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

By Brian D. Earp

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

1. Experimental doubts 

A handful of circumcision advocates have recently begun haranguing the global health community to adopt widespread foreskin-removal as a way to fight AIDS. Their recommendations follow the publication of three [1] randomized controlled trials (RCTs) conducted in Africa between 2005 and 2007.

These studies have generated a lot of media attention. In part this is because they claim to show that circumcision reduces HIV transmission by about 60%, a figure that (interpreted out of context) is ripe for misunderstanding, as we’ll see. Nevertheless, as one editorial [2] concluded: “The proven efficacy of MC [male circumcision] and its high cost-effectiveness in the face of a persistent heterosexual HIV epidemic argues overwhelmingly for its immediate and rapid adoption.”

Well, hold your horses. The “randomized controlled trials” upon which these recommendations are based are not without their flaws. Their data have been harnessed to support public health recommendations on a massive scale whose implementation, it has been argued, may have the opposite of the claimed effect, with fatal consequences. As Gregory Boyle and George Hill explain in their extensive analysis of the RCTs:

While the “gold standard” for medical trials is the randomised, double-blind, placebo-controlled trial, the African trials suffered [a number of serious problems] including problematic randomisation and selection bias, inadequate blinding, lack of placebo-control (male circumcision could not be concealed), inadequate equipoise, experimenter bias, attrition (673 drop-outs in female-to-male trials), not investigating male circumcision as a vector for HIV transmission, not investigating non-sexual HIV transmission, as well as lead-time bias, supportive bias (circumcised men received additional counselling sessions), participant expectation bias, and time-out discrepancy (restraint from sexual activity only by circumcised men).

That’s a whole laundry list of issues, so let me highlight a few of the more substantial. First, consider the “lack of placebo control.” What does that mean? Normally, when you’re trying to determine whether some medical intervention has a disease-fighting effect specific to its own (hypothesized) mechanisms—and over and above the placebo baseline—you have to have a control group. That group gets a dummy intervention, and nobody is supposed to know which participants were exposed to the actual treatment until after the results are in.

After all, if someone knows (or thinks) that they’re getting a great big helping of medicine, they might act in various ways—whether consciously or unconsciously—that have the effect of generating positive health outcomes but which have nothing to do with the intervention itself. In the case of circumcision, however, there’s no way not to know if you’ve received the “medicine”—you have to go through a surgery and then you don’t have a foreskin anymore—so this basic condition of a true clinical trial is violated in the first instance.

But that’s just the tip of the iceberg. As Boyle and Hill point out, the men who were circumcised got additional counseling about safe sex practices compared to the control group, and then they had to refrain from having sex altogether for the simple reason that their lacerated penises had to be wrapped in bandages until their wounds healed – leading to what Boyle and Hill refer to as “time-out discrepancy” in the quote above. By contrast, the non-circumcised men got to keep having sex during the full two month period during which the treatment group was in recovery mode. Then (due to a statistically significant effect having been detected) the trials were stopped early — which tends to lead to an overestimation the true effect size of the treatment. These issues may pose problems for the scientific credibility of the studies. Taken together with the other flaws, here is why:

Let us assume for a second that the circumcised men really did end up getting infected with HIV at a lower rate than the control-group men who were left intact—even though, as we will see in a moment, it would be premature to be convinced that this is so. Why might that outcome have happened?

If you answered, “Because those men knew they were in the treatment group in the first place, had less sex over the duration of the study (because they had bandaged, wounded penises for much of it), and had safer sex when they had it (because they received free condoms and special counseling from the doctors), thereby reducing their overall exposure to HIV compared to the control group” then you are on the right track.

2. Misleading results

Experimental design issues notwithstanding, it is tempting to think that the 60% figure that’s being thrown around in media reports is just too large a percentage to ignore–even if the studies had some flaws. But do you know what the “60%” statistic is actually referring to? Boyle and Hill explain:

What does the frequently cited “60% relative reduction” in HIV infections actually mean? Across all three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV-positive, so the absolute decrease in HIV infection was only 1.31%.

That’s right: 60% is the relative reduction in infection rates, comparing two very small percentages: a bit of arithmetic that generates a big-seeming number, yet one which–without also reporting the absolute risk reduction alongside–arguably misrepresents the results of the study. The absolute decrease in HIV infection between the treatment and control groups in these experiments was just 1.31%, which is likely to have no appreciable effect at the demographic level.

3. Questionable public health recommendations

So far we have been discussing problems with the experiments themselves—what’s called “internal validity” in technical terms. I really want you to read the Boyle and Hill paper here, because they go into painstaking detail about each of a long parade of flaws I can’t hope to cover in one blog post. But let’s switch gears now and talk about the flip-side of things, or what’s called “external validity” – that is, problems with taking what you’ve (supposedly) found in a (relatively) controlled setting like an experiment and applying it to the chaotic mess that is the real world.

Lawrence Green and his colleagues published an important article on just this topic as it relates to “the circumcision solution” in the American Journal of Preventative Medicine. “Effectiveness in real-world settings,” they sensibly point out, “rarely achieves the efficacy levels found in controlled trials, making predictions of subsequent cost-effectiveness and population-health benefits less reliable.”

Some major issues with trying to roll-out circumcision in particular include the fact that the RCT participants—who were not representative of the general population to begin with—had (1) continuous counseling and yearlong medical care, as well as (2) frequent monitoring for infection, and (3) surgeries performed in highly sanitary conditions by trained, Western doctors. All of which would be difficult to replicate at a larger scale in the parts of the world suffering from the worst of the AIDS epidemic. So what should we conclude? Green et al. get it right: “Before circumcising millions of men in regions with high prevalences of HIV infection, it is important to consider alternatives. A comparison of male circumcision to condom use concluded that supplying free condoms is 95 times more cost effective.”

Not only more cost effective, of course but also more effective—period—in slowing the spread of HIV. Condoms are cheap, easy to distribute, do not require the surgical removal of healthy genital tissue, and—yes—are much more effective at preventing infections. Compare. Condoms: 80% minimum reduction in HIV infection, for both males and females [3]. Circumcision: 60% relative risk reduction (and 1.3% absolute reduction), of female-to-male transmission only, according to the most optimistic presentation of data from three contested studies. Of course, one could reasonably argue that men with a high risk HIV infection could use both strategies to boost their protection–wearing condoms and getting circumcised–but the threat of behavioral disinhibition makes this argument a bit more tricky than it appears at first. I explain why in the following section.

4. This is serious business

The most troubling part about all of this is not just that the science behind “the circumcision solution” is being promoted with so little caution or debate, but that the actual implementation of these recommendations may very well lead to more HIV infections, not less. The big idea here is “risk compensation” – the subject of an interesting paper by Robert Van Howe and Michelle Storms.

Risk compensation occurs when people believe they have been provided additional protection (wearing safety belts) [such that] they will engage in higher risk behavior (driving faster). As a consequence of the increase in higher risk behavior, the number of targeted events (traffic fatalities) either remains unchanged or [actually] increases.

They argue:

Risk compensation will accompany the circumcision solution in Africa. Circumcision has been promoted as a natural condom, and African men have reported having undergone circumcision in order not to have to continually use condoms. Such a message has been adopted by public health researchers. A recent South African study assessing determinants of demand for circumcision listed “It means that men don’t have [to] use a condom” as a circumcision advantage in the materials they presented to the men they surveyed. [Yet] if circumcision results in lower condom use, the number of HIV infections will increase. [Citations can be found in the original paper.]

In Uganda, as Boyle and Hill uncovered, the Kampala Monitor reported men as saying, “I have heard that if you get circumcised, you cannot catch HIV/AIDS. I don’t have to use a condom.” Commenting on this problem, a Brazilian Health Ministry official stated: “[T]he WHO [World Health Organization] and UN HIV/AIDS program … gives a message of false protection because men might think that being circumcised means that they can have sex without condoms without any risk, which is untrue.”

Van Howe and Storms spell this all out:

How rational is it to tell men that they must be circumcised to prevent HIV, but after circumcision they still need to use a condom to be protected from sexually transmitted HIV? Condoms provide near complete protection, so why would additional protection be needed? It is not hard to see that circumcision is either inadequate (otherwise there would be no need for the continued use of condoms) or redundant (as condoms provide nearly complete protection).

The argument that men don’t want to use condoms needs to be addressed with more attractive condom options and further education: [they need to be told] that sex without a condom and without a foreskin is potentially fatal, while sex with a condom and a foreskin is safe. No nuance is needed. Offering less effective alternatives can only lead to higher rates of infection.

 Their conclusion?

Rather than wasting resources on circumcision, which is less effective, more expensive, and more invasive, focusing on iatrogenic sources and secondary prevention should be the priority, since it provides the most impact for the resources expended.

That is my conclusion as well. In this article I have focused on just the science behind—and claimed public health benefits of—“the circumcision solution” and shown how contentious they are. I’ve completely ignored the attendant ethical issues, though I discuss these elsewhere.

The studies we’ve looked at, claiming to show a benefit of circumcision in reducing female-to-male heterosexual transmission of HIV, are a lot less bulletproof than their proponents make out; and any real-world roll-out of their procedures would be very difficult to achieve safely and effectively. One possible outcome is that HIV infections would actually increase—both through the circumcision surgeries themselves performed in unsanitary conditions, and through the mechanism of risk compensation and other complicating factors of real life. The “circumcision solution” is no solution at all. It is a misdirection of resources and may be a threat to public health.

 

——————————————————————–

NOTE: UPDATE AS OF MARCH 4, 2014: Please note that the paper by Boyle and Hill, of which this post was meant to be a reader-friendly summary, has been critiqued by Wamai, Morris, and Waskett et al., in a paper published subsequently in the same journal. I encourage readers to take a look at the critique published by these authors, so that they can evaluate the arguments going back and forth between opponents and proponents of (adult) male circumcision. I would note that both Morris and Waskett (the second and third authors of the critique) have been recently criticized (here and here) for misrepresenting the scientific literature on circumcision (which is a similar claim they raise against Boyle and Hill) so this is a contentious area indeed. Please also see this critique of my post by Nathan Geffen, to whom I am most grateful for drawing my attention to various counter-arguments that have been raised against the contentions of Boyle & Hill. If readers are aware of any cogent replies to these counter-arguments that I should take note of, please do let me know.

WORKS REFERENCED (RECOMMENDED READING):

Boyle, G. J. and Hill, G. (2011). Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. Journal of Law and Medicine. Available as a PDF here.

Green et al. (2010). Male circumcision and HIV prevention: Insufficient evidence and neglected external validity. American Journal of Preventative Medicine. Available as a PDF here.

Van Howe, R. S. and Storms, M. (2011). How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa. Available as a PDF here. 

ADDITIONAL RESOURCES:

Darby, R. and Van Howe, R. (2011). Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. Australian and New Zealand Journal of Public Health. Available here.

Green, L., McAllister, R., Peterson, K., and Travis, J. (2008). Male circumcision is not the HIV “vaccine” we have been waiting for. Future Medicine. Available as a PDF here. A short, readable editorial.

I also recommend Zabus, Chantal (Ed.) (2008). Fearful symmetries: Essays and testimonies around excision and circumcision. Available from Amazon.com here.


[1] Auvert B, Taljaard D, Lagarde E et al, “Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial” (2005) 2(11) PLoS Med e298; Bailey RC, Moses S, Parker CB et al, “Male Circumcision for HIV Prevention in Young Men in Kisumu, Kenya: A Randomised Controlled Trial” (2007) 369(9562) Lancet 643; Gray RH, Kigozi G, Serwadda D et al, “Male Circumcision for HIV Prevention in Men in Rakai, Uganda: A Randomised Trial” (2007) 369(9562) Lancet 657.

[2] Halperin DT, Wamai RG, Weiss HA, et al. Male circumcision is an effıcacious, lasting and cost-effective strategy for combating HIV in high-prevalence heterosexual epidemics: the time has come to stop debating the basic science. Future HIV Ther 2008;2(5):399 – 405.

[3] Weller SC and Davis-Beaty K, “Condom Effectiveness in Reducing Heterosexual HIV Transmission” (2002) 1 Cochrane Database of Systematic Reviews Art No CD003255.

 

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

  • law elly says:

    A resourceful, and scholarly piece of work.

  • Ronald Goldman, Ph.D. says:

    Research shows that circumcision causes physical, sexual, and psychological harm. This harm is ignored by circumcision advocates. Please see http://www.circumcision.org/hiv.htm for more information and links to literature.

  • Layla says:

    Excellent piece. I wish your points would get some major mainstream media coverage.
    WHO, Bill Gates, Bono and all the other African circumcision supporters/pushers need to read this.

  • Ron Low says:

    One thing is very clear. Forcible foreskin amputation is unethical.

    For any potentially harmful medical intervention, proxy consent is only valid if waiting for the patient’s own rational informed consent would lead to further harm. Would anyone argue there is an age when someone can consent to sexual activity, but at which one is not able to weigh in on whether to be circumcised?

    • AuntiePatricia says:

      I include manipulation, as a form of power-over or force. advertising, public relations, mind control. People left to their own devices would never conceive of such a thing – unless they were very troubled souls.

  • Petit Poulet says:

    Great blog! Any way to get this a wider readership. What I find disgusting is that the circumcised men who perpetrated this study are trying to sell the idea of infant circumcision in the United States based on their horribly flawed studies (see the recent Commentary in JAMA). If they stuck to the facts and acknowledged the weaknesses of the studies they would be credible, but they didn’t and the new editor of JAMA refused to publish letters to the editor that pointed out the many factual inaccuracies in the Commentary. The problem is that people have not jumped onto the “circumcise the planet” bandwagon quickly enough, so they have to pump up the hyperbole to accomplish their original purpose, which had nothing to do with preventing HIV in Africa and everything to do with promoting infant circumcision in the United States.

    You skipped the most crucial part of the articles you cite: about half of the infections in these studies were not sexually transmitted. How can these studies have estimated the impact of circumcision on sexually transmitted HIV when they never determined the source of the infections and their numbers indicate that half of the infections were not sexually transmitted? Basically, their study design did not allow them to properly test their hypothesis.

    Finally, one detailed criticism. Boyle and Hill mistakenly said that the 1.31% absolute was “not statistically significant.” From a straight numbers point of view, if one does not take into account the various forms of bias and that half of the men were infected through non-sexual contacts, the differences in the studies were statistically significant. The small absolute differences indicate that the these differences are clinically unimportant. These three trial were very large so they had the power to make uninteresting and unimportant findings statistically significant. So being statistically significant cannot be equated with being important.

    • Brian Earp says:

      Dear Petit Poulet,

      I’ve updated the post to remove the error by Boyle and Hill about statistical significance – thank you for bringing this to my attention, and for your informative reply more generally.

      Warmly,
      Brian

      • roger desmoulins says:

        Thank you for your willingness to revise your post.

        All “statistical significance” means is that the sample size was large enough to make meaningful the measured difference between treatments and controls, given the assumed probability model. Hence given a sufficiently large number of subjects, any measured difference between treatment and controls can be deemed “significant.” This is a major failing of conventional statistical methods.

        There are two ways of correcting this. One is to make the threshold significance level a declining function of the log of sample size. This would mean that the chosen significance level for the RACT should have been 1% or even 0.1%, and not 5%. The other way of correcting for this is to adopt Bayesian/subjectivist methods, well documented in the academic literature on statistics, but seldom implemented in software.

        • Jake says:

          I’m afraid you misunderstand. Statistical significance is concerned with whether a given result could have occurred by chance. A statistically significant result is one that is sufficiently unlikely to have occurred by chance. Sample size certainly affects this, as smaller samples are more susceptible to statistical noise, larger samples are needed to detect smaller differences.

          • Petit Poulet says:

            Actually statistical noise has nothing to sample size. Bias and imprecise measurements add noise. Sample size determines how much power you have to demonstrate a given difference between two groups. The downsize of having a large study, which is needed to show small differences, is that you are using such a sensitive tool (which can measure very small differences) is that the sensitive tool can be overwhelmed by the noise of bias and imprecise measurements. In the RCTs the differences were so small that they could have been completely attributed to biases built into the study design that would favor overestimating the treatment effect.

          • Frank OHara says:

            Jake, the statistical significance is small and unreliable. The goal of a study is to eliminate the chance of populations affecting the results. It appears that the studies were constructed to inject bias into them instead of eliminating bias. For instance, the studies have been presented as three seperate studies instead of a single study conducted at the populations of three different cities. This injects the possibility of bias as different cities will have different cultures and practices.

            I have lived in a number of cities. Some had (relatively) large populations of prostitutes while others had virtually no prostitutes. It would be expected that the cities with large numbers of prostitutes would also have large infection rates.

            Likewise, I have lived in one city that was a collector point for homosexuals. It had a reputation for this and gays flocked to a certain area of the city. The other had no reputation such as this and certainly not “gay neighborhoods.” As expected, the first city had a known high rate of infection while the second did not.

            This is a prime example of how bias can affect the outcomes of such research and how statistics can be manipulated. The “African Trials” were initially presented as a single research project but later presented as three seperate studies. What was the reason for this? For the evidence of a study to be taken seriously, it has to be duplicated with the same findings. It appears the African studies were intentionally separated to give credibility. Seperate studies would have (at least) small variations that would result in different findings. By separating them into three cities, it was providing the back-up to give them credibility when they hadn’t earned that credibility They are simply a single study

            The two lead activists in the studies have been rabid proponents of infant circumcision for more than 30 years. That’s on the record. This injects “researcher bias” into the studies and therefore invalidates them.

            By no stretch of the imagination is 1.3% statistically significant. Not until the difference is in the 3%+ range does it become statistically significant. 1.3% is in the range of random.

            It is telling that two of the researchers went on a publicity campaign in The US, not Africa. Round fter round of publicity releases were sent out for almost a year. The research community frowns on this kind of grandstanding. Any credible researcher knows this and only a very few will try to do it because it can hurt their credibility and professional standing. The study had little relavence in The US because of the different cultural practices but the studies were breathlessly promoted in The US for almost a year. It appears it only stopped when the media stopped accepting it.

            .

            • Michael Busch says:

              Formally speaking, a 1.3% decrease can be statistically significant, particularly when the overall rate is only a few percent. Considering the sample sizes of the two groups, if there were no systematic errors at all, we could conclude that circumcision reduced the rate of infection by 1.3 ± 0.5 % as compared to the control. But that is only a marginally significant detection – circumcision could slightly increase the rate and a percent or so of the time, the studies would have seen the opposite.

              More importantly, the systematic errors (which I do not have the data to quantify) appear to be entirely in the direction of biasing these studies in favor of circumcision, so the result is entirely</em< untrustworthy. And, of course, even the claimed level of protection is so minor that risk compensation makes the idea of a wide-spread program insane.

          • Sci0n says:

            Jake H. Waskett is a Circlist member who spends a great deal of his time editing Wikipedia to show a pro-circumcision bias.[1][2] As of early 2011, Waskett has made almost 14,000 edits, more than 1,275 edits to the Circumcision article alone (over twice as many edits to that article as the runner up, Avraham a.k.a. “Avi”). Waskett’s first edit to the article was on the 18th of October 2004, and his last edit was today. Waskett now averages about one edit every 1 days, 20 hours, 29 minutes and 21 seconds, for the Circumcision article.[3]
            Waskett is also known to lurk in parenting forums and blogs, attempting to convince expectant parents to circumcise.[4][5]
            There are those on the Internet who discuss the erotic stimulation they experience by watching other males being circumcised, swap fiction and about it, and trade in videotapes of actual circumcisions.[6] Jake Waskett associates with these like-minded individuals, and participates in their activities.[7] Some call them Circumfetishists.[8]
            Waskett is in regular contact with Brian J. Morris,[9] and is close friends with known pedophile[10] Vernon Quaintance (Gilgal Society creator, Circlist moderator),[11] who was arrested for child pornography in April of 2011,[10] and sexually molested an 11 year old boy.[12] Waskett also associates with the Gilgal Society,[13][14] who publishes circumcision propaganda, fetish stories of young boys being circumcised while others masturbate, and other materials. Gilgal Society has doctors and (circumcision to prevent HIV) researchers among their members.[15]

            J.H. Waskett is listed as a co-author with Daniel Halperin and Thomas E. Wiswell in an anti-intactivist, pro-circumcision article published in 2009 in the American Journal of Public Health entitled “Medicaid coverage of newborn circumcision: A health parity right of the poor.”[16]
            Jake Waskett is not a doctor or medical professional of any kind, nor does he have any type of degree.[13] Waskett is a 34 year old computer software engineer, located in Radcliffe Manchester England.[2][17][18]

            • Victoria-nola says:

              It hadn’t occurred to me that pro-circumcisionists were fetishists. Makes complete sense, since the “study” doesn’t. The expression of this fetish is a trade in nonconsensual, permanent mutilation and as such is highly distressing as it violates all ethics of safe, sane, and consensual sexuality. That they are working to bring such misery down on millions of otherwise healthy men is chilling.

              More broadly, while Wikipedia has some strengths, the medical section is outrageously under the control of Western conventional medicine. No alternate views are allowed to stand. There are people who comb the medical entries constantly, who undo any and all edits made to show positive effects of alternative medicine (or as in this case, alternative viewpoints on accepted practices). The alternative medicine entries are rife with errors that favor conventional medicine and any attempt to correct those errors is undone by the controlling interests. The so-called democracy of information that is supposed to be Wikipedia is distinctly not. As a result, I do not donate to it.

              Anyway thank you to Brian for an extremely useful article.

