offered reasonable protection. It certainly needs to be clarified! Researcher Michel Garenne (Pasteur Institute) also found no good evidence for a protective effect of circumcision on researching data within thirteen African countries in 2008. This type of internal research is much more reliable than cross-country analyses (which regrettably constitute the bulk of the studies used to promote circumcision), and it usually yields no evidence of a protective effect for circumcision.

As I have pointed out in my comment yesterday, the design of the RCTs lacks the robustness required to produce convincing, quantifiable evidence of circumcision’s efficacy, since the participants in the trials may not be representative of the men in the general population. The RCTs should be regarded as producing potentially LESS reliable evidence than “ecological” research conducted within African countries on HIV rates vs. circumcision status.

Jake wrote: “this was just an estimate based on the “16 per 90,000″ figure he listed. While he doesn’t cite a source for that figure, it’s obviously taken from Gairdner’s “Fate of the Foreskin”, which was taken from older children in Britain and hence was inflated due to use of general anaesthesia.”

Your reply sounds like speculation to me. Do you have a source?

” two estimates using the same source data will produce the same answer.”

Again, sounds like speculation. Do you have any information that shows the same source was used? Both studies claimed to have been done 10 years apart.

” and he calculated on the assumption that differences between male and female infant mortality rates were due to circumcision!”

No, I happen to know Bollinger and am in regular contact with him. Bollinger is in the insurance industry as a consultant and therefore has access to medical records. He used these medical records and his access to them. This is his profession, the way he earns his living. There were no assumptions in his research. He conducted his research the same way he would conduct research for his insurance company clients. They don’t pay for speculation, assumptions or incorrect information. His information is as correct as humanly possible.

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“No, what you are espousing is taken from Edgar Schoen whose intent is to scare.” — it’s actually taken from Cold, Storms, and Van Howe’s (all of whom are known for their opposition to circumcision) “Carcinoma in situ of the penis in a 76-year-old circumcised man” (J Fam Pract 1997;44:407-10).

‘You only have to look at the number of cases in The US to confirm that 1:1,437 is incorrect. It’s just simple math, Jake. You can do that, can’t you?’ — which figures did you have in mind?

‘Your figure is taken from either The AMA or AAP who have a vested interest in hiding the deaths.’ — AAFP.

‘Four separate studies by four separate authors have established the actual death rate at approximaately 1 per 7,000 procedures.’ — as I’ve already explained, they’re poor estimates, often based on the same source data.

‘What do you find insulting about it? I think it is true in both cases. I don’t find it at all insulting. To me, it looks like human nature.’ — I find it insulting because there is more to my world than my own personal experiences. I’m an intelligent person, capable of reading and improving my understanding, and forming opinions about other people in different environments.

‘Downplaying the brochure you told me you co-wrote for the Gilgal Society would be an instance of either a lie, or so close it doesn’t make a difference.’ — I haven’t co-written anything for the Gilgal Society, Tom. I know the brochure you mean. We’ve discussed this before, and I told you that I provided some feedback to Prof Morris on a draft of the text. As for “downplaying” this, I genuinely don’t know what you mean.

‘Denying a fixation, when someone belongs to as many circumcision-related groups, and posts in as many circumcision-related forums as you, strikes me as being less than truthful.’ — well, I just searched Google for ‘(“tom tobin” OR “thomas tobin”) circumcision’, it returned 6,010 results. Then I searched for ‘”jake waskett” circumcision’, and it returned 6,420. So I guess we post about as much as each other. Do you regard yourself as having a fixation?

‘Presenting yourself as neutral in discussions in parenting forums, and then relating every possible (and some impossible) benefit of circumcision, while denying any downside, seems less than honest.’ — That’s incredibly unfair, Tom. I don’t present myself as “neutral”, but I do present myself as pro-parental choice. That’s the opinion I hold. And since I generally find myself arguing with anti-circumcision activists, is it any wonder that my arguments reflect that?

‘The way you emphasize the benefits of circumcision, and dismiss any ill effects as rarely occurring is a lie. The quick increase in the post-circumcision surgery rate in the US tells me that.’ — sorry, I don’t understand what you’re saying. Could you rephrase?

‘Why focus on the negative? We are all made of good and evil. I mentioned a lot of fine qualities in you, as well.’ — you’re right: you did say some positive things, and thank you.

Thank you for your candid response, Tom.

I don’t see myself as having a fixation with circumcision. It’s a hobby, and a good cause (I know you’ll want to argue with that, but please just accept that I believe it, okay?). That said, there were certainly times in the past when I’ve felt that I’m spending more time on it than is good for me, that I was continuing a debate long after it ceased to be enjoyable to do so. But I’m much less active in debate forums these days, and so that’s much less common. (I initially had an idealistic and rather naive belief that I could persuade anti-circs of their mistaken beliefs, but eventually I came to the realisation that I can’t change the world.)

I also find the academic side interesting. I like intellectual challenges. I’m a nerd: I’m the type of person who spends weeks working diligently on a program without expectation of financial reward, because it’s interesting. I find researching circumcision interesting, too (and it often involves similar skills, such as data organisation, modelling, and mathematical analysis). Put me in a medical library with a printout of some refs that I want to look up, and I have a great time. And I get just as much enjoyment from analysing the information. It’s tiring, and hard work, but it’s fun.

Spookily, Tom, we seem to have an interest in music in common, too: I play electric blues guitar. (Badly, I’ll admit.) Much as I’ve tried, I can’t comprehend music theory, though!