              • Lon Strickland says:

                I don’t think it’s a conscious fetish, but certainly a flawed cultural habit that could be rooted in fetish. Those advocating the practice are proceeding with a cultural presumption that valid research to its benefits has already been conducted when in fact it has not, and will never be because it can’t. They are conditioned like so many to believe it’s a normal, natural, and widely accepted custom that is supported by science. It’s the very definition of bad science. It is banality at it’s absolute worst. Thanks for calling out Wikipedia too. I was trying to add to the circumcision page before it became “locked for vandalism”. Those on the other side of Wikipedia’s pages are bringing down a staunch hammer on perpetuating male genital mutilation. This can be explained simply by the circumcised penises in the pants of those in charge. There are many men in positions of power who cannot confront the truth and humility of the unfortunate state of their manhood.

                • Victoria-nola says:

                  If what Scion wrote is true:

                  “There are those on the Internet who discuss the erotic stimulation they experience by watching other males being circumcised, swap fiction and about it, and trade in videotapes of actual circumcisions.[6] Jake Waskett associates with these like-minded individuals, and participates in their activities.[7] …” [I don't know if true because I don't know where those citations are referenced.]”

                  If what Scion wrote is true, it can certainly be said that some of the pro-c’s are fetishists. The discussion of the erotic stimulation they experience is actually part of the fetish– the discussion of the stimulation provides further stimulation. Writing fiction and watching videotapes are also definitely part of it. I don’t doubt that such fetishists exist, since there are fetishists about every avenue of human experience, and circumcision being a very loaded topic would bring about a lot of psychic attention. If those fetishists are also pressing for universal circumcision, that’s immoral. Fetishes that cause harm to others are immoral to express and many potential ones are illegal (such as chld p rn). So as long as they continue to affirm that cn is not harmful, they can continue to get their jollies.

                  In such cases it definitely would be a conscious fetish, and, a conflict of interest to be pressing for universal mandates. That conflict of interest is highly disturbing to me.

                  • Lon Strickland says:

                    Yea… I have a hard time accepting it, but you’re probably right. Fetishes are bizarre, and genital mutilation could easily be some kind of twisted sexual release for certain deranged individuals. It’s a freaky reality even without the fetish angle. It just pours salt on an already festering wound. I’ll never forget the attitude toward it when I had my son. There is a range from casual to deviant ways to approach the topic. I even had one nurse ask where he had been circumcised without even knowing if we’d done it or not… as if opting not to remove his primary source of ejaculation is just simply inconceivable. What a strange world we live in.

          • Jake says:

            ‘Jake, the statistical significance is small and unreliable.’ — on what basis do you say that?

            ‘This injects the possibility of bias as different cities will have different cultures and practices.’ — why would performing an experiment in several different environments create bias? That doesn’t make sense.

            ‘The “African Trials” were initially presented as a single research project but later presented as three seperate studies. … It appears the African studies were intentionally separated to give credibility. … By separating them into three cities, it was providing the back-up to give them credibility when they hadn’t earned that credibility They are simply a single study’ — again, what basis do you have for making these claims?

            ‘The two lead activists in the studies have been rabid proponents of infant circumcision for more than 30 years. That’s on the record. This injects “researcher bias” into the studies and therefore invalidates them.’ — first there are three studies, hence three lead researchers. Second, to prove this claim you’ll have to explain a) what constitutes a “rabid proponent”, and b) show that they’ve been so for “more than 30 years”. The latter will prove a particularly interesting challenge, I fear, because Auvert’s first publication on circumcision was in 2001, Bailey’s was in 1998, and Gray’s in 1992.

            ‘By no stretch of the imagination is 1.3% statistically significant. Not until the difference is in the 3%+ range does it become statistically significant. 1.3% is in the range of random.’ — statistical significance has nothing to do with magnitude. It’s a measure of how likely a result could have occurred by chance.

          • Tony says:

            Sci0n says:
            May 26, 2012 at 8:12 pm

            Please, don’t. This type of argument makes all of us look bad through association. I, at least, want no part of that. I don’t need it, and worse, it’s wrong. We have the facts and ethics on our side. Let’s use them. It’s easy enough to poke the necessary holes in the flawed arguments Jake and others float that we can do it without this approach.

            For example:

            J.H. Waskett is listed as a co-author with …

            This isn’t the place to do so, but rebut the paper, not the byline. Do that enough and the byline begins to discredit itself. That requires the necessary work, not a substitute for the argument.

        • makomk says:

          If memory serves me correctly, you do actually need to take into account the fact that the study was terminated early when calculating statistical significance though. Otherwise you end up overestimating the statistical significance of the results; that is to say, you’re much more likely to falsely conclude there’s a difference between the control group and the treatment group due to random chance than you think you are. I’m not sure off-hand whether these researchers applied the appropriate corrections but given how common this mistake is and how bad the rest of their methodology is it’s entirely possible that the results are not actually statistically significant at all!

      • Steven Rogers says:

        In the comment by Petit Poulet, Boyle and Hill’s statement about statistical significance has been misrepresented as “an error”. However, Petit Poulet has not read carefully what Boyle and Hill actually wrote. On page 322, they clearly defined their use of the term “statistically significant” as having the precise meaning: “relevant from a policy implementation perspective”. In qualifying their use of the term “statistical significance”, Boyle and Hill expressly highlighted the fact that the 1.3% is of no consequence in the real world outside the micro-environment of the trumped up RCTs.

        Aside from the numerous fatal flaws in the African RCTs, the unadjusted 1.3% was also in part a statistical artifact due to the RCTs being vastly overpowered having employed excessive sample sizes in order to artificially ensure a “statistically significant” result, even though there was no practical or clinical significance (ie. when sample sizes are large enough, results will always be statistically significant–even though they are trivial or meaningless). Moreover, the 1.3% reduces to close to ZERO after making corrections for the multiple known sources of error bias that Boyle and Hill carefully documented.

        Figure 2 on page 321 of Boyle and Hill’s critique shows the massive sample sizes used to obtain a miniscule apparent reduction in HIV following circumcision. Despite this blatant manipulation of significance levels by the RCT investigators, the epidemiological evidence is the only real evidence that counts–and Figure 1 clearly shows that in several sub-Saharan countries, CIRCUMCISED males have a HIGHER prevalence of HIV infection.

        Circumcision can only worsen the HIV epidemic because:

        1) Some men may become HIV infected from the circumcision procedure itself when surgical instruments, syringes etc are used on multiple patients, but inadequately sterilized.

        2) At least 25% of men engage in sexual intercourse before their circumcision wounds have healed (half as early as 3 weeks).

        http://www.aidsmap.com/Quarter-of-men-resume-sex-before-wounds-from-circumcision-fully-healed-in-Zambian-study/page/2227154/

        3) Many circumcised men mistakenly think that they have a “natural condom” so they believe they are “immune to HIV infection” and can be promiscuous with impunity. How wrong they are!

        • Jake says:

          ‘On page 322, they clearly defined their use of the term “statistically significant” as having the precise meaning: “relevant from a policy implementation perspective”’ — which is an unconventional use of the term, to say the least.

          ‘In qualifying their use of the term “statistical significance”, Boyle and Hill expressly highlighted the fact that the 1.3% is of no consequence in the real world outside the micro-environment of the trumped up RCTs.’ — they expressed that opinion, yes. Whether it is a fact is another matter.

          ‘Aside from the numerous fatal flaws in the African RCTs, the unadjusted 1.3% was also in part a statistical artifact due to the RCTs being vastly overpowered having employed excessive sample sizes in order to artificially ensure a “statistically significant” result’ — you’re confusing several different concepts here. If the RCTs were overpowered, that would affect the statistical significance (in the conventional sense of the term, not the Boyle/Hill sense) of the result. It wouldn’t affect the magnitude of the result. (And, incidentally, you haven’t provided any evidence that the RCTs were overpowered.)

          ‘Moreover, the 1.3% reduces to close to ZERO after making corrections for the multiple known sources of error bias that Boyle and Hill carefully documented.’ — you haven’t provided any evidence for this claim, either.

          ‘Figure 2 on page 321 of Boyle and Hill’s critique shows the massive sample sizes used to obtain a miniscule apparent reduction in HIV following circumcision.’ — the samples are large, certainly, but what evidence do you have to support your claim that they were excessively so?

          ‘Figure 1 clearly shows that in several sub-Saharan countries, CIRCUMCISED males have a HIGHER prevalence of HIV infection.’ — as noted elsewhere on this page, observational studies are inherently susceptible to confounding, so the fact that such results are seen in several such studies isn’t terribly surprising.

          • Steven Rogers says:

            ‘Figure 1 clearly shows that in several sub-Saharan countries, CIRCUMCISED males have a HIGHER prevalence of HIV infection.’ — as noted elsewhere on this page, observational studies are inherently susceptible to confounding, so the fact that such results are seen in several such studies isn’t terribly surprising.

            These are NOT studies (observational or otherwise)–they are the actual EPIDEMIOLOGICAL DATA! The epidemiological data is the ONLY evidence that actually counts in the real world.

            What your denial of the epidemiologal data demonstrates is that the peddlers of the “Circumcision prevents HIV/AIDS” lie such as yourself are hell bent on promoting genital mutilation, at all costs. Medically sanctioned circumcision of misinformed adults or defencelesses unconsenting minors is tantamount to criminal sexual abuse.

            Just as female circumcision (genital mutilation) is a despicable atrocity intended to permanently reduce the sexual sensation of women, so too, male circumcision is nothing but penile-sexual reduction surgery (genital mutilation) intended to permanently reduce the sexual sensation/function of men. Circumcision under false pretences (ie. without FULLY INFORMED consent) is a human rights’ violation.
            http://www.cirp.org/library/sex_function/

          • Joseph4GI says:

            “…they expressed that opinion, yes. Whether it is a fact is another matter.”

            You know, you have no control over information outside of Wikipedia.

            Boyle and Hill present the evidence for their allegations perfectly. Luckily, readers can read the paper for themselves and arrive at their own conclusions instead of taking your word for it…

            “…you haven’t provided any evidence for this claim, either.”

            The evidence is cited in this blog; that you are trying to act authoritative on the matter and pretend like you can simply wave it away is a different matter.

            “…as noted elsewhere on this page, observational studies are inherently susceptible to confounding, so the fact that such results are seen in several such studies isn’t terribly surprising.”

            This entire post is merely pompous hand waving.

            I have faith that people will look up the links provided in this blog for themselves and not merely take your word for it.

            Readers ought to know who this Jake person is, and that he’s not merely the “dispassionate observer” that he tries to portray himself to be.

            Google “Jake Waskett” and “CircLeaks” and be informed as to Jake’s objectivity.

          • Jake says:

            ‘These are NOT studies (observational or otherwise)–they are the actual EPIDEMIOLOGICAL DATA! The epidemiological data is the ONLY evidence that actually counts in the real world.’ — well, how do you suppose those data were obtained? They were obtained by selecting a sample, recording data from that sample, and then summarising it. In other words, a study, in the “research or a detailed examination and analysis of a subject, phenomenon, etc” sense of the word. The fundamental mistake you’re making is to compare two types of information (RCTs and observational studies) and reject the higher-quality evidence because it disagrees with the lower-quality evidence.

            (Note: This is actually a reply to Steven Rogers’ post dated May 24, 2012 at 10:41 am. I’m replying to my own comment due to the limitations of this blog.)

          • Joseph4GI says:

            “The fundamental mistake you’re making is to compare two types of information (RCTs and observational studies) and reject the higher-quality evidence because it disagrees with the lower-quality evidence.”

            This assumes that the supposed “RCTs” are indeed the “higher-quality evidence” you and others claim it to be.

            Brian Earp, and others point to evidence that shows it is not.

            Maybe you might not agree or even acknowledge that what is pointed to is “evidence,” Jake, but luckily others can read for themselves.

            The so-called “RCT’s” from Africa are not the “gold standard” their purporters claim them to be.

          • Hugh7 says:

            It is striking that large numbers of non-randomly selected volunteers, more than 10,000 in total, generated a relatively small number of infections (64 circumcised, 137 non-circumcised – both far outnumbered by dropouts), but that the trials were all shortened, at the beginning for the experimental groups and at the end for all groups. This would magnify any inacccuracies.

  • Robert Darby says:

    It is possible to acknowledge that circumcision could reduce the risk of a male’s acquiring HIV through unprotected intercourse with an infected female partner (the small print that always gets left out when the media report “circumcision prevents AIDS”) without concluding that it is a reasonable prevention strategy. Prophylactic removal of breast tissue would infallibly eliminate the risk of breast cancer in both males and females; removal of one testicle would probably halve the risk of testicular cancer; and prophylactic amputation of a leg would probably eliminate the risk of football and motor bike injuries. The question is whether you accept the body as it has evolved and try to protect all of it from disease, injury and deformation of all kinds, or whether you try to re-engineer the body so that it conforms to some mad scientist’s ideal, some sort of armour-plated fortress that will repel the assaults of the micro-organisms that feed on us – but in the process destroy much of our humanity. The human genitals deserve to be accepted as nature made them, not as they might have been designed by a committee of tunnel-visioned medical experts. Micro-organisms have many cunning ways of getting into the body, but the idea of stopping them by amputating or steel-plating all the possible entry points belongs not to the world of evidence- and ethics-based medicine, but the nightmare world of Dr Frankenstein.

    The “circumcision for AIDS” strategy reminds me of a nasty joke I heard many years ago: that the female genitalia ought to be moved to their shoulders, so as to protect them from the risk of rape by midgets. And also of the gothic horror world of Shintaro Kago’s “Punctures”, in which people pre-emptively remove various body parts (teeth, fingers, internal organs) so that they won’t have to worry about anything subsequently going wrong with them. [1] (Though at least these are adults doing it to themselves, not – as with circumcision – to non-consenting children.)

    [1] http://kc-anathema.livejournal.com/pics/catalog/40853

    It’s also possible to acknowledge that limited, targeted circumcision of informed adults at high risk of HIV in regions with high levels of female infection could be helpful without agreeing that mass, indiscriminate programs are acceptable in such places, much less that children should be circumcision; much much less that the strategy should be applied in developed countries with low levels of female to male transmission; and much much much less that it should be applied to children in such environments. The circumcision promoters are always quick to insist that circumcision is not enough, and that men must continue to use condoms as well; in which case, why not forget the circ and just use the condoms?

    What strikes me as a medical historian is the consistency of the historical pattern since nineteenth century medicos demonised the foreskin: as soon as a new disease leaps to the forefront of public anxiety, circumcision enthusiasts suggest that the foreskin has something to do with it and that yet more circumcision is the answer. The claim that mass circumcision (ideally of children, since adults are not so easily coerced) is necessary to control AIDS is largely a re-run of the nineteenth century conviction that mass circumcision was necessary to control syphilis. In each case, an incurable disease had so terrified the public that they were ready to accept almost anything if it offered the possibility of increasing their safety without the need to change their habits.

    What gets forgotten is that HIV is not a particularly contagious disease and that you have to go to some trouble to contract it; apart from blood transfusions, tattoos, surgery and intravenous drug use (where circumcision would obviously make no difference), the only way you can become infected with HIV is through unprotected intercourse with an infected partner. The simplest way to run no risk of HIV infection, therefore, is not to be promiscuous and to practise safe sex. This policy has successfully kept HIV infection at a very low level in countries such as Australia, Germany and Britain, but western health agencies seem to have much the same attitude towards Africans as the military doctor Eugene Hand [2] exhibited towards American Blacks: because they are too stupid to use condoms and too sex crazed not to be promiscuous, the only thing that can be done is to circumcise them in the hope of slightly reducing the risk. The foreskin is targeted not because it is a particularly useful point of intervention, but because it is an easy target for surgical removal and a once-off procedure, after which the agencies can congratulate themselves that they have done all that they possibly can, and the experts can fly home to enjoy their lavish consultancy fees. (Thanks, Bill.)

    [2] http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=63&Itemid=52

    It should also be remembered that there are strong cultural pressures to use the AIDS scare as the latest means of preserving circumcision as a routine procedure among the cultures that traditionally practise it. The billions poured into the World Health Organisation and UNAIDS represent a bizarre alliance between American medical research money, African tribalism and Muslim religiosity, all of which forces have an emotional commitment to finding new and “scientific” justifications for continuing their traditional practices.

    • Brian Earp says:

      Dear Rob,

      I think you make an important point when you write: “It’s also possible to acknowledge that limited, targeted circumcision of informed adults at high risk of HIV in regions with high levels of female infection could be helpful without agreeing that mass, indiscriminate programs are acceptable in such places, much less that children should be circumcision; much much less that the strategy should be applied in developed countries with low levels of female to male transmission; and much much much less that it should be applied to children in such environments.” … I’ll try to include this perspective in future writings on this topic!

      Best,
      Brian

    • Seamus says:

      Thank you, Robert.

  • Jake says:

    “That’s a whole laundry list of issues” — yes, but it’s easy to make unfounded accusations. How many are valid?

    ‘First, consider the “lack of placebo control.”’ — this is true, but unrealistic. After all, think about it: how could one prevent a man from knowing whether he’s been circumcised?

    ‘As Boyle and Hill point out, the men who were circumcised got additional counseling about safe sex practices compared to the control group’ — they do make that claim in the abstract, but in the text they assert that it’s true only of the Ugandan trial. (And the study reporting on that trial says nothing of the kind: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60313-4/fulltext)

    ‘and then they had to refrain from having sex altogether for the simple reason that their lacerated penises had to be wrapped in bandages until their wounds healed’ — this is true, and it’s why all three trials sampled HIV at multiple intervals through the study period. Thus, if the healing period were responsible for the apparent reduction in risk, then there would be lower risk of HIV at the early testing point, but equal risk later on. That wasn’t the case.

    ‘That’s right: 60% is the relative reduction in infection rates, comparing two vanishingly small percentages: a clever bit of arithmetic that generates a big number, and one which wildly misrepresents the results of the study.’ — why on earth does it “wildly misrepresent” the results? It’s a perfectly reasonable comparison to make, and in fact it’s fairly standard for epidemiological studies to report relative risks…

    ‘The absolute decrease in HIV infection between the treatment and control groups in these experiments can hardly be considered clinically significant’ — I think most people would think preventing 13 HIV cases in a thousand men in 2 years is quite worthwhile.

    ‘I really want you to read the Boyle and Hill paper here, because they go into painstaking detail about each of a long parade of flaws I can’t hope to cover in one blog post’ — but, again, how many are valid?

    • bo says:

      Thank you for taking the time to write this. It’s disappointingly easy to list a whole host of problems, post a link to the article, and have everyone believe it’s true.

      Everyone mentions the lack of placebo control. Seriously, what do they want the investigators to do? Even with a sham procedure, the participants could pretty easily unblind themselves by looking down. So, is this a question that can’t be studied because there’s no placebo or blinded participants? Of course not. Placebo controlled trials are great, but they are not the only way to study something.

      The point about refraining from sex in the intervention group is also often made, and every time it is made, it is clear that the study wasn’t read. There is a very clear table on the 5th page of the study that shows the incidence of HIV infection in several time periods. Critics are right that the first time period will have some bias because the circumcision group will not be having sex for part of that time period. However, the reduced incidence of HIV transmission was present and more significant during the later time periods.

      Finally, your point about relative risk reduction is perfect. Anyone that claims this is wrong clearly doesn’t read many medical studies. Absolute risk reduction is also important, but it’s dependent on the underlying risk of infection in the study population. So, relative risk reduction is most important to know, and then you can apply that to different populations to get an understanding of their absolute risk reduction.

      Thank you for your effort, but I think people will just skim the post and trust the bad reporting of the original post.

      • Elisabeth Vaeth says:

        Yes. A thousand times yes. You can argue the ethics of circumcision itself or the merits of mass circumcision as a useful HIV control policy, but making false claims about how these studies were designed, implemented and reported on will HURT your cause, not help it. Reporting relative risk is not manipulating the numbers!!

      • Joseph4GI says:

        “Everyone mentions the lack of placebo control. Seriously, what do they want the investigators to do? Even with a sham procedure, the participants could pretty easily unblind themselves by looking down. So, is this a question that can’t be studied because there’s no placebo or blinded participants? Of course not. Placebo controlled trials are great, but they are not the only way to study something.”

        But then having no control defeats the purpose of a “controlled” trial, doesn’t it. So much for the “gold standard…”

        “However, the reduced incidence of HIV transmission was present and more significant during the later time periods.”

        The trials were ended early, the “reduced incidence” is an exaggerated number, and, with no control, that the infinitesimally small “reduction” is in fact due to circumcision is pure assumption. Incidentally, there is no demonstrable proof that the foreskin facilitates HIV transmission and that circumcision “reduces” it.

        The relative 60% is a gross exaggeration of a tiny number. But even accepting this figure at face value, it fails to manifest itself in other populations where circumcision is a widespread practice, as others will point out. Not to mention that condoms would still be conclusively more effective anyway.

        It should strike people as odd that a dedicated group of circumcision enthusiasts are working as hard as they can to necessitate a superfluous surgical practice in lieu of cheaper, less invasive, more effective means.

        There is something wrong with trying to legitimize genital mutilation with “research.”

        • bo says:

          Despite your claim that they have no control, they do actually have a control group. It’s not a placebo-controlled trial, but it is a controlled trial. The control group is the group that had no surgical intervention. In research studies there are many different types of control groups you can use. You can use randomized placebo controls. You can use open-label, no intervention controls. You can use standard of care controls. You can use patients as there own control, typically with a placebo. These are all controls, and they used a control group in this study.

          The 60% is not a gross exaggeration of a tiny number. It is just what the relative risk reduction is. They show the absolute risk as well. They are trying to communicate with people that understand the difference and know what the two mean.

          Your point about condoms is true. They work great. If only people used them more consistently. At every appointment the importance of condom use was emphasized.

          • Wendy says:

            <>

            Yes, the importance of condom use of was emphasized at every appointment. Of course, the circumcised men had many more appointments than the intact ones did. In other words, they got A LOT more counseling in the use and effectiveness of condoms. How does that not confound the results?

            • Jake says:

              ‘In other words, they got A LOT more counseling in the use and effectiveness of condoms.’ — what evidence do you have to support this claim, Wendy?

      • Hugh7 says:

        “Even with a sham procedure, the participants could pretty easily unblind themselves by looking down. ” Not necessarily, when many men in circumcising cultures are mistaken about their own circumcision status. They could be told it was a placebo circumcision, or even truthfully that it was a “circular incision”. Even if they realised they had not been circumcised, it would require the same hygienic precautions, abstinence, counselling etc. as circumcision, and thus put them much more on all fours with the experimental group. The real circumcision at the end of the trial would obliterate all traces of the sham operation.

        “However, the reduced incidence of HIV transmission was present and more significant during the later time periods.” You are now talking about periods of a few months and mere handfuls of cases, with varying time lags between infection and detection. The margins of error in these figures must by now well overwhelm any significance. It is at this point also that the lack of contact tracing and any evidence that the men did in fact contract HIV through heterosex becomes highly relevant.

        You can indeed apply RRR to differing populations, and when you apply the “60%” to the trivial proportion of HIV that is transmitted from female to male in the western world, the futility of mass infant circumcision for this purpose becomes most evident.

        • bo says:

          You say that the margins of error in these figures must by now well overwhelm significance. This is incorrect. At these time periods, which were up to 2 years after randomization, the differences were statistically significant.

          I agree about your point on application to the western world. These studies, in my opinion, should not affect practices here. I’m not convinced they should affect practices in the countries they were performed in either.

    • roger desmoulins says:

      We both agree that placebo control is impossible to achieve. You conclude that we should go ahead and do clinical trials without placebo control. I prefer to conclude that the impossibility of placebo controls casts a shadow over the interpretability and validity of the clinical trials.

      The fundamental problem with the African clinical trials is that they were not allowed to run long enough. We cannot rule out that over time, the %age of treatments who are HIV+ gradually converges with the %age of controls that are, so that given enough time, the difference between treatments and controls fails to be statistically significant (a concept about which I have reservations BTW). The hypothesis is that circumcision only delays the inevitable.

      If you have serious disagreements with Boyle and Hill, submit a comment to the Journal of Law and Medicine.

      • bo says:

        I think that you can see that after the initial time period in the Uganda there was a sustained benefit of decreased incidence of new HIV in the intervention group. The following 3 time periods had a reduced incidence in the intervention group. Lowering the incidence is the goal, and it is beneficial. Even if everyone gets HIV eventually in both groups, delaying it is beneficial.

        • Joseph4GI says:

          “I think that you can see that after the initial time period in the Uganda there was a sustained benefit of decreased incidence of new HIV in the intervention group.”

          You mean, there appears to be a decreased incidence of HIV in a tiny subgroup of men, assuming they all acquired HIV sexually.

          “The following 3 time periods had a reduced incidence in the intervention group.”

          Again, a very short time, and in a small fraction on the intervention group, assuming HIV was acquired sexually; that the “reduction” is due to circumcision is pure assumption.

          “Lowering the incidence is the goal…”

          No, the goal appears to be to give circumcision validity, a goal tha “researchers” have been aiming for for at least a century… Lowering incidence of HIV should not come at the cost of bodily integrity and gross human rights violations.

          “Even if everyone gets HIV eventually in both groups, delaying it is beneficial.”

          You are simply raving mad.

          • Jake says:

            “You mean, there appears to be a decreased incidence of HIV in a tiny subgroup of men, assuming they all acquired HIV sexually.” — actually, one set of numbers is smaller than the other regardless of any assumptions you might make.

            “Again, a very short time, and in a small fraction on the intervention group” — HIV affects people in that environment at that rate. That’s why a large sample was needed.

            “No, the goal appears to be to give circumcision validity, a goal tha “researchers” have been aiming for for at least a century” — they must be fairly old by now, then?

          • Joseph4GI says:

            “…actually, one set of numbers is smaller than the other regardless of any assumptions you might make.”

            Yes, one set of numbers is smaller than the other. It is a leap of faith to say the difference was caused by circumcision, as it assumes that the men all acquired HIV via heterosexual contact with HIV+ women, and it assumes that circumcision has a “protective effect,” the very thing the studies are setting out to prove.

            There is no demonstrable proof that the foreskin “facilitates” HIV transmission, and that circumcision “reduces” it; this is assumed to be true apriori. The “researchers” propose hypotheses as to why they believe circumcision may have a “protective” effect, but these have either never been demonstrated to be true, or have been completely debunked.

            Lack of a working hypothesis, assuming what the researchers are trying to prove is true from the very beginning without any demonstrable scientific proof, is probably the biggest flaw of these “studies.” At best, they’re statistics embellished with correlation hypothesis.

            “HIV affects people in that environment at that rate. That’s why a large sample was needed.”

            Are all cases of HIV in that environment heterosexually transmitted, is the question. Why only look at the tiny subgroup of men who acquired HIV, and why assume they all acquired it heterosexually?

            “…they must be fairly old by now, then?”

            Some are, yes.

          • Jake says:

            ‘Yes, one set of numbers is smaller than the other. It is a leap of faith to say the difference was caused by circumcision, as it assumes that the men all acquired HIV via heterosexual contact with HIV+ women, and it assumes that circumcision has a “protective effect,” the very thing the studies are setting out to prove.’ — it’s not really accurate to call it an “assumption”. The studies were designed to test the hypothesis that circumcision has a protective effect, and did so by arranging the experiment such that circumcision was the difference between the two groups, thus if there were any observed differences in HIV acquisition, it must be due to circumcision status.

            ‘Why only look at the tiny subgroup of men who acquired HIV’ — it’s impossible to measure risk if one excludes those who became HIV positive. Consequently it’s impossible to assess the effect of circumcision (or, indeed, anything else). The best one could do is ask a lot of questions about the men who didn’t acquire HIV, and form hypotheses about what might have protected them. Then, later studies would need to test those hypotheses.

            ‘and why assume they all acquired it heterosexually?’ — it’s a reasonable assumption to make, but it’s not essential because it’s about how circumcision protects, rather than the key question, whether. You could argue, if you really want, that they acquired HIV because of nocturnal visits by leprechauns, and leprechauns have an fondness for men with foreskins. It’s not a very plausible theory — certainly less so than heterosexual transmission — but if you find it a more palatable explanation then fine. The point is that we know that circumcision protects heterosexual men. There are a number of proposed mechanisms for that, some with strong supportive evidence, some less so.

            (Note: this is a reply to Joseph4GI’s comment dated May 24, 2012 at 11:11 am.)

            • makomk says:

              “The studies were designed to test the hypothesis that circumcision has a protective effect, and did so by arranging the experiment such that circumcision was the difference between the two groups”

              Actually, they didn’t. Remember that this was in reply to bo’s claim that the Uganda study found a long-term sustained decrease in the incidence of HIV infections. The longer-term part of the study had no control group because they circumcised all the members of the control group they could still contact at the 12 month mark. All the researchers actually found was that the rate of HIV infection amongst the men they were studying decreased after the 12 month mark; their assumption that this was due to circumcision somehow becoming more effective over time rather than (for instance) the men settling down and having sex with fewer partners was just an assumption.

              As I recall the researchers went even further and assumed that the rate of infection would continue to decrease at the same pace, extrapolated it out into the future based on that assumption, and presented the extrapolated figures quite prominently in their paper as evidence of a long-term benefit from circumcision.

          • Joseph4GI says:

            “…it’s not really accurate to call it an “assumption.”

            Until it can be demonstrably proven, then it’s actually quite accurate.

            “The studies were designed to test the hypothesis that circumcision has a protective effect…”

            A hypothesis that is never proven, let alone “tested…”

            “…and did so by arranging the experiment such that circumcision was the difference between the two groups, thus if there were any observed differences in HIV acquisition, it must be due to circumcision status.”

            That is, assuming all the men acquired HIV sexually, and the greater number of circumcised men that didn’t get HIV didn’t acquire it because of the “protective effect of circumcision.” (Which, by the way, is yet to be demonstrably proven to exist…)

            “…it’s impossible to measure risk if one excludes those who became HIV positive. Consequently it’s impossible to assess the effect of circumcision (or, indeed, anything else).”

            I think you misunderstood my question; to obtain the relative 60%, only those who became HIV positive are taken into account. Factor in the thousands of other men who didn’t get HIV and you get the unimpressive 1.37% number.

            “The best one could do is ask a lot of questions about the men who didn’t acquire HIV, and form hypotheses about what might have protected them. Then, later studies would need to test those hypotheses.”

            Here are a few observations and questions; A grand total of 10,908 were involved in these experiments. 5497 were intact, 5,411 were circumcised. Out of that, only 201 men aquired HIV, 137 intact, 64 circumcised respectively. Focusing on the difference between the men that got HIV, the “difference” looks rather impressive. However, 5360 intact men didn’t get HIV as opposed to 5347. Additionally, we’re assuming all of the men that got HIV acquired it sexually. Even assuming they all did, sure the “difference” between them sounds significant, but then that’s 201 out of 10,908 men. The overwhelming majority of both kinds of men didn’t get HIV. So why is it we only look at the difference between the men that got HIV, and not the fact that the grand majority of men didn’t get HIV? If the 5347 circumcised men didn’t get HIV because they were “protected” by circumcision, what about the 5360 intact men who didn’t get HIV?

            Instead of researching “how circumcision protects men,” why aren’t “researchers” interested in why the other intact men didn’t get HIV?

            Are the “researchers” interested in helping reduce HIV transmission, or in finding use for a controversial procedure?

            “‘and why assume they all acquired it heterosexually?’ — it’s a reasonable assumption to make, but it’s not essential because it’s about how circumcision protects, rather than the key question, whether.”

            This sounds incredibly stupid.

            If we don’t know for a fact the men acquired HIV heterosexually, how can you know “whether” circumcision “protected” them or not?

            It’s probably not reasonable to assume that all of the men got HIV through some other non-sexual means, such as needle-use, or they acquired it at a hospital iatrogenically.

            But don’t we know that a certain percentage of the men didn’t acquire HIV heterosexually for a fact?

            “You could argue, if you really want, that they acquired HIV because of nocturnal visits by leprechauns, and leprechauns have an fondness for men with foreskins. It’s not a very plausible theory — certainly less so than heterosexual transmission — but if you find it a more palatable explanation then fine.”

            They could have acquired it via a mode of transmission that does not even involve the penis or the foreskin, such as needles, or visiting a healthcare facility. (Iatrogenic HIV transmission is a big problem in Africa.)

            “The point is that we know that circumcision protects heterosexual men.”

            The point is that you don’t, and there is no actual way to prove it, and all you can do is point to dubious statistics and repeat that they were caused by circumcision ad-nauseam.

            “There are a number of proposed mechanisms for that, some with strong supportive evidence, some less so.”

            Actually, none that can be scientifically demonstrated.

            Without a mechanism, claiming that circumcision “protects heterosexual men” is empty assertion.

            It is logically fallacious to begin by assuming what you’re trying to prove.

          • Jake says:

            ‘A hypothesis that is never proven, let alone “tested…”’ — it was, in fact, tested.

            ‘That is, assuming all the men acquired HIV sexually’ — that assumption is unnecessary, because it relates to how circumcision protects, not whether.

            ‘I think you misunderstood my question; to obtain the relative 60%, only those who became HIV positive are taken into account.’ — wrong. If you only take those who acquired HIV into account, you can’t calculate a relative risk or an absolute risk reduction. To calculate either you need to know both the number who became HIV+ and those who remained HIV negative.

            ‘So why is it we only look at the difference between the men that got HIV, and not the fact that the grand majority of men didn’t get HIV? If the 5347 circumcised men didn’t get HIV because they were “protected” by circumcision, what about the 5360 intact men who didn’t get HIV?’ — I don’t think anyone has suggested that the 5347 circumcised men didn’t get HIV because of their circumcisions, Joseph. Only a fraction of men do acquire HIV over a lifetime (the figure varies from place to place). Ideally, we’d all like that figure to be zero. It isn’t, of course, but the intent is to reduce it. To do that, it’s necessary to study why people acquire HIV.

            ‘Instead of researching “how circumcision protects men,” why aren’t “researchers” interested in why the other intact men didn’t get HIV?’ — I’m sure they are interested, but studies generally address only one, or a small number of, research questions at a time. Hypotheses generated during these studies will probably be researched in future studies.

            ‘If we don’t know for a fact the men acquired HIV heterosexually, how can you know “whether” circumcision “protected” them or not?’ — we know from these data that it protected them. The most likely explanation for that is that circumcision affects heterosexual transmission, but it doesn’t matter how that happens. It’s like arguing that we don’t know whether Newton’s or Einstein’s model of gravity is correct: in most everyday situations, it doesn’t matter. The Earth still orbits the sun.

            ‘They could have acquired it via a mode of transmission that does not even involve the penis or the foreskin, such as needles, or visiting a healthcare facility’ — it’s possible, yes, but that’s inconsistent with the fact that circumcision made a significant difference to incidence.

          • Joseph4GI says:

            “…it was, in fact, tested.”

            What was “tested” was the assumption, with no scientific proof, that circumcision had a “protective effect” on circumcision. That circumcision “prevents HIV” is presented, from the beginning, as a foregone conclusion.

            “that assumption is unnecessary, because it relates to how circumcision protects, not whether.”

            The assumption is necessary, because if none of the men acquired HIV sexually, then their circumcision status is irrelevant. If the numbers reported are accurate, then there is in fact a number of men who acquired HIV asexually, which means that circumcision would not have made a difference for them, which means that, for those men, it would not be possible to test “whether” circumcision “protects” or not.

            “…we know from these data that it protected them.”

            What is known from the data was that there was a difference of HIV transmission in a very tiny subgroup of over 10,000 men. We do not know for a fact that the difference was caused by circumcision.

            “The most likely explanation for that is that circumcision affects heterosexual transmission, but it doesn’t matter how that happens.”

            Or rather, you and others would like for the explanation to be that circumcision affects heterosexual transmission, with absolutely no demonstrable proof whatsoever. Of course it matters how that happens; without this knowledge it could be argued that leprechauns that like to give HIV to intact men exist, in which case it’s not circumcision that is the problem.

            “It’s like arguing that we don’t know whether Newton’s or Einstein’s model of gravity is correct: in most everyday situations, it doesn’t matter. The Earth still orbits the sun.”

            The logic is this analogy is backwards; Newton and Einstein were trying to explain an observable phenomenon, not to determine that a phenomenon does or does not exist. The RCTs attempt to measure a phenomenon, the assumption that circumcision has a “protective effect” against heterosexually transmitted HIV, without actually knowing for a fact that it exists.

            It’s like measuring “the power of God” by counting how many people were healed from illness by praying for them in the name of Jesus.

            ‘They could have acquired it via a mode of transmission that does not even involve the penis or the foreskin, such as needles, or visiting a healthcare facility’ — it’s possible, yes, but that’s inconsistent with the fact that circumcision made a significant difference to incidence.”

            It is not a fact that circumcision made any kind of a difference, but an unproven assumption.

            Let’s demonstrably establish that circumcision has any effect on the transmission of HIV before we claim that it makes a difference, “significant” or otherwise.

    • Joseph4GI says:

      “… it’s easy to make unfounded accusations. How many are valid?”

      Likewise, it’s easy to hand wave and tell others that accusations are invalid.

      “…this is true, but unrealistic.”

      Then the so-called “studies” themselves are unrealistic.

      ” if the healing period were responsible for the apparent reduction in risk, then there would be lower risk of HIV at the early testing point, but equal risk later on. That wasn’t the case.”

      Of course, one of the problems pointed out is that the studies were terminated early, further skewing the results…

      “…why on earth does it “wildly misrepresent” the results?”

      I’d say that masking an absolute, unimpressive 1.37% with the sensational “60%” without mentioning what exactly that number represents is wild misrepresentation. It makes is sound like 60% of the “thousands of men” involved in the trial were “protected” (for the short duration of the trial), and the other 40% got HIV. All, of course, assuming the men who acquired HIV did so sexually, with no demonstrable proof that the foreskin “facilitates” HIV transmission, and that circumcision “reduces” it.

      “It’s a perfectly reasonable comparison to make, and in fact it’s fairly standard for epidemiological studies to report relative risks…”

      It is not reasonable to blow a tiny number out of proportion by deceptively masking it with a bigger one, especially a “study” with methodological flaws which was ended early by “researchers” with an agenda to implement “mass circumcision” in mind.

      “I think most people would think preventing 13 HIV cases in a thousand men in 2 years is quite worthwhile.”

      At least you would like to think so. And, that’s assuming that the men in the “studies” all acquired HIV heterosexually; another flaw in the so-called “research.”

      “…but, again, how many are valid?”

      Luckily, people can read and judge for themselves, instead of taking your word for it.

      Who exactly are you again?

      Is this the self-same Jake Waskett who spends the majority of his life imposing his pro-circumcision bias on Wikipedia?

      For more on who Jake Waskett is, Google “Jake Waskett” and “CircLeaks.” It is important that readers know the objectivity of the source.

      • CB says:

        I too was wondering if this was the infamous Jake Waskett – that “waskally” (Elmer Fudd voice) circ fetishist.
        I’m thinking Bo might be Brian Morris, his partner in creepy fascination with genital cutting.

    • Petit Poulet says:

      I think Brian appropriately refers readers to look at the original articles that include the laundry lists. No one of any substance or valid educational background has been able to challenge the validity of these claims. The inability to have a true placebo control group could act to overestimate the treatment effect. To deny that would be folly. How much of an impact that had in overestimating the treatment effect is unknown. It has been shown that studies that halted prematurely markedly overestimate treatment effect, especially in studies where the outcome of interest happens infrequently, as was the case in these randomized clinical trials.

      Jake does not seem to understand why lead-time bias is important in these trials or that early termination only increases the impact of the lead-time bias. The outcome that was reported in these trials was the difference in the rates of HIV infection per the time the participants were at risk for sexual acquisition of the virus. The problem is that the men in the treatment group were not at risk for infection while they were recovering from the surgery, yet the researchers treated them as though they were at risk when they were not. An analogy would be comparing the number of points scored by a basketball player per minute played. Player one plays all 60 minutes in a game and scores 20 points. So he scored 20 points per game. Player two plays only 30 minutes and scores 10 points, so he scored 10 points per game. But the outcome of interest, the number of points per minute, was the same for both players. Basically the researchers reported the difference in points per game as though they were the points per minute and player one scored twice as many points per minute as player two, counting player two’s time on the bench as though he was out on the court. Is this academic misconduct? Is such reporting dishonest? How did the editorial staff of the Lancet and their peer-reviewers let this slip through without questioning it? How could researchers at Johns Hopkins, one of the world’s most prestigious medical research institutions, allow such a basic design flaw be included in a multi-million dollar NIH-funded study? Why would the NIH fund a study with such an obvious design flaw? How was this missed? This is one of the most basic elements of study design and the leading research institution screwed it up. Was this an oversight, or was this obviously design flaw included on purpose? So, were the researchers from Johns Hopkins ignorant, negligent, or deceptive?

      Any one who is familiar with epidemiology and statistics knows that when researchers emphasize the relative risks instead of the absolute risk, they are both hiding something and hyping their results. The problem is that average person doesn’t know this. The pharmaceutical companies do this all the time to promote their drugs. Take a hypothetical example: Drug A compared to placebo had a relative risk reduction of 50%. When you read the study you find out that the 50% reduction was a difference of a 0.5% risk of heart attack over 5 years versus a 0.25% risk of heart attack over 5 years. The absolute risk reductions 0.25% over five years. So 400 people would need to take the drug for 5 years to prevent one heart attack. If the drug costs $200 a month, it would cost $4.8 million to prevent one heart attack. So a 50% relative risk reduction sound really fantastic, but the medication is not a reasonable option.

      There are several problems with the 13 case of HIV infection per 1000 men. First, the 13 number is high because of the various forms of bias in the study that would work to overestimate the treatment effect and the fact that half of the men in these studies probably did not get infected through sexual means. The other problem is that the control group was basically no intervention. There are other prevention modalities available that are much more effective. If you want to use relative risk reduction, condoms, for the individual who uses them faithfully, has a relative risk reduction of greater than 99%. Likewise ART has a relative risk reduction of greater than 99%. The circumcision numbers, if you want to believe Jake, are anemic by comparison. If someone were given accurate information and an accurate assessment of the risks, very few would choose circumcision over condoms (especially when they are told they would have to wear condoms regardless of whether they are circumcised or not) or ART.

      Finally, Jake, you make a rookie mistake that we often see in third year medical students. They decide on a diagnosis and they selectively use the symptoms and test results to confirm their decision that their diagnosis is correct. In your case, you firmly believe that every male on the planet needs to be circumcised (overstated perhaps slightly) and you gather every bit of data to support this belief, which only convinces you further that your belief it correct. The correct scientific and clinical approach is to look at the patient in his totality, listen to all of his story, do a complete physical examination, look at all of the tests, and use all of this information to arrive at a diagnosis. This approach is much more likely to lead to the correct diagnosis. If the purpose is to reduce HIV infections, there are better more effective, less expensive approaches and circumcision is not the best answer and one could easily argue that it should not be part of the solution. If the purpose is to circumcise the planet, then your approach is appropriate. Your approach will not lead to the best approach to reducing HIV infection.

      • Jake says:

        “Jake does not seem to understand why lead-time bias is important in these trials or that early termination only increases the impact of the lead-time bias. [...] The problem is that the men in the treatment group were not at risk for infection while they were recovering from the surgery, yet the researchers treated them as though they were at risk when they were not.” — on the contrary: I do understand, and I’ve shown that the studies included mechanisms that made it possible to eliminate this as an explanation for the results. For example, in the South African trial there were two infections in intervention group in the first three months (which comfortably includes the normal healing period), and nine in the control group. In months 4 to 21, there were 18 in the intervention group and 40 in the control group. So there is a greater “protective” effect of circumcision in the healing period, likely because men can’t use their penises, but there is also a real protective effect afterwards.

        “Any one who is familiar with epidemiology and statistics knows that when researchers emphasize the relative risks instead of the absolute risk, they are both hiding something and hyping their results.” — no, I don’t think so. Actually, I’m struggling to think of a study that stressed ARR instead of relative risk reduction.

        “There are several problems with the 13 case of HIV infection per 1000 men. First, the 13 number is high because of the various forms of bias in the study that would work to overestimate the treatment effect and the fact that half of the men in these studies probably did not get infected through sexual means.” — There’s no evidence that either of those claims are correct.

        “The other problem is that the control group was basically no intervention.” — no, it wouldn’t be ethical to require participants to refrain from condom use, for example.

        “If you want to use relative risk reduction, condoms, for the individual who uses them faithfully, has a relative risk reduction of greater than 99%” — Possibly an exaggeration. USAID state “Scientific studies of sexually active couples, where one partner is infected with HIV and the other partner is not, have demonstrated that the consistent use of latex condoms reduces the likelihood of HIV infection by 80 to 90 percent.”

        “In your case, you firmly believe that every male on the planet needs to be circumcised (overstated perhaps slightly) and you gather every bit of data to support this belief, which only convinces you further that your belief it correct.” — rather than speculating (incorrectly) about what I believe, may I suggest that you address what I’ve actually said?

        • Joseph4GI says:

          “…on the contrary: I do understand, and I’ve shown that the studies included mechanisms that made it possible to eliminate this as an explanation for the results.”

          Or, at least, you’ve tried to.

          Can you tell us, Jake, what exactly your credentials are? Where did you go to school? Was your are of study epidemiology? What other epidemics have you studied? Or is your interest purely circumcision and legitimizing it for yourself and forcing it on others?

          “For example, in the South African trial there were two infections in intervention group in the first three months (which comfortably includes the normal healing period), and nine in the control group. In months 4 to 21, there were 18 in the intervention group and 40 in the control group. So there is a greater “protective” effect of circumcision in the healing period, likely because men can’t use their penises, but there is also a real protective effect afterwards.”

          What was the number of men involved in each study?

          Why should we focus only on the tiny subgroup of men who acquired HIV?

          How many of these can be confirmed to be heterosexual transmissions?

          How can it be said for sure that the “reduced” number of incidence was due to circumcision?

          What is the mechanism whereby the foreskin “facilitates” sexual HIV transmission?

          Can it be demonstrably proven that removing the foreskin “reduces” sexual HIV transmission?

          Incidentally, how are researchers so sure HIV is spread primarily through sexual contact?

          There are people on the ground in Africa that argue that the idea that HIV is spread primarily through sexual promiscuity is a sham; that there are other modes of transmission that are being minimized, if not outright ignored.

          The following blogs are of note to those interested in HIV in Africa:

          http://hivinkenya.blogspot.com/

          http://dontgetstuck.wordpress.com/

          “…no, I don’t think so. Actually, I’m struggling to think of a study that stressed ARR instead of relative risk reduction.”

          Maybe need to read studies other than those that support circumcision?

          Again, who are you? What are your credentials? Where did you go to school? What is your area of study? Are you an epidemiologist? Why should you be trusted over Boyle, Hill, even Brian Earp, who is more qualified to speak on the subject than you are?

          “There’s no evidence that either of those claims are correct.”

          Well. At least no evidence that you, Jake Waskett will acknowledge…

          Fortunately, people can read the evidence and come to a conclusion on their own without you holding their hands…

          “…no, it wouldn’t be ethical to require participants to refrain from condom use, for example.”

          Which means that real trials would not be ethical.

          Actually, these trials in and of themselves were not very ethical. Interestingly enough, all three were ended on the grounds that “it would be unethical to continue further.” Which raises the question as to why they were begun in the first place…

          They claimed “ethics” AFTER they achieved the results they were looking for, and then circumcised the remaining men. Arguing “ethics” and making it so any further study were “unethical” was a clever way for the “researchers” to give themselves the last word. In essence, the “results” of these “studies” are unconfirmable. “No further study is necessary.” How scientific!

          “We don’t need to look through your telescope, Mr Galileo. We know there cannot be more than seven heavenly bodies.”

          “In your case, you firmly believe that every male on the planet needs to be circumcised (overstated perhaps slightly) and you gather every bit of data to support this belief, which only convinces you further that your belief it correct.” — rather than speculating (incorrectly) about what I believe, may I suggest that you address what I’ve actually said?

          Petit Poulet has addressed your every word, and is hardly “speculating.” How about disclosing your conflicts of interests for your readers to determine your objectivity?

          Who are you, Jake Waskett?

          What do you do with your life? What are your credentials? What are your interests? What is your connection to circumcision? Do you actually care about the HIV epidemic? Or only in as much as it pertains to the vindication of circumcision?

          Who is Vernon Quaintance?

          What is Gilgal Society?

          People can read about who you are here:

          http://circleaks.org/index.php?title=Jake_H._Waskett

          Before you pretend to be a victim of “ad-hominem,” let me post what Wikipedia has to say on “ad-hominem” and conflict of interest:

          “Conflict of Interest: Where a source seeks to convince by a claim of authority or by personal observation, identification of conflicts of interest are not ad hominem – it is generally well accepted that an “authority” needs to be objective and impartial, and that an audience can only evaluate information from a source if they know about conflicts of interest that may affect the objectivity of the source. Identification of a conflict of interest is appropriate, and concealment of a conflict of interest is a problem.”

          Are you as “dispassionate” as you try to portray yourself to be?

          Let people come to their own conclusions.

          • Jake says:

            “What was the number of men involved in each study?” — in the South African trial, for which I quoted the above figures, there were 1,620 men in the circumcision group and 1,654 in the control group.

            “Why should we focus only on the tiny subgroup of men who acquired HIV?” — to calculate risk, we need to consider the men who acquired HIV and those who did not.

            “How many of these can be confirmed to be heterosexual transmissions?” — Your question isn’t meaningful, because it’s not possible to know the exact cause of each case.

            “How can it be said for sure that the “reduced” number of incidence was due to circumcision?” — it’s possible that it might have been due to chance, for example. But it’s extremely unlikely, and reasonably easy to calculate exactly how unlikely.

            “What is the mechanism whereby the foreskin “facilitates” sexual HIV transmission?” — it’s likely that there are multiple mechanisms. For a good overview, see: Dinh MH, Fahrbach KM, Hope TJ. The role of the foreskin in male circumcision: an evidence-based review. Am J Reprod Immunol. 2011 Mar;65(3):279-83

            “Maybe need to read studies other than those that support circumcision?” — Can you cite some examples that emphasise absolute risk?

            “Interestingly enough, all three were ended on the grounds that “it would be unethical to continue further.” Which raises the question as to why they were begun in the first place…” — it’s not complicated. When they began, there was no experimental evidence proving the connection between circumcision and HIV. As a result of the trials, though, that changed and human knowledge grew.

          • Joseph4GI says:

            “…in the South African trial, for which I quoted the above figures, there were 1,620 men in the circumcision group and 1,654 in the control group.”

            And how many of the men in each group acquired HIV heterosexually?

            Can it be said for a fact that the higher incidence of HIV transmission was a result of not being circumcised?

            “…to calculate risk, we need to consider the men who acquired HIV and those who did not.”

            Exactly what I say.

            If I’m not mistaken, the 60% often bandied about on the media was the difference between only the small subgroups of circumcised and intact men that acquired HIV. Taking into account the men who did not acquire HIV is what yields the absolute 1.38%, which is not as impressive. And then even still, it is being assumed that HIV was sexually transmitted.

            “Your question isn’t meaningful, because it’s not possible to know the exact cause of each case.”

            It is very meaningful. If it is not possible to know the exact cause of each case, then it cannot be safely assumed that all of these men acquired HIV sexually. It is a puzzlement for me to understand how exactly they isolated that the greater number of men that didn’t get HIV because they were “protected” via circumcision.

            How do they do this? Or is it simply assumed, without demonstrable scientific proof whatsoever, that the (tiny, infinitesimally small) difference between intact and circumcised group of men who got HIV was a direct result of circumcision?

            “…it’s possible that it might have been due to chance, for example. But it’s extremely unlikely, and reasonably easy to calculate exactly how unlikely.”

            What needs to be calculated is how many men got HIV as a result of heterosexual HIV transmission, and in how many men did circumcision avert HIV transmission. I can’t see how this is possible without even knowing for sure that circumcision does anything to prevent HIV transmission.

            “…it’s likely that there are multiple mechanisms.”

            None that can be demonstrably proven, is there.

            “When they began, there was no experimental evidence proving the connection between circumcision and HIV.”

            And there still isn’t.

            “As a result of the trials, though, that changed and human knowledge grew.”

            That is, if you call the assertion of opinion, speculation, and wild assumption “growth of human knowledge.”

            On the contrary; invoking “ethics” to prohibit others from confirming scientific findings is an impediment to the growth of human knowledge, not to mention deceptive and self-serving. Circumcision had been an ethical dilemma long before the so-called “trials”; interesting that “ethics” were invoked by “researchers” once they achieved the results they were looking for…

          • Jake says:

            ‘And how many of the men in each group acquired HIV heterosexually?’ — I’ve already addressed that question.

            ‘Can it be said for a fact that the higher incidence of HIV transmission was a result of not being circumcised?’ — And that.

            ‘If I’m not mistaken, the 60% often bandied about on the media was the difference between only the small subgroups of circumcised and intact men that acquired HIV. Taking into account the men who did not acquire HIV is what yields the absolute 1.38%, which is not as impressive.’ — wrong. Both calculations involve all four figures. Call the number of circumcised men who acquired HIV ‘A’, and the number who did not ‘B’. Call the number of uncircumcised men who acquired HIV ‘C’, and the number who didn’t ‘D’. To calculate the absolute risk reduction, calculate the risk in uncircumcised men (C divided by C + D) and subtract the risk in circumcised men (A divided by A + B). Transform the result to a percentage by multiplying by 100. To calculate the relative risk reduction, divide the risk in circumcised men (A/A+B) by the risk in uncircumcised men (C/C+D). Subtract the result from one. Then transform to a percentage by multiplying by 100.

            ‘It is very meaningful. If it is not possible to know the exact cause of each case, then it cannot be safely assumed that all of these men acquired HIV sexually. It is a puzzlement for me to understand how exactly they isolated that the greater number of men that didn’t get HIV because they were “protected” via circumcision.’ — the experimental design ensures that circumcision is the difference between the two groups; since their penis affected the risk, and since the men were heterosexual, heterosexual sex is a reasonable deduction.

            ‘Or is it simply assumed, without demonstrable scientific proof whatsoever, that the (tiny, infinitesimally small) difference between intact and circumcised group of men who got HIV was a direct result of circumcision?’ — that’s the point of randomisation: to ensure that characteristics are evenly divided between the two groups except for the characteristic that is being studied.

            [re mechanisms] ‘None that can be demonstrably proven, is there.’ — I suppose it depends what you call ‘proof’.

            [re experimental evidence] ‘And there still isn’t.’ — that’s your opinion. It’s not reasonable to expect other people to apply your assessments when making their decisions. They will apply their own.

            (Again, I’m replying to Joseph4GI’s post.)

          • Joseph4GI says:

            “I’ve already addressed that question.”

            There’s no way to tell, is there.

            “And that.”

            The so-called “RCT’s” can’t say for sure, can they.

            Thanks for the explanation; still deceptive to present the relative number in lieu of the unimpressive absolute one though…

            “the experimental design ensures that circumcision is the difference between the two groups; since their penis affected the risk, and since the men were heterosexual, heterosexual sex is a reasonable deduction.”

            The “experimental design” assumes heterosexual sex is the only mode of HIV transmission, and that circumcision has any “preventive effect.” Heterosexual sex is in fact not the only mode of transmission, as the men could have acquired it via needle sharing, or iatrogenically at a healthcare facility, which is a big problem in Africa.

            “I suppose it depends what you call ‘proof’.”

            I dunno, usually demonstrable evidence that anyone can observe?

            “‘And there still isn’t.’ — that’s your opinion. It’s not reasonable to expect other people to apply your assessments when making their decisions. They will apply their own.”

            The same can be said about you and *your* opinion.

            Let people apply their own assessments, and not Jake Waskett’s, or mine.

          • Jake says:

            ‘Thanks for the explanation; still deceptive to present the relative number in lieu of the unimpressive absolute one though…’ — I don’t agree. It is, as I say, extremely common (standard practice, even) in epidemiological studies to present the relative risk, and for good reason.

            The absolute risk reduction varies tremendously from one environment to another. For example, in some countries sub-Saharan Africa as much as a quarter of the population are HIV positive, so the risk of HIV transmission per sexual encounter is very high. In developed countries, on the other hand, the HIV prevalence is typically half a percent or less. Suppose one were to test an intervention (condoms, say) that was 80% effective. If you conduct the study in sub-Saharan Africa, the absolute risk reduction will probably be 50 times that if you performed the study in, say, France. But the relative risk reduction is the same.

            Also, the relative risk allows one to produce a rough estimate of the absolute risk reduction (ARR) in a given environment. It allows us to predict the high ARR in sub-Saharan Africa and the low ARR in developed countries. In turn, that allows back-of-the-envelope cost-benefit analyses that show strong arguments for circumcision in some areas and weaker arguments in others.

            ‘Let people apply their own assessments, and not Jake Waskett’s, or mine.’ — I agree, and I’d hope that they will do so.

  • Dan Bollinger says:

    I heard a friend of one of the African researchers say on national radio that the study he worked on was manipulated to show circumcision worked. These “studies” are clearly unethical, making the lead researchers immoral.

    • Rob Pollard says:

      “I heard a friend of one…” So what? We’ve gone to a game of telephone now? People “hear” a lot of things. Give some evidence (or at least link), or get out.

      • John Strand says:

        Mr. Bollinger has indeed previously posted in numerous areas with a great deal of information – so why don’t you look them up yourself before you rudely attack him -
        evidence and links abound – otherwise get out.

  • JimmyWang says:

    It seems the anti-circumcision fanatics always try to find reasons not
    to circumcise.

    The African studies are valid and conclusive according to the Cochrane Institute.

    And if that’s not enough, the circumcision intervention in Africa is working
    even better than the studies showed. So anybody who claims circumcision
    will increase HIV infection is clearly wrong.

    • roger desmoulins says:

      The Cochrane Institute is not the last word on anything. Whether circumcision is effective in blunting the African AIDS epidemic will take at least another 10 years to determine, if only because of “risk compensation.”

    • Joseph4GI says:

      “It seems the anti-circumcision fanatics always try to find reasons not to circumcise.”

      Saving surgery as a very last resort, for when all other methods of treatment have failed happens to be standard medical practice.

      There is something wrong with the logic of “studying” to necessitate surgery.

      What is the goal?

      Is it to reduce HIV transmission, or is it to vindicate your favorite surgery?

      It seems the pro-circs are desperate trying to find any and every reason to circumcise men and children.

      The “research” is unethical and it is bogus. It also fails to correlate with reality; I’m afraid the “reduced” incidence of HIV fails to manifest itself in the real world…

    • Derrick says:

      “It seems the anti-circumcision fanatics always try to find reasons not to circumcise.”

      So the people who promote preserving the human body and saving surgery as an absolute last resort are fanatics now? Yeah, no. If anybody should be called “fanatics”, it’s people like you and the individuals behind these HIV trials who go to any length to justify this practice because it was done to them.

      Anyway, great post, Brian. It’s nice to see some rational voices speaking about this issue for a change.

    • Petit Poulet says:

      I think you pose the question incorrectly. You set up circumcision as the default position. I think cutting on genitals needs to be justified, not the not cutting on genitals. Surgery is a last resort, not the default.

      Rather than rely on the opinions of others, I suggest you read the studies carefully. If you do you find that various forms of bias built into the studies. If you can find where they confirmed that the infections were sexually transmitted, you will get a gold star.

      Not sure how circumcision in Africa where there are eight or more countries where the circumcised men have higher prevalence of HIV infection than the men who are not circumcised. I guess they didn’t get the memo in those countries that they were supposed to a 60% lower risk. The problem is external validity. In an experiment you can design the study to favor the result you want, but that doesn’t happen in the real world.

      • Jake says:

        “Not sure how circumcision in Africa where there are eight or more countries where the circumcised men have higher prevalence of HIV infection than the men who are not circumcised. I guess they didn’t get the memo in those countries that they were supposed to a 60% lower risk” — it’s impractical to sample the circumcision and HIV status of an entire country, so it would be more realistic to say that there have been studies conducted in eight countries where there has been greater HIV prevalence among circumcised men. Unfortunately, such observational studies are highly susceptible to confounding. For example, circumcision status is often associated with location (urban vs rural), which in turn is associated with HIV risk.

        • Joseph4GI says:

          “…it’s impractical to sample the circumcision and HIV status of an entire country…”

          But it’s perfectly practical to apply a relative number that applies to only a tiny subgroup of men to entire populations, right?

          “Unfortunately, such observational studies are highly susceptible to confounding. For example, circumcision status is often associated with location (urban vs rural), which in turn is associated with HIV risk.”

          Additionally, the fact that a person is circumcised and HIV+ does not necessarily mean that he acquired it sexually; sexual intercourse is not the only mode of transmission (the same is true for intact men).

          Hey, you know where else this is a confounding factor?

          • bo says:

            Transmission from routes other than heterosexual sex are less likely to be a confounder in a randomized trial, which is one of the main reasons you do a randomized trial. In a randomized trial, if people are at risk for HIV transmission from other routes, they should be evenly split between the intervention and control groups, because of the randomization. People may get HIV from other routes, but they should be evenly split, contaminating the data from both groups equally. That’s why you try to choose a setting for the trial in which most of the HIV is transmitted through the route you are trying to study. There could still be a confounder related to transmission mechanism here, but it would be a different kind. It would be if something else that puts you at less risk of HIV is related to circumcision, e.g., if people in the circumcision started using fewer IV drugs after the circumcision.

          • Hugh7 says:

            “In a randomized trial, if people are at risk for HIV transmission from other routes, they should be evenly split between the intervention and control groups, because of the randomization. ”
            Not necessarily, if for example their circumcision status puts them at different risks from iatrogenic transmission. It is commonly reported that circumcised men avoid doctors, for example.

          • bo says:

            Replying to Hugh: “Not necessarily, if for example their circumcision status puts them at different risks from iatrogenic transmission. It is commonly reported that circumcised men avoid doctors, for example.”

            In the Uganda trial (and if I remember right, the other trials too), similar numbers of people in each group were lost to follow-up. Actually, slightly more in the control group were lost to follow up.

            • Hugh7 says:

              Yes, and by definition we don’t know why they were lost to follow up, but we need not assume both groups were lost for the same reasons.

              Control group men, but not intervention group men, might drop out because they had changed their mind about getting circumcised – especially if they had talked to the men who had been circumcised. (Since recruitment was by snowball methods, the subjects were all likely to know each other – another source of sampling error.)

              Intervention group men might well drop out after finding out they had HIV (they were encouraged to get tested at another clinic) when they, unlike the control group men, had undergone a painful and marking operation in the hope and expectation of preventing it.

              (Your reply does not actually address my comment that the different groups might be at different risks of iatrogenic transmission.)

              • Hugh7 says:

                And it would take only a handful of such dropouts in each trial to completely destroy the significance of the findings.

  • Mark Lyndon says:

    (I tried posting this earlier ith supporting links. Sorry if it appears more than once)

    Unless men are going to have unsafe sex wth HIV+ women, then how can this possibly help them?

    Male circumcision doesn’t seem to work in the real world anyway. From a USAID report:
    “There appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher.”

    The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups “believe that circumcised men do not need to use condoms”.

    From the committee of the South African Medical Association Human Rights, Law & Ethics Committee :
    “the Committee expressed serious concern that not enough scientifically-based evidence was available to confirm that circumcisions prevented HIV contraction and that the public at large was influenced by incorrect and misrepresented information. The Committee reiterated its view that it did not support circumcision to prevent HIV transmission.”

    The one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw.

    ABC (Abstinence, Being faithful, and especially Condoms) is the way forward.

  • roger desmoulins says:

    It cannot be emphasised enough that the outcome of the African clinical trials tell us nothing about whether it is advisable to circumcise newborns in countries around the North Atlantic. North America and the AIDS belt of eastern and southern Africa are very different kettles of fish. It seems that the Editor of the JAMA cannot see this point. I fear that the AAP Task Force is another entity that will fail to make this distinction.

    Also, why circumcise all newborn males to reduce, allegedly, the frequency of problems that can be eliminated by fidelity and condoms? If the foreskin is unsanitary, why is Europe not in the throes of an epidemic of AIDS and cervical cancer?

    • bo says:

      This is a great point. I feel like people are concerned that this will be taken as a reason to circumcise babies here, and you are quite right that it shouldn’t. Most importantly because our incidence of HIV infections is so much lower. Even if we had similar transmission patterns (we don’t), then we would see the same relative risk reduction, but the absolute risk reduction would be so low here that it wouldn’t be worth it.

      Also, informed consent.

      • Joe says:

        I think that is a well justified concern, especially in countries where circumcision has been common. Informed consent is an important point too, and applies to African children as well. Informed consent and ‘voluntary’ is a concept that many of these programs popping up in Africa seem to not be very concerned with as they shift their targets from older teens and men to infants.

  • Jonathan Urbach says:

    You make some interesting points here, seemingly the most important of which is that circumcision may be used in lieu of condoms, which would lead to disastrously higher rates of transmission of the virus.
    But I find your argument regarding the statistical relevance of “relative reduction in HIV infections” alarmingly lacking. A Fisher exact test using the numbers you provided for sample size of the control and treatment groups gives a p-value of 4.5x10E-113 for the likelihood of that happening by chance alone. In other words, it’s significant. To assert that comparing a small fraction to another small fraction is somehow not valid is extremely misleading.
    Of course the statistics do not tell us what are the are the underlying causes of the observed decrease in HIV infections.

    • Joseph4GI says:

      I’m sure if you data mine enough you’ll find just the numbers you’re looking for…

      Shows you how desperate people are at trying to make this “work.”

      The studies are fabricated, fraudulent and an insult to science, pure and simple.

      But let’s assume they were valid for the sake of argument.

      Would the same “research” be enough to legitimize circumcision in women?

      Is there a magical number of “studies” that would ever forgive the WHO for “recommending” female circumcision ” to reduce HIV” in women?

      The answer is no, they would not.

      Genital mutilation, whether it be wrapped in culture, religion or “research” is still genital mutilation.

      It is mistaken, the belief that the right amount of “science” can be used to legitimize the deliberate violation of basic human rights.

      • Jonathan Urbach says:

        I only used the four numbers I was presented with as my data set. Your assertion that I’m “mining the data to find numbers I’m looking for” reveals that you have an axe to grind, and a disregard for statistics. But I do this kind of statistics all the time, and Brian Earp’s assertion of non-significance of the statistics is wrong.

        I am willing to even allow for the fact that the significance in the statistics reflects an artifact of the way the study was conducted. In that case, these studies results would be indeed as meaningless as you are trying to claim. To assess that would require that I look much more deeply into these studies than I have.

        To be honest, I am vaguely ticked about having my foreskin removed when I was 8 days old. I have a philosophical problem with it, and as far as I’m concerned, there are probably a great many reasons not to have circumcision. If it were me, given the choice, I would personally opt to use condoms and keep my foreskin, rather than be circumcised. And even if the research is solid, and people without foreskins have some degree of protection against catching HIV, it does not remove my philosophical problem with what I too regard as an unnecessary medical procedure on the body.

        I am trying to be objective here. Making misleading statements about stats does not solve the problem, and it does not give anyone credibility.

      • bo says:

        Could you provide evidence that the studies are fabricated? I have heard people having problems with the study design, but I haven’t heard any evidence that they are fabricated.

        • Joseph4GI says:

          The evidence, the circumstances, the flaws you are reading about here, knowing the people who try to use their “research” to justify this, their background, the history of circumcision and circumcision “research” all lead me to believe that this is one giant hoax; perhaps a sort of “last hurrah” circumcision advocates are trying to have for themselves.

          Circumcision and its “benefits” were not discovered yesterday; circumcision is a religious, cultural rite that certain groups have long fought to defend, be it be appeal to “culture,” which fails, and female circumcision is the prime example, or argument of “medical benefits” etc.

          Who are the “researchers” behind all of this? What are their religious convictions? What investment do they have in finding “benefit” in this particular procedure? How long have they been trying to “prove” it’s “beneficial?” What is the reason they don’t use their supposed “findings” to find a solution that doesn’t involve cutting off part of the genitals?

          Knowing the facts, the history, both of circumcision and it’s “researchers” leads me to believe it’s all fake fabrication of fake numbers. How do we confirm the studies even happened? Who is monitoring these “researchers,” aside from others who are working with them? How do I know it’s not all carefully planned, contrived words on paper these people hoped nobody would confirm?

          Just look at all the holes in this so called “research!” Look at how many others have critiqued it. Look at how many other studies fail to arrive at the same conclusion. Look at how many other countries in the world where circumcision is near universal, yet the 40/60 number fails to manifest itself. Other countries in Africa. The Philippines. Malaysia. Bangladesh. The USA.

          The numbers don’t add up. There is no demonstrable causal link. Data from other countries and research is ignored. The “researchers” are hasty in implementing what they’ve been trying to justify for years; the forced mutilation of non-consenting infants.

          This “research” is a disgrace to science and modern medicine, not to mention humanity.

          They are a complete fabrication, and sooner or later this is going to break into the scientific scandal of the century.

        • James Mac says:

          Very telling these pro-circumcision researchers cherry-picked countries where HIV/AIDS was more prevalent in the genitally-intact to carry out their RCTs to determine whether circumcision provided a protective effect from HIV/AIDS.

          There was a greater number of African countries where HIV/AIDS was more prevalent in circumcised men, where researchers *could* have gone to determine whether circumcision increased the risk of acquiring HIV/AIDS. Not part of the plan, it seems.

          Same with Wawers’s follow-up (modern-day Tuskegee) study in Uganda, where women were knowingly exposed to HIV infected men to determine whether women would become infected at a lower rate if their partners were circumcised. Leaving aside the grossly unethical design of the study, it’s very telling the study was halted early (for reasons of ‘futility’) after it was discovered women were becoming infected by circumcised partners at a ~50% higher rate than the genitally intact group, announcing only that circumcision did not protect women from HIV.

          So…, initial results showing a protective effect to men lead to studies being halted early and immediately followed by hyped-up calls for mass circumcision campaigns, while initial results showing an increased risk to women lead to the study being quietly halted early. Seems an increased risk to women was nothing more than an inconvenient result to the pro-circumcision researchers. It should have raised a big red flag, but continues to be ignored.

          For the sake of humanity and the honourable traditions of science, the fraudulent activities (scientific, medical and financial fraud) of all those involved need to be widely exposed with consequences applied.

          • Jake says:

            ‘Very telling these pro-circumcision researchers cherry-picked countries where HIV/AIDS was more prevalent in the genitally-intact to carry out their RCTs to determine whether circumcision provided a protective effect from HIV/AIDS.’ — first of all, what evidence do you have that the researchers did so? And secondly, why on earth would they do so (remember that different countries have different cultural associations with circumcision, meaning that the confounding differs between countries. But an RCT, through randomisation, removes these associations, thus allowing the true effect of circumcision to be measured)?

            ‘Same with Wawers’s follow-up (modern-day Tuskegee) study in Uganda, where women were knowingly exposed to HIV infected men to determine whether women would become infected at a lower rate if their partners were circumcised’ — or, put in less inflammatory terms, women who were already in a sexual relationship with HIV+ men were monitored asa part of the study.

            ‘it’s very telling the study was halted early (for reasons of ‘futility’) after it was discovered women were becoming infected by circumcised partners at a ~50% higher rate than the genitally intact group’ — or, more accurately, the study found no statistically significant differences between the groups. Since the (non-significant) differences occurred among couples who had sex before healing had completed, it would be unreasonable to expect the results to become statistically significant given more time – rather, the effect of early sex would be diluted as the study ran for a longer period. I’m sorry if this seems dull and uninteresting in comparison to your insinuations of wicked deception and conspiracy, but sometimes the real world is mundane.

          • James Mac says:

            The only association the RCTs effectively removed was an association with reality.

          • Joseph4GI says:

            ‘…first of all, what evidence do you have that the researchers did so?”

            It’s not “evidence” as it is observable fact. The “researchers” were careful to ignore countries that didn’t agree with what they wanted to find.

            “And secondly, why on earth would they do so?”

            Because they had the long-standing agenda to vindicate circumcision, as they, as well as others, have been trying to do for at least a century.

            It is disingenuous to present circumcision as this “innovation” that was only discovered yesterday, when it is a historically controversial procedure that “researchers” and religious fanatics have been trying to vindicate for centuries.

            Many researchers, even circumcision advocates like yourself, have deep-seated convictions to present only “evidence” that puts circumcision in a positive light, never research that contradicts it. If needs be, you’ll deny their existence, if not intentionally fail to acknowledge it.

            “…remember that different countries have different cultural associations with circumcision, meaning that the confounding differs between countries…”

            Meaning you’re dismissing real-world data because it disagrees with your pro-circumcision stance.

            “But an RCT, through randomisation, removes these associations, thus allowing the true effect of circumcision to be measured.”

            That is, assuming “randomization” actually happened; the group of men in the studies does not represent a random sample of the population, but men who conscious of HIV transmission and were making a conscious effort to find ways to reduce their chances of HIV transmission. The only thing “random” about these “trials” was what groups the men were put in.

            “…or, more accurately, the study found no statistically significant differences between the groups. Since the (non-significant) differences occurred among couples who had sex before healing had completed, it would be unreasonable to expect the results to become statistically significant given more time – rather, the effect of early sex would be diluted as the study ran for a longer period.”

            Waffle, waffle, waffle, waffle…

            In the end, the studies were ended early because Wawer didn’t find the “protective effect” she was looking for, but discovered, much to her dismay, that there was a tendency in the opposite direction; women were 50% more likely to acquire HIV from a circumcised partner.

            “I’m sorry if this seems dull and uninteresting in comparison to your insinuations of wicked deception and conspiracy, but sometimes the real world is mundane.”

            Dull, uninteresting and false.

            It’s amazing the level to which you try to convince others that you and other circumcision enthusiasts are “dispassionate observers.”

            To learn a bit more about Maria Wawer and her antics, readers should go here:

            http://circleaks.org/index.php?title=Maria_J._Wawer

            Circumcision wasn’t just discovered yesterday; advocates are working ever diligently to clothe a historically controversial procedure with pseudo-science. The concept of using circumcision to “prevent” this or that disease isn’t “new and innovative,” advocates of circumcision have been trying to do this for at least a century. For a timeline on the history of circumcision “research” and the quest to circumcise the masses, readers can go here:

            http://www.whale.to/a/timeline.html

          • Jake says:

            ‘It’s not “evidence” as it is observable fact. The “researchers” were careful to ignore countries that didn’t agree with what they wanted to find.’ — it’s an observable fact that the trials were carried out in South Africa, Uganda, and Kenya. The reason why those countries were chosen is not an observable fact. To support the claim that researchers deliberately chose countries in the expectation that such a choice would favour a particular result, some evidence is needed. You’d have to show that i) evidence of country-wide associations between circumcision and HIV is available, ii) that it was available before the trials began, iii) that the researchers were aware of it, iv) that the researchers expected it to make a difference, and v) that this was the primary consideration in their choice. Finally, you’d have to rule out other explanations (such as, for example, that the researchers simply chose a location where they had done previous work).

            ‘Because they had the long-standing agenda to vindicate circumcision, as they, as well as others, have been trying to do for at least a century.’ — I understand the conspiracy theory; there’s no need to explain that part of it. My point was not about motives but scientific practicality: since RCTs eliminate pre-existing confounding factors, it would not be reasonable to expect the choice of country to make a difference.

            ‘Meaning you’re dismissing real-world data because it disagrees with your pro-circumcision stance.’ — no, meaning that observational studies report differing results because of different confounding factors. This has nothing to do with pro- or anti-circumcision viewpoints; it’s a simple fact.

            ‘That is, assuming “randomization” actually happened; the group of men in the studies does not represent a random sample of the population, but men who conscious of HIV transmission and were making a conscious effort to find ways to reduce their chances of HIV transmission. The only thing “random” about these “trials” was what groups the men were put in.’ — since randomisation actually refers to the division between groups, your point is not obvious.

            ‘In the end, the studies were ended early because Wawer didn’t find the “protective effect” she was looking for, but discovered, much to her dismay, that there was a tendency in the opposite direction; women were 50% more likely to acquire HIV from a circumcised partner.’ — no, as I’ve already explained, there was no statistically significant difference, and the trial was stopped for futility, because it was apparent that it would not find a statistically significant difference either way. Continually alleging some kind of conspiracy, without evidence, and in contradiction to the available facts, is simply daft.

            (Note: this is a reply to Joseph4GI’s comment dated May 24, 2012 at 12:45 pm.)

          • Joseph4GI says:

            “…it’s an observable fact that the trials were carried out in South Africa, Uganda, and Kenya. The reason why those countries were chosen is not an observable fact.”

            It is quite observable that the researchers ignore countries and statistics that do not conform to their pro-circumcision bias. And they have a pro-circumcision bias, which is another observable fact; one only need to look at their curriculum vitaes to see how circumcision is their life’s work.

            “To support the claim that researchers deliberately chose countries in the expectation that such a choice would favour a particular result, some evidence is needed.”

            The evidence is in these “researchers’” previous behavior; the great majority of them had been trying to associate circumcision with a “reduced rate of HIV” for quite some time, and they were determined to do it. There were past failed attempts before the 2006 trials that finally were used by the WHO to “recommend” circumcision as HIV prevention.

            Circumcision is not “new,” it’s a historically controversial procedure that “researchers” have been trying to wrap in pseudo-science for decades.

            “You’d have to show that i) evidence of country-wide associations between circumcision and HIV is available, ii) that it was available before the trials began, iii) that the researchers were aware of it, iv) that the researchers expected it to make a difference, and v) that this was the primary consideration in their choice.”

            If I’m not mistaken, weren’t “researchers” trying to associate circumcision with a reduced HIV transmission rate since 1986, when Aaron J. Fink invented the idea? This would mean that i) The researchers would have been collecting data since then, ii) it would have been plenty of data since before the studies were published in 2006, iii) as the people responsible for collecting it, the “researchers” were full aware, iv) the researchers knew there was a pre-existing difference they could exploit for their antics. v) Their history shows what their intentions were.

            “Finally, you’d have to rule out other explanations (such as, for example, that the researchers simply chose a location where they had done previous work).”

            Of course they would have done previous work; it’s how they knew these were places they could exploit.

            Other places would not produce the desired result because they knew well in advance that the correlations didn’t exist.

            “My point was not about motives but scientific practicality: since RCTs eliminate pre-existing confounding factors, it would not be reasonable to expect the choice of country to make a difference.”

            Well, at least actual, well-executed RCTs are *supposed* to eliminate pre-existing confounding factors; I argue that that these aren’t RCTs at all, but statistics embellished with causation hypothesis.

            There are many reasons these can’t even be called real RCTs, many of which are outlined in this very blog post.

            “no, meaning that observational studies report differing results because of different confounding factors. This has nothing to do with pro- or anti-circumcision viewpoints; it’s a simple fact.”

            You mean like the confounding factors being pointed out in these supposed “RCT’s?”

            This has everything to do with your pro-circumcision viewpoint; pro-circumcision studies are flawless; studies you don’t agree with can be dismissed by “confounding factors” real or imagined.

            In this case I’d take the observational studies over the famed “RCT’s,” as observational studies merely report the status quo and aren’t looking for favor in any one result, and the supposed “RCT’s” were conducted by people with pro-circumcision agendas.

            “…since randomisation actually refers to the division between groups, your point is not obvious.”

            No, “randomized” means a random sample of the population, which these men were not; the only “randomization” WAS the division between groups.

            “no, as I’ve already explained, there was no statistically significant difference, and the trial was stopped for futility, because it was apparent that it would not find a statistically significant difference either way.”

            No, as you keep trying to deny, the trial was stopped because it didn’t find the “statistically significant difference” Wawer was finding for. It was “futile” because the effect she was looking for was not being observed, and in fact was leaning towards the other direction. Wawer admits this herself.

            “Disappointingly, when we looked at the women partners of the (HIV) positive men, who’ve been circumcised, compared to the partners who had not been circumcised, we actually found a slightly higher rate of transmission from the positive circumcised men than from positive uncircumcised men. “~Maria Wawer

            “Continually alleging some kind of conspiracy, without evidence, and in contradiction to the available facts, is simply daft.”

            As is continually denying a conspiracy in fact which is rather obvious. I’m afraid actions speak louder than words…

            Who are you, Jake Waskett?

            What do you do with your life? What are your credentials? What are your interests? What is your connection to circumcision? Do you actually care about the HIV epidemic? Or only in as much as it pertains to the vindication of circumcision?

            Who is Vernon Quaintance?

            What is Gilgal Society?

            People can read about who you are here:

            http://circleaks.org/index.php?title=Jake_H._Waskett

            Before you pretend to be a victim of “ad-hominem,” let me post what Wikipedia has to say on “ad-hominem” and conflict of interest:

            “Conflict of Interest: Where a source seeks to convince by a claim of authority or by personal observation, identification of conflicts of interest are not ad hominem – it is generally well accepted that an “authority” needs to be objective and impartial, and that an audience can only evaluate information from a source if they know about conflicts of interest that may affect the objectivity of the source. Identification of a conflict of interest is appropriate, and concealment of a conflict of interest is a problem.”

            Are you as “dispassionate” as you try to portray yourself to be?

            Let people come to their own conclusions.

          • Jake says:

            ‘It is quite observable that the researchers ignore countries and statistics that do not conform to their pro-circumcision bias. And they have a pro-circumcision bias, which is another observable fact; one only need to look at their curriculum vitaes to see how circumcision is their life’s work.’ — well, I just searched PubMed for articles by B. Auvert. 22 of 101 (roughly a fifth) were about circumcision. 53 of the 157 results for RC Bailey (roughly a third) were about circumcision. And 54 of 356 (roughly a seventh) of the results for RH Gray were about circumcision. So I’d agree that it’s clearly a research interest.

            ‘The evidence is in these “researchers’” previous behavior; the great majority of them had been trying to associate circumcision with a “reduced rate of HIV” for quite some time, and they were determined to do it.’ — at best that’s a possible motive. That’s a long way from providing evidence that the choice was intentional.

            ‘Circumcision is not “new,” it’s a historically controversial procedure that “researchers” have been trying to wrap in pseudo-science for decades.’ — So you keep saying.

            ‘If I’m not mistaken, weren’t “researchers” trying to associate circumcision with a reduced HIV transmission rate since 1986, when Aaron J. Fink invented the idea?’ — Alcena was actually the first to suggest a link. In any case, that doesn’t address any of the issues I’ve raised.

            ‘Of course they would have done previous work; it’s how they knew these were places they could exploit.’ — basically, you’re determined to interpret absolutely anything as a sign of ill intent, aren’t you?

            ‘There are many reasons these can’t even be called real RCTs, many of which are outlined in this very blog post.’ — and, as I showed, those criticisms don’t stand up to scrutiny.

            ‘No, “randomized” means a random sample of the population, which these men were not’ — http://www.medterms.com/script/main/art.asp?articlekey=38700

            ‘No, as you keep trying to deny, the trial was stopped because it didn’t find the “statistically significant difference” Wawer was finding for. It was “futile” because the effect she was looking for was not being observed, and in fact was leaning towards the other direction. Wawer admits this herself.’ — nothing in the words you quote contradicts what I have said.

          • Joseph4GI says:

            “So I’d agree that it’s clearly a research interest.” – And if readers were to look up more on what they’ve actually said and how hard they’re using their “research” to push circumcision, they’d observe a clear bias.

            “at best that’s a possible motive. That’s a long way from providing evidence that the choice was intentional.”

            (See above…)

            “So you keep saying.”

            And it’s true.

            http://www.whale.to/a/timeline.html

            “Alcena was actually the first to suggest a link. In any case, that doesn’t address any of the issues I’ve raised.” – But it does demonstrate how long “researchers” have been trying to establish a link. Which was a point *I* was trying to make.

            “basically, you’re determined to interpret absolutely anything as a sign of ill intent, aren’t you?”

            Let readers look up these “researchers” and “interpret” for themselves.

            “…as I showed, those criticisms don’t stand up to scrutiny.”

            You haven’t actually showed anything, just merely waved your hand…

            Fortunately, readers can look for themselves and decide if the criticisms “stand up to scrutiny” or not.

          • Jake says:

            ‘And if readers were to look up more on what they’ve actually said and how hard they’re using their “research” to push circumcision, they’d observe a clear bias.’ — I’m not so sure. I don’t observe a clear bias. But, of course, I have my own biases, as do you, and our biases may be affecting our perception.

            ‘And it’s true. http://www.whale.to/a/timeline.html‘ — wow. A collection of statements made about circumcision (some sensible, some silly) during the course of 170 years. Sorry, I don’t find that persuasive; it’s barely even a coherent argument.

            ‘But it does demonstrate how long “researchers” have been trying to establish a link. Which was a point *I* was trying to make.’ — I think one of the difficulties we’re facing is that you seem to insist upon viewing researchers as an indivisible unit with a single mind, akin to the Borg of Star Trek. It makes it very hard to follow your theories.

          • Joseph4GI says:

            “I don’t observe a clear bias. But, of course, I have my own biases, as do you, and our biases may be affecting our perception.”

            Thank you, Jake, this actually the first time I’ve seen you admit you may have a bias. I don’t have trouble admitting mine. Fortunately others can look up the “researchers” of circumcision and form their own conclusions.

            “wow. A collection of statements made about circumcision (some sensible, some silly) during the course of 170 years. Sorry, I don’t find that persuasive; it’s barely even a coherent argument.”

            That’s ok; I’m sure others will…

            “I think one of the difficulties we’re facing is that you seem to insist upon viewing researchers as an indivisible unit with a single mind, akin to the Borg of Star Trek. It makes it very hard to follow your theories.”

            When one looks at the literature, who writes it, what other “researchers” are involved, it becomes clear that all of them are in fact, connected with each other and actually do function as “one mind” as you put it. It’s not actually as complicated as you would like to lead others to believe.

            Readers ought to study the history of circumcision “research,” it’s authors and their behavior. One will observe that there is a pervading attitude to get authorities to endorse “mass circumcision.” The conclusion to much of these studies tends to be “and this is why all men and boys must be circumcised.”

            Readers don’t have to take mine or your word for it; they can study the history and judge for themselves.

          • Jake says:

            ‘Thank you, Jake, this actually the first time I’ve seen you admit you may have a bias. I don’t have trouble admitting mine.’ — everyone has biases, Joseph, and I’m no exception. I respect these authors, and admire much of their work. That’s a bias: it makes me inclined to defend them. Even something as simple as finding it incredibly distasteful to dismiss unfavourable scientific findings by attacking the authors is a bias, since it makes one instinctively want to show that such attacks are invalid. I have that bias, as well. Simply being involved in the circumcision debate, being repeatedly attacked, generates a bias, since it produces unfavourable feelings towards our opponents, and one naturally wants to prove wrong those who we dislike. That’s another bias. I have plenty.

            So we all have biases. The key is to compensate for those biases through rigorous application of logic, mathematics, and evidence. A logical statement is either correct or it is not, regardless of the biases of the person who states it. The same is true of mathematics, and of evidence.

            In this particular case, you could start by identifying these authors’ publications and what constitutes evidence of bias on their part. But I think that a major difficulty will present itself, and that’s that what you interpret as “pro-circumcision bias” could just as easily be interpreted as a relatively unbiased scientist finding a result favourable to circumcision. You may merely perceive this as bias because you’re so hostile towards circumcision that you find the prospect of a fact favourable to circumcision impossible to accept. That is to say, the terrible bias you perceive may be nothing more than your own reflection.

          • Joseph4GI says:

            “everyone has biases, Joseph, and I’m no exception. I respect these authors, and admire much of their work. That’s a bias: it makes me inclined to defend them.”

            You are also a known circumcision fanatic who has been observed online by other intactivists for years. You are tenacious in your defense for circumcision, and only turned to “science” because you have an interest in advocating and defending circumcision, not in actual disease prevention.

            My bias is towards the preservation of the human body, and the respect of human rights. I cannot respect authors who make it a point to legitimize the deliberate destruction of the human body, especially the destruction of the bodies of healthy, non-consenting children. I respect authors who seek to prevent disease, keeping the respect of bodily integrity and the rights of the innocent in mind. I respect authors who want to learn how the human body works, not find reasons to treat it with disrespect like a piece of garbage.

            “Even something as simple as finding it incredibly distasteful to dismiss unfavourable scientific findings by attacking the authors is a bias, since it makes one instinctively want to show that such attacks are invalid. I have that bias, as well.”

            Your bias is in the defense of circumcision and the authors who produce, or seemingly produce, the results that support your myopic case. You do not find it “incredibly distasteful” that I dismiss “unfavorable scientific findings by attacking the authors,” you cannot stand that anyone would dare question the “research” that supports your cause, and point out bias and ulterior motive in the “authors” that produce it.

            You want your readers to believe that circumcision was “discovered” as a “mode of prevention” just recently through “research,” when the circumcision debate has been going on for a few centuries, and this is not the first time “researchers” have been trying to make a case for circumcision by finding “benefits” through “research.”

            People have more convictions to defend circumcision than they will declare on their papers. People with such convictions have incentive to withhold negative findings, exaggerate positive findings, even outright lie about them. And advocates who aren’t “researchers” themselves will take the published “findings” and run with them.

            It shouldn’t be considered “attacking authors” and defenders of circumcision to point out what their conflicts of interest are, when they’re failing to declare them on the papers they publish and/or refer to.

            They have reasons other than a genuine interest in public health to be writing circumcision “studies,” and I have reasons vested in a conviction for truth and the respect for the rights and intelligence of others for wanting to point them out.

            Others have a right to know the objectivity of a source. Pointing out conflicts of interests in others need not be considered “personal attack.”

            “Simply being involved in the circumcision debate, being repeatedly attacked, generates a bias, since it produces unfavourable feelings towards our opponents, and one naturally wants to prove wrong those who we dislike. That’s another bias. I have plenty.”

            Also, choosing to get circumcised as an adult to fulfill a childhood fantasy, belonging to pro-circumcision circles, many of which aren’t modest about their sexual fixation on circumcised penises and the act of circumcision itself, being affiliated with Brian Morris who wants the Australian government to make circumcision mandatory, not to mention Vernon Quaintance who very recently was caught with child porn tapes (gee I wonder what was on them…)… Yes, indeed you have plenty of biases, but there is a problem if you dislike those who have the gall to point them out. (Perhaps that in and of itself is another bias?) It is certainly juvenile if you are trying to “prove wrong” people because they demand truth, clarity and integrity.

            “So we all have biases. The key is to compensate for those biases through rigorous application of logic, mathematics, and evidence. A logical statement is either correct or it is not, regardless of the biases of the person who states it. The same is true of mathematics, and of evidence.”

            Compensate? Or hide?

            A bias will also cause one to apply faulty logic, skewed mathematics and misrepresent evidence, if even present it at all. In some cases, a bias will also cause one to deny the existence of evidence. An illogical statement can be made to sound correct, even when it is not, by a biased person. In order for others to evaluate what you say effectively, it is necessary for them to know what your potential conflicts of interest may be.

            You present what appears to be “strong evidence” in favor of male circumcision. But how strong is the evidence? Are you presenting it accurately, or are you exaggerating it? Are you presenting ALL of the evidence? Or merely that which supports your case? There is reason to believe that what you present isn’t the whole picture, that you may be exaggerating numbers that support your case, while dismissing those that don’t, and people need to know why.

            I didn’t wake up one day and think to myself “Today is a good day to hate Jake Waskett.” You have a history, and reason to make sure circumcision is only presented in a positive, and never in a negative light. People need to know this before they evaluate what you say.

            People also have a right to know that I am an activist for human rights, and am against the forced genital mutilation of children, and I actively speak out against the practice. But then, this is something that I will not deny if you tell others. On the contrary, I will proudly declare it.

            “In this particular case, you could start by identifying these authors’ publications and what constitutes evidence of bias on their part. But I think that a major difficulty will present itself, and that’s that what you interpret as “pro-circumcision bias” could just as easily be interpreted as a relatively unbiased scientist finding a result favourable to circumcision.”

            Maybe it might be “unbiased scientific finding” of a “favorable result to circumcision.” Maybe. Or, it may be clearly biased presentation, and you and others want to declare it as “unbiased.” There is only one way to tell; readers who are interested in finding out need to look into the history of circumcision itself. They need to investigate the authors, how long they’ve investigated, what they can be quoted saying (and you won’t find this on PubMed), and what they can be seen doing; actions speak louder than words. A pro-circumcision bias is easily interpreted as “relatively unbiased” by those with a pro-circumcision bias. You see, to an advocate of circumcision, penises are circumcised by default, while having a foreskin is a forced phenomenon that a doctor inflicts on a child at birth by sewing it on. To an advocate of genital integrity, the penis with a foreskin is an intrinsic part of basic human anatomy found in all males at birth. Who’s biased? Those defending their natural bodies? Those defending a non-action? Or is it those who defend an artificial, forced phenomenon? I’ll let readers decide for themselves.

            “You may merely perceive this as bias because you’re so hostile towards circumcision that you find the prospect of a fact favourable to circumcision impossible to accept. That is to say, the terrible bias you perceive may be nothing more than your own reflection.”

            It could be that I have a bias. But an external observer needs to ask; who has the bias? Who has the axe to grind? Is it those who want to defend a non-action in lieu of better ways to afford “medical benefits?” Or is it those who wish to defend a historically controversial practice, who are most likely subjects of it, or conductors of it themselves?

            Who is projecting? Who is the pot, who is the kettle?

            I’ll leave this to external readers to decide.

            If it can be proven to me scientifically, that circumcision indeed may have a “benefit,” I will accept; I have no choice.

            I will still insist that scientists need to find ways to provide this same “benefit” without circumcision. I will demand they isolate the mechanism, and investigate ways for them to replicate it without the need to destroy the human body. You might say I have a bias in favor of the foreskin, but isn’t it standard medicine to investigate the root of the problem? To save surgery as a very last resort? When a man has toe fungus, does the doctor recommend amputation of the toes? Or does he seek ways to stop the fungus from growing? If a child develops ear infection, does a pediatrician indicate surgery to remove the ear, or does he treat the infection? Perhaps circumcision may prevent HIV somehow. But if so, then why not find out how the foreskin facilitates HIV transmission, and develop a drug that stops this from happening without removing the foreskin?

            Do doctors have a “bias” in favor of toes or ears for advising against amputating them “to prevent disease?”

            Favoring medical treatment over surgical removal is not so much a “bias” in favor of anything as it is standard medical practice.

            If it can scientifically be demonstrated that the foreskin facilitates HIV transmission, and that removing it “reduces” it, then I will accept the fact.

            I will still insist it be an older man’s choice to decide whether he wants to become circumcised over using condoms, and I will insist that doctors use their knowledge of the mechanism of HIV transmission to find ways to reduce it without the need for surgery.

            So what is it?

            What is the mechanism whereby the foreskin facilitates HIV transmission, and circumcision reduces it?

            A “protective effect” needs to be proven that it exists before it can be measured. Probably the biggest problem the latest “studies” have is that they all begin by assuming to be true apriori that which they’re trying to prove.

            It is irrefutable fact; scientists don’t know for sure that the “results” they see in their “research” is truly caused by circumcision or not; this is pure assumption and unproven opinion.

          • Bo says:

            Replying to Joseph4GI.

            The investigators in the African trials did not assume a priori that circumcision prevents HIV transmission, as you assert. In fact, the null hypothesis (the hypothesis assumed to be correct) was that circumcision would not affect HIV transmission. Based on their results, the rejected the null hypothesis.

            • Hugh7 says:

              They carried out their research on the basis of the fallacy that correlation is causation, using cherrypicked data from countries with different circumcision rates and HIV rates – where data based on man-against-man comparisons show no such correlations. Their subsequent enthusiasm for circumcision goes far beyond what the data show – for example, there is no evidence that infant circumcision has any effect on HIV acquistion.

          • Jake says:

            ‘You are also a known circumcision fanatic who has been observed online by other intactivists for years. You are tenacious in your defense for circumcision, and only turned to “science” because you have an interest in advocating and defending circumcision, not in actual disease prevention.’ — I think that’s an example of, as you’ve put it yourself, beginning by assuming to be true a priori that which you’re trying to prove. :-)

            ‘I cannot respect authors who make it a point to legitimize the deliberate destruction of the human body…’ — what do you mean by “make it a point to legitimize the deliberate destruction’? For example, if a scientist researches whether circumcision affects a given disease, is he “making it a point to legitimize deliberate destruction”? Or does he have to do something else? If so, what? (And if you could explain in non-inflammatory terms, that would be greatly appreciated.)

            ‘You do not find it “incredibly distasteful” that I dismiss “unfavorable scientific findings by attacking the authors,” you cannot stand that anyone would dare question the “research” that supports your cause, and point out bias and ulterior motive in the “authors” that produce it.’ — I find it very amusing that you’re trying to tell me what I think. (Or perhaps you’re about to tell me that I don’t find it amusing. I wait with interest to find out what I think!)

            ‘You want your readers to believe that circumcision was “discovered” as a “mode of prevention” just recently through “research,” when the circumcision debate has been going on for a few centuries, and this is not the first time “researchers” have been trying to make a case for circumcision by finding “benefits” through “research.”’ — I would suggest that those two statements are not mutually exclusive. Yes, those arguing for circumcision in the past have cited evidence in support of their position. Similarly, those arguing against have likewise cited evidence in support of their arguments. Some of the evidence cited in the distant past was extremely poor, by modern standards.

            ‘People have more convictions to defend circumcision than they will declare on their papers. People with such convictions have incentive to withhold negative findings, exaggerate positive findings, even outright lie about them.’ — I find it interesting that you make this accusation only against your opponents. In reality, I think it’s always possible that anyone will lie, but it’s unlikely, and the potential consequences are serious, which generally keeps people honest.

            ‘It shouldn’t be considered “attacking authors” and defenders of circumcision to point out what their conflicts of interest are’ — I’d agree to a certain extent, but there is a difference between “pointing out a conflict of interest” and “making a personal attack”. You seem to think, judging by your actions here and elsewhere, that you can make whatever attacks you like as long as you call them “conflicts of interest”. Claiming that someone is biased and refusing to back that up with evidence is a classic example of a personal attack.

            ‘They have reasons other than a genuine interest in public health to be writing circumcision “studies,” and I have reasons vested in a conviction for truth and the respect for the rights and intelligence of others for wanting to point them out.’ — but, as you freely admit, you’re passionately opposed to what you view as genital mutilation, so the personal attacks you make in pursuit of truth and respect are awfully convenient for your cause…

            ‘Also, choosing to get circumcised as an adult to fulfill a childhood fantasy, belonging to pro-circumcision circles, many of which aren’t modest about their sexual fixation on circumcised penises and the act of circumcision itself, being affiliated with Brian Morris who wants the Australian government to make circumcision mandatory, not to mention Vernon Quaintance who very recently was caught with child porn tapes (gee I wonder what was on them…)’ — believe what you choose, Joseph. I’m sure you will anyway.

            ‘Compensate? Or hide?’ — the goal should be to make our biases unimportant.

            ‘A bias will also cause one to apply faulty logic, skewed mathematics and misrepresent evidence, if even present it at all’ — really? It “will” cause one to do so? That’s an extraordinary claim to make.

            ‘You have a history, and reason to make sure circumcision is only presented in a positive, and never in a negative light. People need to know this before they evaluate what you say.’ — I’m not sure if that’s true, but what of others, Joseph. What about people who only present circumcision in a negative light. Do people need to know about that, too?

            ‘It could be that I have a bias. But an external observer needs to ask; who has the bias? Who has the axe to grind? Is it those who want to defend a non-action in lieu of better ways to afford “medical benefits?” Or is it those who wish to defend a historically controversial practice, who are most likely subjects of it, or conductors of it themselves?’ — I’d suggest that you’re asking the wrong questions. You’re essentially asking which position is morally superior (in your extremely one-sided framing of the issue), but that’s not the same question as who is biased. People can be biased in favour of what is “good” just as easily as they can be biased in favour of what is “bad”. For example, try asking a person a scientific question in such a way that there is an implication that a particular answer will save the life of a child. Most people will be biased towards giving that answer. That’s a morally good bias, but it’s still a bias.

            ‘If it can be proven to me scientifically, that circumcision indeed may have a “benefit,” I will accept; I have no choice.’ — I doubt that you’ll ever acknowledge the proof.

          • Joseph4GI says:

            “I think that’s an example of, as you’ve put it yourself, beginning by assuming to be true a priori that which you’re trying to prove.”

            I’m afraid denial and feigning dissimulation will not erase your recorded past, Jake, sorry…

            ” what do you mean by “make it a point to legitimize the deliberate destruction’? For example, if a scientist researches whether circumcision affects a given disease, is he “making it a point to legitimize deliberate destruction”?”

            If he writes failed study after failed study until he gets one with the positive results he’s looking for, as opposed to investigating other more effective, less invasive modes of prevention, yeah, I’d say he’s on a mission. Scientists should be seeking to prevent disease, not devalue the human body.

            “Or does he have to do something else? If so, what? (And if you could explain in non-inflammatory terms, that would be greatly appreciated.)”

            So glad you asked! Each researcher has their own different reasons for wanting to produce “research” with positive results for circumcision, but I’ve narrowed it down to four major reasons.:

            1, cultural bias; an author may be part of a culture where circumcision is the norm. He may be circumcised himself, or she may have allowed her male children to be circumcised, or s/he may be married to a circumcised spouse. There is a determination to justify what has happened to one’s self, what happened to a partner, or what s/he may have allowed to his/her children.

            2. Religious bias; this one’s easy. It is no secret that circumcision is important to Islam, some African tribal cultures, and it is central to Judaism. In fact, Jews cling tenaciously to the practice, and mark in their history times when governments in the countries in which they lived tried to ban it. Especially in the recent past, circumcision has been heavily scrutinized, as you see it happening here, and “religious freedom” and “parental choice” are no longer valid alibis for the circumcision of children. For this reason, even the most devout rabbis cite “research” of the so-called “benefits” of circumcision. Pseudo-medical reason is necessary because Jews can no longer claim religious immunity. It is no surprise, then, that a disproportionate number of “researchers” and authors of “studies” that “prove” circumcision is “medically beneficial” happen to be Jewish. Throughout the history of circumcision as “medicine,” a number of Jewish “researchers” have tried to associate circumcision with the prevention of some horrific disease. Abraham Wolbarst was solely responsible for the invention of the myth that circumcision rendered males immune to penile cancer, for example. In response to the fact that many physicians were speaking out against circumcision, and the fact that insurance companies started dropping coverage for circumcision, Aaron J. Fink started heavily promoting the idea that circumcision prevents HIV transmission, which he admits even at the time, that he had no proof for. (Note: There still is no proof.) Other Jewish scientists, such as Daniel Halperin took this idea and ran with it. Edgar Schoen has tried to sell the idea that countries should adopt “mass circumcision” for all boys in many countries, but he was rejected wherever he went. He has tried to use his influence to sway the AAP, and is responsible for their currently wishy-washy stance (the AAP took a firmer stance against the practice, but they changed their tune as soon as Schoen became chair of the AAP Circumcision Taskforce.) Operation Abraham from Israel is busy trying to promote circumcision as HIV prevention in Africa, and they’ve gone to other countries, such as the USA and countries in South America to do this. Tsemeret Fuerst heads the PrePex company which currently hopes to circumcise 20 million Africans in the so-called name of HIV prevention. Pure coincidence? A genuine interest in disease prevention? Or strategic insulation of a practice historically controversial for Jews? Readers need to read up on the history and decide for themselves.

            Readers should note: Circumcision is very important to all Jews, even Jews that call themselves “non-practicing,” “agnostic” and/or “atheist.” Jewish anthropologist Leonard Glick notes in his book Marked in Your Flesh how even “atheist” Jews will circumcise their children just to please the family and social circles in which they live. The conviction to defend circumcision runs deep, even for Jews who say they are non-practicing.

            3. Finance: the most obvious one. Of course, if circumcision is your livelihood, you don’t want to report negative findings. You want nothing but positive findings, and have financial incentive to not publishing negative findings, if not outright deny them. Circumcision is a money maker; doctors can charge from 100 US dollars to 300, but figures of 400 to 500 are not unheard of. It’s a relatively simple procedure that does only take a few minutes, and doctors can do a few at a time. In America alone, 1.3 million boys are circumcised annually. At a dollar a head, that’s already 1.3 million dollars. Now multiply that by 100, and that figure grows exponentially. 300 or 500, and that’s even more.

            And that’s just the procedure; circumcision entails procedure-specific equipment and utensils. The clamps used aren’t free, for example. The circumstraint board to which they tie the child for the operation also costs money. In Africa, where “mass circumcision” campaigns are being carried out, there is the necessity for “circumcision packs” that manufacturers prepare and sell. Some manufacturers of circumcision equipment are vying for a piece of the HIV fund pie. David Tomlinson wants to sell his AccuCirc device there for example. (He happens to be the “chief expert on circumcision,” at the World Health Organization. Go figure…) PrePex is hoping to sell 20 million devices at around 20 to 30 US dollars each. Malaysian manufacturers were trying to market the TaraKlamp in Kwazulu Natal. Will these companies be interested in negative figures for circumcision? Can they be trusted in fully informing the African men they’re trying to circumcise?

            4. And finally, a bias sicker than the rest; circumfetishism. There are those on the Internet who have a sexual fixation for the circumcised penis, and/or derive sexual gratification from the act of circumcision itself. Some call them circumfetishists. They gather in groups to discuss the erotic stimulation they experience by watching other males being circumcised, swap erotic fiction and trade videotapes of actual circumcisions, and justify circumcision and their enthusiasm for it by wrapping it in pseudo-scientific jargon. Gilgal Society is one such group, based in the UK.

            Other circumfetish groups exist, such as Circlist, Acorn Society, and the Cutting Club, and they openly admit to a morbid fascination with circumcision to the point of sado-masochistic fetish. These groups advertise that doctors are among their members. Furthermore, there are anecdotal accounts of doctors becoming sexually aroused when circumcising boys. Circumcision certainly provides an opportunity not only to handle boys’ penises without the condemnation that a sexual assault (in the sense that phrase is normally used) would attract, but also the opportunity to exercise power over another human being, to alter the penis and to control it and the boy’s future sexual life.

            (The paragraph above is an excerpt from “In Male and Female Circumcision, Medical, Legal, and Ethical Considerations in Pediatric Practice,” Denniston GC, Hodges FM and Milos MF eds., Kluwer Academic/Plenum Publishers, 1999, New York; 425-454)

            Very recently, head of Gilgal Society Vernon Quaintance was caught with graphic footage of child abuse. People in the know can only imagine what was on those tapes.

            Vernon Quaintance is only the beginning. It ought to concern people that many prominent “circumcision experts” are members of, or closely associated with Gilgal Society, and/or other circumfetish groups. Some circumcision “experts” would like their audience to believe that they are “objective,” “impartial,” and/or “dispassionate” authorities on the matter of circumcision, when, in fact, they are passionate circumcision enthusiasts, quite a few who are members of circumfetish groups, such as mentioned above.

            Jake Waskett can be included as a member of CircList, and as someone who closely corresponds (corresponded?) with Vernon Quaintance. Some conversations between them are available on record.

            Jake closely associates with Australian circumcision enthusiast Brian Morris, who, up until recently, used to publish pamphlets where his name appeared along side the Gilgal Society logo. Brian Morris has since tried to scrub clean any association he had with Gilgal Society.

            The peculiar thing about the pamphlets Brian Morris used to put out is that the names of many prominent circumcision “researchers” and people who claim to be “experts” on circumcision appear on them.

            Bertran Auvert, Robert Bailey, and Daniel Halperin appear as authors. These are some of the prominent men who are flooding the medical literature with “studies” that say circumcision “reduces HIV transmission,” as well as other diseases.

            Thomas Wiswell, author of debunked circumcision/UTI “research” that has been long dismissed by authorities such as the AAP, appears as an author on one of the Morris/Gilgal pamphlets.

            So does Edgar Schoen.

            So does Jake Waskett.

            To see the pamphlets that Brian Morris used to distribute up until today, go here:

            http://circleaks.org/images/e/e5/Gilgal_For_Women_leaflet.pdf

            http://circleaks.org/images/c/c8/Gilgal_Parents-Guide.pdf

            “Bias” or pure “coincidence?”

            Conspiracy in theory? Or conspiracy in fact?

            Am I crazy for concluding that all of these “researchers” are in this together?

            I’ll let the readers decide.

            “I find it very amusing that you’re trying to tell me what I think. (Or perhaps you’re about to tell me that I don’t find it amusing. I wait with interest to find out what I think!)”

            What I find amusing is how you’re trying to pretend to be dissimulated; like people don’t actually know what you think!

            You’re on record, sir, explain yourself.

            Or not, you can keep denying what we know about you, it’s your choice…

            “Yes, those arguing for circumcision in the past have cited evidence in support of their position.”

            More accurately, they tried to garner support for their pre-determined position by writing “research” that others would see through in the future. They were looking to push an agenda, not find any new knowledge or information about the human body. Often “researchers” have ulterior motives that aren’t declared on their “research.”

            “Similarly, those arguing against have likewise cited evidence in support of their arguments.”

            Those arguing against spend most of their time trying to undo the lies that circumcision “researchers” have spun. Remember, it is circumcision advocates who have an action to defend.

            “Some of the evidence cited in the distant past was extremely poor, by modern standards.”

            Sooner or later, “evidence” is going to be futile.

            There would never be enough “evidence” or “medical benefits” for health organizations to endorse female genital cutting; human rights and ethics would take precedence.

            Thanks to the discussions like these which are finally happening, the same will be true of male circumcision.

            “I find it interesting that you make this accusation only against your opponents.”

            It shouldn’t be too surprising; remember, those against circumcision are defending a non-action. History shows it is circumcision advocates who have an axe to grind.

            “In reality, I think it’s always possible that anyone will lie…”

            But circumcision advocates have way more incentive; there is a lot more at stake for them. Coming to terms that one has been mutilated or has allowed his/her children to be mutilated, revising “thousands of years of tradition,” losing an easy, hefty stipend, facing lawsuits etc.

            What is at stake for us? Do we have some sort of ritual where we sow on a foreskin onto a baby? What “tradition” do we make out of an unconscious non-action? (We don’t celebrate allowing a child to keep his/her eyelids, ears, nose, labia, those are just normal parts of the human body…) What money do those who advocate leaving healthy organs alone have to lose? What lawsuits do doctors have to face for not reaping profit from not performing surgery on a healthy patient?

            Who has more of an incentive to lie?

            I leave readers with this question.

            “…but it’s unlikely, and the potential consequences are serious, which generally keeps people honest.”

            At least in theory.

            Potential consequences are serious for those who get CAUGHT. And even then, history is full of examples where people use loopholes people can use to evade responsibility. Yitzchok Fischer is still at large, even though he killed a baby by infecting his circumcision wound with herpes via oral suction, and it’s been reported he has killed a few more babies, and hospitalized others. The Jewish community will not allow the city of New York to issue a warning against the practice of traditional oral suction lest they claim “anti-Semitism.”

            It would be nice if people faced consequences for their actions; then maybe people would be more honest.

            Most unfortunately, that’s just not the way the world works…

            “I’d agree to a certain extent, but there is a difference between “pointing out a conflict of interest” and “making a personal attack”.”

            There is. And you can’t pout “personal attack” every time people point out yours.

            “You seem to think, judging by your actions here and elsewhere, that you can make whatever attacks you like as long as you call them “conflicts of interest”.”

            And you seem to think you can evade having to declare your conflicts of interest by claiming “personal attacks.”

            “Claiming that someone is biased and refusing to back that up with evidence is a classic example of a personal attack.”

            Actually, wherever possible, I provide links to my claims. It is not my fault you disregard records of your own past as evidence.

            Answer the questions posed to you about yourself instead of running in a cave screaming “personal attack.”

            Who are you, Jake Waskett?

            What are your credentials?

            Where did you go to school?

            With what authority do you feel you can make medical value judgements?

            With what authority do you take a position against the medical organizations in the West?

            Why should anyone take your word over Brian Earp? Boyle and Hill? Sorrels? Van Howe and Storms?

            Are you an epidemiologist? A pediatrician? A surgeon? A urologist? Surely you must at least have SOME kind of medical degree?

            What is it?

            What is your affiliation with Brian Morris of the University of Sidney?

            What correspondence do you have with him?

            What is Gilgal Society?

            Who is Vernon Quaintance?

            What is your affiliation with him?

            What is CircList?

            Tell us about your affiliation, or non-affiliation with CircList and Gilgal Society.

            Who is Dr. Zarifah?

            Tell us, Jake Waskett.

            Answer these questions, and then tell us why they should not be considered “conflict of interest,” but a “personal attack.”

            I’ll repeat what WikiPedia has to say on “Ad hominem” (AKA: personal attack):

            Conflict of Interest: Where a source seeks to convince by a claim of authority or by personal observation, identification of conflicts of interest are not ad hominem – it is generally well accepted that an “authority” needs to be objective and impartial, and that an audience can only evaluate information from a source if they know about conflicts of interest that may affect the objectivity of the source. Identification of a conflict of interest is appropriate, and concealment of a conflict of interest is a problem.

            Don’t hide your answers, Jake Waskett. Concealment of them is a problem.

            “but, as you freely admit, you’re passionately opposed to what you view as genital mutilation, so the personal attacks you make in pursuit of truth and respect are awfully convenient for your cause…”

            They are not “personal attacks” if they are TRUE, Jake.

            Now, answer the questions posed to you.

            Watch you evade and not answer a one.

            Coward.

            “…believe what you choose, Joseph. I’m sure you will anyway.”

            Answer, Jake.

            Type in the reply box that you don’t know what I’m talking about.

            Do it.

            Intactivists are recording your every step. You know that right?

            Your words are on record.

            “the goal should be to make our biases unimportant.”

            The goal should be to declare our biases so that people can verify the objectivity of their sources.

            “‘A bias will also cause one to apply faulty logic, skewed mathematics and misrepresent evidence, if even present it at all’ — really? It “will” cause one to do so? That’s an extraordinary claim to make.”

            It shouldn’t be too surprising…

            But then again, a skunk can’t smell its own stink…

            Or maybe it does but will continue to deny it anyway…

            “I’m not sure if that’s true, but what of others, Joseph.”

            Worry about yourself first.

            “What about people who only present circumcision in a negative light. Do people need to know about that, too?”

            Yes, others need to know about people who only present circumcision in a negative light, and why.

            The difference here is, said people don’t actually deny their interests, like you do.

            “I’d suggest that you’re asking the wrong questions. You’re essentially asking which position is morally superior (in your extremely one-sided framing of the issue), but that’s not the same question as who is biased.”

            No, I think the questions I asked were quite clear, and they do not need to be re-interpreted.

            Circumcision was not discovered yesterday; it has history and people have fought to defend and preserve it. It is a money maker. It is the object of some people’s sexual fantasies.

            While having a foreskin is a non-action, circumcision is a forced phenomenon.

            The question I pose remains; readers need to study up on the history of circumcision.

            Who has an incentive to lie?

            Who has more to lose from the discrediting of circumcision?

            Who has more to gain from making it indispensable?

            “People can be biased in favour of what is “good” just as easily as they can be biased in favour of what is “bad”. For example, try asking a person a scientific question in such a way that there is an implication that a particular answer will save the life of a child. Most people will be biased towards giving that answer. That’s a morally good bias, but it’s still a bias.”

            Yes, and people should know about them either way. And, as I’ve said, I’ve no problem letting people know what mine are; it’s concealing them that is a problem.

            I find your above paragraph very interesting, as circumcision, particularly infant circumcision, is often presented by your colleague Brian Morris, as something that “saves lives.” I guess he’s trying to make the above theory work in his favor?

            Actually, now that I think of it, the tactic of using the fear of death has been used since the dawn of the age of “circumcision research,” hasn’t it. It was used then, and it’s being used now.

            It’s really easy to try and manipulate people by assuming what their biases are, and make them behave in a way that conforms to yours.

            If you want to make people do something, find a way to make them believe that not doing it is going to kill someone…

            But if a person is smart enough, they’ll realize that they’re becoming victims of a logical fallacy; presenting an “either-or” question is nothing more than bifurcation.

            Circumcision isn’t the only way to prevent disease (if it indeed can be proven that it can…)

            “‘If it can be proven to me scientifically, that circumcision indeed may have a “benefit,” I will accept; I have no choice.’ — I doubt that you’ll ever acknowledge the proof.”

            Who is “assuming” who’s thoughts now?

            When and if “researchers” can demonstrably prove that the foreskin soaks up HIV, and removing it “repels” it, I will stop doubting the “research” in Africa.

            I will continue arguing that circumcision needs to be a grown man’s decision, that “researchers” need to use the data they discover to find alternatives to genital cutting, but I will stop doubting.

          • eshu21 says:

            Bo says: May 26, 2012 at 3:51 pm Replying to Joseph4GI. The investigators in the African trials did not assume a priori that circumcision prevents HIV transmission, as you assert. In fact, the null hypothesis (the hypothesis assumed to be correct) was that circumcision would not affect HIV transmission. Based on their results, the rejected the null hypothesis.

            Sorry Bo, but there is a world of difference between a stated hypothesis, needed for grants and for publication, and an obviously biased unstated hypothesis evidenced by the same researchers’ previously expressed biased statements. Could studies with such blatant flaws be constructed by genuinely impartial researchers?

          • Jake says:

            ‘I’m afraid denial and feigning dissimulation will not erase your recorded past, Jake, sorry…’ — you certainly have a talent for accusations, Joseph.

            ‘If he writes failed study after failed study until he gets one with the positive results he’s looking for’ — how about a definition for those of us who aren’t able to read minds?

            ‘So glad you asked! Each researcher has their own different reasons for wanting to produce “research” with positive results for circumcision, but I’ve narrowed it down to four major reasons.’ — sorry, I’m not really interested in your theories about possible biases.

            ‘Am I crazy for concluding that all of these “researchers” are in this together?’ — it’s perfectly reasonable to suppose that researchers communicate (and sometimes collaborate) with other researchers in their field. It’s not so reasonable to suppose that there is a big conspiracy.

            ‘What I find amusing is how you’re trying to pretend to be dissimulated; like people don’t actually know what you think!’ — ah, yes, of course. You believe you can read minds.

            ‘More accurately, they tried to garner support for their pre-determined position by writing “research” that others would see through in the future. They were looking to push an agenda, not find any new knowledge or information about the human body. Often “researchers” have ulterior motives that aren’t declared on their “research.”’ — as I’ve noted above, you seem very determined to find ill intent in just about anything, whether or not it’s actually there.

            ‘It shouldn’t be too surprising; remember, those against circumcision are defending a non-action. History shows it is circumcision advocates who have an axe to grind.’ — okay, Joseph.

            ‘What is at stake for us? Do we have some sort of ritual where we sow on a foreskin onto a baby? What “tradition” do we make out of an unconscious non-action? (We don’t celebrate allowing a child to keep his/her eyelids, ears, nose, labia, those are just normal parts of the human body…) What money do those who advocate leaving healthy organs alone have to lose? What lawsuits do doctors have to face for not reaping profit from not performing surgery on a healthy patient?’ — I would think that anyone observing this debate will agree that anti-circumcision activists are an extremely passionate bunch, probably because they imagine themselves to be saving defenceless babies from evil mutilators. Belief is a powerful motivator, often more so than financial gain. Consider, for example, those who hijack planes and fly them into skyscrapers.

            ‘There is. And you can’t pout “personal attack” every time people point out yours.’ — I find that personal attacks are by far the most common, and I often point them out when they occur.

            ‘The goal should be to declare our biases so that people can verify the objectivity of their sources.’ — it’s usually better to use the methods that I described to

            “‘A bias will also cause one to apply faulty logic, skewed mathematics and misrepresent evidence, if even present it at all’ — really? It “will” cause one to do so? That’s an extraordinary claim to make.”

            [Re I doubt that you’ll ever acknowledge the proof.] ‘Who is “assuming” who’s thoughts now?’ — I don’t presume to know your thoughts. I’m just making a prediction – a guess – based on my observations of your behaviour. Maybe I’m wrong. I hope I am.

    • Petit Poulet says:

      Given that a difference is not due to chance alone is only one step in the evaluation process. The next step, which should be part of any evaluation of a scientific, psychological, sociological, or medical study is to ask the two important questions: So what? and Who cares? If the difference is so small that it doesn’t it isn’t important then the study findings are not important. The question that those promoting the findings of these trials have failed to ask is how does circumcision compare to condoms and secondary prevention using ART. The reason they don’t ask is that circumcision is not a viable option when compared to these other approaches.

  • Ladyfingers says:

    Why won’t “Jake” respond to these queries about his behaviour and affiliations with Brian Morris and Vernon Quaintance as recorded at CircLeaks?

    • Jake says:

      I see no need to respond, Ladyfingers, because none of the allegations on that site are remotely connected with the issues that we’re discussing.

      • JimmyWang says:

        The anti-circ’s are so predictable. When they can’t win based on facts
        they try personal attacks.

        • Jake says:

          Yep. Every time…

        • Joseph4GI says:

          You mean like when pro-circs like Brian Morris project their guilt onto others and dare to call us “foreskin fetishists?”

          “Conflict of Interest: Where a source seeks to convince by a claim of authority or by personal observation, identification of conflicts of interest are not ad hominem – it is generally well accepted that an “authority” needs to be objective and impartial, and that an audience can only evaluate information from a source if they know about conflicts of interest that may affect the objectivity of the source. Identification of a conflict of interest is appropriate, and concealment of a conflict of interest is a problem.”

          • JimmyWang says:

            You people should look in the mirror.

            No evidence, no matter how compelling will convince you that
            there are health benefits to circumcision.

            So just what is the “conflict of interest” that you’re referring to?

            Seems to me that everybody for circumcision is so because
            of the scientific evidence that they are able to point you to.
            In spite of your attempts to show that there’s something wrong
            with the evidence, time and time again it’s pointed out to you
            why the research is valid and you are wrong.

            Once you lose that battle then you resort to
            personal attacks on the researchers like you’re doing now.

            Just my observation of how you people operate.

          • bo says:

            This reply is to JimmyWang says: May 24, 2012 at 3:41 pm.

            This has needed to be said. No amount of data would convince them that circumcision is good because they think it is morally wrong. That’s a very acceptable position. I don’t think we should be circumcising children either. These studies show that circumcision can prevent HIV transmission, but they don’t answer the question of whether it’s worth it. For people that want to be circumcised anyway, it’s a nice benefit, but I think the level of benefit seen in these studies should push very few if anyone to circumcision. The number needed to treat is pretty high for a surgical procedure, in my opinion. But, that’s not the point.

            Everyone here arguing against these studies is grasping at straws, trying to show all these ways the research is flawed, but their real problem with them is that they don’t think people should get circumcised. I think they lose a lot of credibility, when they could just argue for what their opinion really is. It’s extremely reasonable to try to get people to stop circumcising their kids. Argue that! It’s also really reasonable to look at the findings from these studies and come to the conclusion that the benefit isn’t great enough to justify a surgical procedure, even in this very high risk population. Argue these points. Then you won’t look like morons for arguing that they shouldn’t have looked at relative risk. They certainly should have looked at relative risk reduction, and anyone in health care that you argue with knows that. Everyone thinking circumcision is bad has a very reasonable position, but they’re just arguing terribly, because they aren’t arguing the points they actually agree with. They’re trying to find other things that are wrong.

            Think about it this way. If people did a study that convinced you all that circumcision protected against HIV transmission, would you be for circumcision. I don’t think so, and that’s very acceptable. Argue the points you actually believe in and you can convince people that your position is right.

          • Joseph4GI says:

            “You people should look in the mirror.”

            Interestingly, it is the same advice I have for you.

            Circumcision advocates tend to have incorrigible problems with projection.

            “No evidence, no matter how compelling will convince you that
            there are health benefits to circumcision.”

            There may be “health benefits” to circumcision yet.

            But here’s the trick, can these same “health benefits” be achieved without it?

            Is this about “health benefits,” or is this about legitimizing a superfluous procedure?

            If there were better, cheaper, less invasive ways to achieve the “health benefits” of circumcision, would you be interested?

            The answer to these questions would speak volumes.

            “So just what is the “conflict of interest” that you’re referring to?”

            I’ve narrowed down the possible conflicts of interests circumcision advocates have to these four; culture (you need to justify what’s been done to you, what you’ve done to your child), religion (you need to justify your religious beliefs, not really that different from creationism really), finance (obviously if this is your livelihood you will protect it) and sexual fixation with circumcised penises, or the act of circumcision itself, esp. when performed forcibly on others.

            Jake Wasket falls in the last category. Others have followed him and know exactly who he is, though he often tries to deny it and pretend to be dissimulated.

            “Seems to me that everybody for circumcision is so because of the scientific evidence that they are able to point you to.”

            Or it would seem. A pseudo-scientific front is usually a cover for something else, though. The “scientific evidence” is usually an ex-posto-facto crutch for other things, such as, the fact that you yourself are circumcised, you circumcised your son, you have religious convictions, or, you’re just obsessed with circumcision.

            “In spite of your attempts to show that there’s something wrong with the evidence, time and time again it’s pointed out to you why the research is valid and you are wrong.”

            The so-called “evidence” is so obviously flawed, which is probably the reason the majority of medical organizations in the world reject it and move on.

            Let’s assume for the sake of argument that all of the “evidence” is sound and valid; there are still better, more effective ways to prevent disease.

            Progress is marked by the replacement of the old with the new and better. Science is always trying to make itself obsolete.

            It makes absolutely no sense to want to “study” “the benefits” of a procedure, instead of seeking to make surgery obsolete.

            Circumcision “researchers” are unique in that, while real scientists and researchers are trying to move us forward, they want set modern medicine back a couple of thousand years.

            “Once you lose that battle then you resort to personal attacks on the researchers like you’re doing now.”

            “Conflict of Interest: Where a source seeks to convince by a claim of authority or by personal observation, identification of conflicts of interest are not ad hominem – it is generally well accepted that an “authority” needs to be objective and impartial, and that an audience can only evaluate information from a source if they know about conflicts of interest that may affect the objectivity of the source. Identification of a conflict of interest is appropriate, and concealment of a conflict of interest is a problem.”

            It is important that an audience know the objectivity of their source.

            “Just my observation of how you people operate.”

            I have no problem declaring my conflicts of interest.

            Up front, I don’t pretend to have any kind of “neutral point of view” when it comes the subject of circumcision. I am dead against the forced circumcision of healthy, non-consenting minors, male or female, and I make no exception for “religion” or “culture.” The only time that a child should undergo surgery is when there is actual medical or clinical indication, and all other methods of treatment have failed. (This also happens to be standard medical practice.)

            The forced genital mutilation of minors is what this is ultimately about.

            I have no problem with older men choosing circumcision over other alternatives.

            It is using “research” and “science” to legitimize child abuse with which I have a problem.

            Genital mutilation, whether it be wrapped in culture, religion or “research” is still genital mutilation.

            It is mistaken, the belief that the right amount of “science” can be used to legitimize the deliberate violation of basic human rights.

          • Joseph4GI says:

            “This has needed to be said. No amount of data would convince them that circumcision is good because they think it is morally wrong.”

            I will not deny that some people may need circumcision. I will also not deny that circumcision might have *some* benefits.

            It is also a fact that circumcision is a highly controversial topic, one which has been raging on for a few hundred years, and people have their biases and convictions about it. This will skew any “evidence” people present.

            The bottom line is this; is circumcision medically necessary in healthy, non-consenting individuals? What “benefits” does circumcision have that cannot already be achieved by better, less expensive, more effective means? Why aren’t researchers working on trying to PHASE OUT circumcision, instead of trying to find more reasons to necessitate it?

            “That’s a very acceptable position. I don’t think we should be circumcising children either.”

            But you know that ultimately, this is what it’s all about. There would be no problem otherwise.

            “These studies show that circumcision can prevent HIV transmission, but they don’t answer the question of whether it’s worth it.”

            The “studies” show nothing of the sort. At best they’re heavily skewed statistics with the strong assertion that they were caused by circumcision. The “researchers” cannot provide a causal link and just “assume” circumcision as this “protective effect” apriori.

            Assuming these “studies” were legitimate, asking whether it’s “worth it” would follow. That should be up to a man to decide; but already, they’re being touted by advocates of INFANT circumcision.

            “For people that want to be circumcised anyway, it’s a nice benefit, but I think the level of benefit seen in these studies should push very few if anyone to circumcision. The number needed to treat is pretty high for a surgical procedure, in my opinion. But, that’s not the point.”

            Again, assuming, these “studies” were true…

            “Everyone here arguing against these studies is grasping at straws, trying to show all these ways the research is flawed, but their real problem with them is that they don’t think people should get circumcised.”

            Um, FALSE.

            At least for me, I have no problem if an adult man wants to get circumcised. It is certainly a disservice to tell him that circumcision would prevent HIV, when this is not the case though.

            I could stick to the “moral” argument that circumcising a child is wrong, but the fact is these “studies” are horrendously flawed, and lies should be dispelled whenever possible.

            “I think they lose a lot of credibility, when they could just argue for what their opinion really is.”

            The same can be true for circumcision advocates; do they really care bout the validity of “studies?” Or do they care that they have some “intellectual weapon” against those who oppose the genital mutilation of infants?

            “It’s extremely reasonable to try to get people to stop circumcising their kids. Argue that!”

            And we do.

            “It’s also really reasonable to look at the findings from these studies and come to the conclusion that the benefit isn’t great enough to justify a surgical procedure, even in this very high risk population.”

            Assuming the “research” was valid…

            “Argue these points. Then you won’t look like morons for arguing that they shouldn’t have looked at relative risk.”

            I think it’s pretty reasonable to point out that the relative risk masks a very tiny number.

            “They certainly should have looked at relative risk reduction, and anyone in health care that you argue with knows that.”

            Are you sure?

            “Everyone thinking circumcision is bad has a very reasonable position, but they’re just arguing terribly, because they aren’t arguing the points they actually agree with. They’re trying to find other things that are wrong.”

            If they are… why not?

            “Think about it this way. If people did a study that convinced you all that circumcision protected against HIV transmission, would you be for circumcision.”

            That answer would be the same as I have always said it; it should be up to a grown man to consider the “risks and benefits” of cutting off a perfectly healthy part of his body off.

            “I don’t think so, and that’s very acceptable. Argue the points you actually believe in and you can convince people that your position is right.”

            If people are using lies and deception to promote genital mutilation, then those lies and deception should be called out.

            People have incentive to lie about circumcision and the “research” they conduct. Publishing negative findings means questioning your culture. Publishing negative findings means questioning your 6000 year old “tradition.” Publishing negative findings means questioning your circumcision, and/or the circumcision of your children. People have beliefs, reputations and sanities to protect.

            “Studies” and their authors need to be scrutinized and monitored carefully.

            A person with the right brain can easily clothe their opinions with numbers and science. In time a lie is known though.

            These “studies” are horrendously flawed, and they will sooner or later explode into the scientific scandal of the century.

          • Joe says:

            In reply to Bo: May 24, 2012 at 3:55pm

            Bo: I agree with you that most here are arguing terribly. I don’t think the argument though is about whether anyone should get circumcised, I doubt very much that anyone arguing against circumcision here would be opposed to an adult doing whatever they please to their own body (though perhaps I am wrong). The main concern where it relates to these specific trials is, for most opposed to circumcision (but maybe not most writing here), how is that information to be used? Is it used to inform consenting men or target and prey on boys and infants? If the former, are the men being properly informed especially with regard to the limitations on the effect? Where this service is being promoted, are the recipients’ receiving the rigorous counseling that those who promoted circumcision promised would be performed? Most of what I’ve seen in the last 4 years or so tells me that circumcision is not being provided in an ethical manner, boys and infants are being targeted as opposed to consenting adults, and most are not getting much (if any) counseling which makes me wonder if consent (when they have it) is truly informed.

            • Frank OHara says:

              Joe wrote: “I doubt very much that anyone arguing against circumcision here would be opposed to an adult doing whatever they please to their own body (though perhaps I am wrong).”

              Of course not. That’s part of the “rights” issue. A man has the right to do (mostly) what ever he wants with his body and there are those in the medical profession who are anxious to help him achieve his wishes.

              “Is it used to inform consenting men or target and prey on boys and infants?”

              Arugably it is. They have little control over their bodies. In many cases, their protectors (parents) are their worst enemies. If not done at birth, often deception is used to deprive them of their property (foreskins). The older boys are often unaware of what is about to happen to them. They think they are going to the doctor’s office for a routine visit as they have done before or the seriousness of the procedure is down played.

              .

          • bo says:

            Good point Joe.

  • Derrick says:

    Even the 60% number is pretty weak in my opinion, considering that most American news organizations are advertising circumcision as some kind of surgical vaccine against HIV. Also, I think it is not unreasonable to argue that the RCT studies are flawed- they were terminated early and that is a fact, and there ARE multiple recorded statements from the people behind these studies that point to some pro-circumcision bias on their part that would put the credibility of these studies into question. I just don’t see how anybody can support these studies when they are plagued with these problems, unless they needed some reason to justify the practice.

    Of course, as you have said, bo, even if there were some concrete benefit to circumcising, circumcision still removes useful sexual tissue permanently and so I would never in a million years support the circumcision of children who don’t have the capacity to consent. I would like it if male children were protected from any sort of genital modification by law as women are, but I guess that’s not going to happen in my lifetime.

    • bo says:

      The trials were stopped early, because they were already statistically significant during a data analysis that was performed at a pre-specified time-point.

      • Joseph4GI says:

        The trials were stopped early while the numbers were favorable to the authors who wrote them.

        When looking at these “studies” one must also ask, who are the authors?

        What is their connection with circumcision?

        How long have they been looking to find a “connection” between circumcision and HIV?

        Is this about HIV prevention? Or the vindication of a controversial procedure that is growing ever unpopular?

  • Henry says:

    bo says:
    May 24, 2012 at 3:55 pm

    This reply is to JimmyWang says: May 24, 2012 at 3:41 pm.

    “This has needed to be said. No amount of data would convince them that circumcision is good because they think it is morally wrong. That’s a very acceptable position. I don’t think we should be circumcising children either.”

    These people here and elsewhere who want circumcision sexual mutilation to be foisted (due to “studies” and brainwashing and the horrible mystique that mutilating the penis confers a “better penis”, “better sex”, “less disease”, “no disease”, “stink”, etc.) on unsuspecting, unaware, brainwashed intact men really know (but don’t want others to know) that once this is done on a widespread scale a shift will be made to the torturing and sexual mutilation of helpless, healthy baby boys, and that once that happens on a widespread scale so that an increasing population of baby boys is cut, then it will be impossible to stop male sexual mutilation (MSM) in Africa. So I’d never believe anyone who says or writes what bo wrote.

    “These studies show that circumcision can prevent HIV transmission, but they don’t answer the question of whether it’s worth it. For people that want to be circumcised anyway, it’s a nice benefit,..”

    If they want circumcision, then that would be OK only if every intact man was properly educated about the awful sexual damage circumcision guarantees. Then I figure the percentage of FULLY EDUCATED intact men who really want circumcision would be quite low. But as it is now, these intact men are not educated about the lifelong importance of male foreskin nor about the certain damage caused if the foreskin is lost. They’re being pressured and brainwashed and their unwise “leaders” in the government and elsewhere are only falling for and then promoting the “studies”, the “findings”, the “research”. If the bad forces win,
    in the end the baby boys will be tortured and sexually mutilated and Africans will forever be enslaved to this religion-based, religion-blessed atrocity and fraud.

    “Everyone here arguing against these studies is grasping at straws, trying to show all these ways the research is flawed, but their real problem with them is that they don’t think people should get circumcised.”

    Again, if only a small percentage of an intact male population wants circumcision, it might be OK only if those men didn’t force the same on their baby boys. If they do force this on their baby boys, then MSM spreads. The major problem though is that a very high percentage of intact men are being pressured
    and not educated and brainwashed into thinking they’ll be “improved”. Once the entire intact male population (or nearly all of it) is converted into a sexually mutilated male population, then the shift will be made to the sexual mutilation of baby boys. AND SEXUAL MUTILATORS KNOW THIS though they pretend to be against the cutting of boys and of baby boys.

    “I think they lose a lot of credibility, when they could just argue for what their opinion really is. It’s
    extremely reasonable to try to get people to stop circumcising their kids. Argue that!”

    Here in the US, this is difficult, stressful work to stop this madness, this child sexual mutilation perversion but the rate of infant circumcision sexual mutilation has been fortunately dropping. So many of the unaware, the uninformed encounter proper education and enter Internet forums and they still reject the information and are either thrilled their boys are mutilated (degraded forever) or they refuse to recognize that infant circumcision is an atrocity and a fraud.

    “It’s also really reasonable to look at the findings from these studies and come to the conclusion that the benefit isn’t great enough to justify a surgical procedure, even in this very high risk population. Argue these points. Then you won’t look like morons for arguing that they shouldn’t have looked at relative risk. They certainly should have looked at relative risk reduction, and anyone in health care that you argue with knows that. Everyone thinking circumcision is bad has a very reasonable position, but they’re just arguing terribly, because they aren’t arguing the points they actually agree with. They’re trying to find other things that are wrong.”

    No, EVERYTHING about getting some healthy man’s healthy foreskin cut off is wrong because no proper, complete education is offered and because pressure and deception are used to brainwash intact African men. Once bad people (the “researchers” from the sexually mutilated US and others from other lands) are
    intent on bringing about MSM, then MSM easily spreads and, in the case of Africa, will lead to the widespread if not ubiquitous torturing and sexual mutilation of helpless, healthy boys.

    “Think about it this way. If people did a study that convinced you all that circumcision protected against HIV transmission,”

    But it doesn’t. Look what happened to the US in the unfolding of and the very long running of the biggest, most horrifying, FAILED “medical” experiment in history! [And cut men HATE to use condoms.] Sexually mutilated men always feel fine when all the men (or nearly all men) around them are also sexually mutilated. Sexual mutilation of baby boys creates future sexual mutilators. [This MMC -- "medical male circumcision" -- should be called MSM.]

    • JimmyWang says:

      Henry, got any more charged words you can use to express your opinion?

      Your angry rant shows you can’t possibly think rationally about this topic.

      Circumcision provides life-long health benefits with no downside.
      The evidence is there.

      Parents make decisions for their children all the time and they should
      do so with the best information available.

      • bo says:

        Saying things like this is not going to help the discussion at all.

        Similarly, saying that there circumcision has life-long health benefits with no downside is ridiculous. For many, if not most, people there will be few or no benefits. If you’re having sex with a long-term single partner, then you probably won’t benefit at all from the HIV protection. And, there’s reasonable evidence, given the significant amount of nervous tissue being removed, that you alter the experience of sex in a negative way. This is hard to study in a RCT, but the evidence seems pretty reasonable to me that it’s true.

        • bo says:

          sorry that I’m terrible at using blockquotes. I was trying to quote the first two lines of JimmyWang’s post:

          “Henry, got any more charged words you can use to express your opinion?
          Your angry rant shows you can’t possibly think rationally about this topic.”

      • Derrick says:

        “Your angry rant shows you can’t possibly think rationally about this topic.”

        It’s funny that you say this, and then immediately afterwards you say this:

        “Circumcision provides life-long health benefits with no downside.”

        Risk of infection, bleeding, excessive skin removal resulting in painful erections, loss of parts of the glans penis, meatal stenosis, and even death- none of that constitutes a “downside” to you? And even when a circumcision is successful, it always results in the permanent loss of functional sexual tissue, so to try to make the argument that there is “no downside” to circumcision is patently and demonstrably false, and you should be ashamed of yourself for even suggesting such a thing.

        • Derrick says:

          *so the argument that there is “no downside” to circumcision is patently and demonstrably false

      • Joseph4GI says:

        “Circumcision provides life-long health benefits with no downside. The evidence is there.”

        That all depends on what you call a “downside.”

        I’m afraid the evidence is lacking; this is why no medical organization in the world has endorsed infant circumcision.

        The trend of opinion on routine male circumcision is overwhelmingly negative in industrialized nations. No respected medical board in the world recommends circumcision for infants, not even in the name of HIV prevention. They must all point to the risks, and they must all state that there is no convincing evidence that the benefits outweigh these risks. To do otherwise would be to take an unfounded position against the best medical authorities of the West.

        “Parents make decisions for their children all the time and they should do so with the best information available.”

        It should strike people as odds that there isn’t enough evidence for any medical organization in the world to endorse infant circumcision, but parents are expected to weigh this same “evidence” and somehow do better.

        The foreskin is not a birth defect. Neither is it a congenital deformity or genetic anomaly akin to a 6th finger or a cleft. Neither is it a medical condition like a ruptured appendix or diseased gall bladder. Neither is it a dead part of the body, like the umbilical cord, hair, or fingernails.

        The foreskin is not “extra skin.” The foreskin is normal, natural, healthy, functioning tissue, with which all boys are born; it is as intrinsic to male genitalia as labia are to female genitalia.

        Unless there is a medical or clinical indication, the circumcision of a healthy, non-consenting individual is a deliberate wound; it is the destruction of normal, healthy tissue, the permanent disfigurement of normal, healthy organs, and by very definition, infant genital mutilation, and a violation of the most basic of human rights.

        Without medical or clinical indication, doctors have absolutely no business performing surgery in healthy, non-consenting individual, much less be eliciting any kind of “decision” from parents.

        Genital mutilation, whether it be wrapped in culture, religion or “research” is still genital mutilation.

        It is mistaken, the belief that the right amount of “science” can be used to legitimize the deliberate violation of basic human rights.

        • JimmyWang says:

          There is no right amount of science that would convince you
          no matter how conclusive.

          If the health benefits were acknowledged, people
          would not be able to say circumcision is morally wrong or a
          violation of human rights.

          • bo says:

            If there are health benefits to something, it can still be immoral. There can also be health benefits that are outweighed by adverse effects. I agree that people should be able to admit to some health benefits with circumcision, but your statement does not helping this debate.

          • Derrick says:

            “If the health benefits were acknowledged, people would not be able to say circumcision is morally wrong or a violation of human rights.”

            I don’t know how many times I have to spell this out for you, but circumcision REMOVES FUNCTIONAL TISSUE FROM A HUMAN BEING PERMANENTLY. To impose an operation on a child who can’t consent and deprive him of that tissue IS morally wrong and DOES violate his human rights. Period.

            This would not be acceptable for any other part of the human body, and the penis should be no exception.

          • Petit Poulet says:

            Jimmy, if you want to believe what you say and that makes you feel better about yourself, who am I to interfere. If you think that your beliefs should be those of everyone, then you will need to back them up with some facts. The problem is that the facts won’t back you up.

            It is not clear if circumcision provides any life-long benefits. There are many circumcised men who hope it does, but the science is not clear on this. There is a downside. Several babies die each year from circumcision. Many have to have operations to correct the mistakes made at the original circumcision. Every baby loses the most sensitive portion of the penis. So there is a well-documented downside.

            Parents are allowed to make decisions for their children within reason. This does not include cutting of non-regenerative body parts. The problems is that physicians should know better and not allow parents the options, but instead the physicians pockets about $200 if the parents say yes.

            Cutting off the entire penis would have more benefits than cutting off the foreskin. The risk of STDs, sexually transmitted HIV and penile cancer would be eliminated. So cutting off the penis fair game and not a violation human rights.

            • Jake says:

              ‘It is not clear if circumcision provides any life-long benefits.’ — on the contrary, there’s strong evidence that it provides multiple benefits in terms of reduced risk of a number of conditions.

              ‘Several babies die each year from circumcision.’ — this is true, although the numbers are smaller than the deaths due to penile cancer, HIV, etc., if the same number of babies were left uncircumcised.

              ‘Many have to have operations to correct the mistakes made at the original circumcision.’ — from time to time this does happen, unfortunately.

              ‘Every baby loses the most sensitive portion of the penis.’ — doubtful, but certainly the child does lose his foreskin. Your implied assumption that this is negative, however, is dubious at best.

              ‘Cutting off the entire penis would have more benefits than cutting off the foreskin. The risk of STDs, sexually transmitted HIV and penile cancer would be eliminated. So cutting off the penis fair game and not a violation human rights.’ — the problem here is that you’re considering only half of the equation. One can’t meaningfully assess something by considering only the pros and not the cons. Any reasonable person weighing the pros and cons of penectomy would have to conclude that it is a net harm. The same is not true of circumcision.

              • Jake says:

                (Sorry, the above post was intended as a reply to Petit Poulet’s post dated May 24, 2012 at 9:50 pm.)

              • Joseph4GI says:

                “on the contrary, there’s strong evidence that it provides multiple benefits in terms of reduced risk of a number of conditions.”

                Whether the evidence is “strong” is certainly subject to interpretation; circumcision advocates certainly seem to think so; the majority of medical organizations in the industrialized world all say that there is no convincing evidence to recommend circumcision.

                “this is true, although the numbers are smaller than the deaths due to penile cancer, HIV, etc., if the same number of babies were left uncircumcised.”

                The assumption being that circumcision prevents penile cancer and HIV; it does not. Circumcision advocates cling to “correlations” found in *some* research, but aside from cherry-picked statistics, there is no demonstrable scientific proof that circumcision prevents any of these diseases. Penile cancer is vanishingly rare, and it is not necessary to be circumcised in order to practice safe sex.

                ‘”Many have to have operations to correct the mistakes made at the original circumcision.’ — from time to time this does happen, unfortunately.”

                Considering that even “if” circumcision affords the benefits advocates say it does, the same “benefits” can already be achieved by non-invasive means, how is this even medically conscionable?

                “‘Every baby loses the most sensitive portion of the penis.’ — doubtful, but certainly the child does lose his foreskin. Your implied assumption that this is negative, however, is dubious at best.”

                Actually it is demo storable that the foreskin is the most sensitive part of the penis, but you will not acknowledge the study that says so because it conflicts with your pro-circumcision bias. It is not only negative to be forcibly cutting off normal, healthy flesh from a child’s genitals, however worthless *you* might think it might be; without medical indication it is medical fraud and child abuse.

                “the problem here is that you’re considering only half of the equation. One can’t meaningfully assess something by considering only the pros and not the cons. Any reasonable person weighing the pros and cons of penectomy would have to conclude that it is a net harm. The same is not true of circumcision.”

                Semantic hedging; a technical term that allows you to get away with calling circumcision “not harmful.”

                Before considering the “pros and cons” of amputating normal, healthy flesh from the genitals, let’s talk about what the functions of the foreskin are.

                What is the foreskin?

                What does it do?

                Why are males born with it?

                Is it a dead part of the body, like a nail or umbilical cord?

                Or does it have blood vessels and nerves?

                What does it do?

                And please, let’s hear someone who is genuinely objective on the matter, not a known circumfetishist, please.

                • Jake says:

                  ‘Whether the evidence is “strong” is certainly subject to interpretation; circumcision advocates certainly seem to think so; the majority of medical organizations in the industrialized world all say that there is no convincing evidence to recommend circumcision.’ — you’re confusing separate issues. My statement was about the question “Are there benefits?” You’re citing organisations that have addressed the question “are the benefits of sufficient magnitude to outweigh risks and costs to the degree that universal circumcision should be recommended?”

                  ‘The assumption being that circumcision prevents penile cancer and HIV; it does not.’ — the evidence shows that it does. I understand that you dispute it, but I’m afraid I’ll still base my statements on the real world.

                  ‘Considering that even “if” circumcision affords the benefits advocates say it does, the same “benefits” can already be achieved by non-invasive means, how is this even medically conscionable?’ — if there’s no net harm, on average, then what’s the problem?

                  ‘Actually it is demo storable that the foreskin is the most sensitive part of the penis, but you will not acknowledge the study that says so because it conflicts with your pro-circumcision bias’ — there’s actually only a single study making such a claim, and that study had some very serious flaws.

                  ‘It is not only negative to be forcibly cutting off normal, healthy flesh from a child’s genitals, however worthless *you* might think it might be; without medical indication it is medical fraud and child abuse.’ — your opinion is noted, but I’m afraid I don’t share it.

                  • Joseph4GI says:

                    “My statement was about the question “Are there benefits?” You’re citing organisations that have addressed the question “are the benefits of sufficient magnitude to outweigh risks and costs to the degree that universal circumcision should be recommended?”

                    No, I think readers can read you were clearly alleging that “there is strong evidence…” And I respond by saying, not “strong” enough.

                    “the evidence shows that it does.”

                    No, some studies, but not others show it *might.* The evidence is inconclusive and does not convince the rest of the world.

                    “I understand that you dispute it, but I’m afraid I’ll still base my statements on the real world.”

                    Well, at least part of it…

                    “…if there’s no net harm, on average, then what’s the problem?”

                    Well. At least *you* don’t think there’s no “net harm…” Others can show it does. That’s why we’re here.

                    “…there’s actually only a single study making such a claim, and that study had some very serious flaws.”

                    Well. At least you and your colleague Brian Morris seem to think so…

                    “your opinion is noted, but I’m afraid I don’t share it.”

                    It is not opinion, but rather a principle that applies to the rest of medicine.

                    The standard of care for therapeutic surgery requires the medical benefits of the surgery to far outweigh the medical risks and harms, or for the surgery to correct a congenital abnormality. Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is unethical and inappropriate to perform surgery for therapeutic reasons where medical research has shown there to be other techniques to be at least as effective and less invasive.

                    • Jake says:

                      ‘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.

                    • Joseph4GI says:

                      ““Strong evidence” is about the level of certainty in the benefit…”

                      Judging from the position statements of most respected medical organizations in the world, it’s not high enough…

                    • Jake says:

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

                  • Tom Tobin says:

                    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? Or the recommendation of the American Cancer Society, which states that circumcision does not prevent penile cancer? Pretty much everyone acknowledges that penile cancer is most likely caused by the HPV virus, which has a vaccine.
                    How is removing half the skin of someone’s genitals, “no net harm”? Is it considered no net harm for females? If it is considered harmful for women, why should it not be considered harmful for males? Why would the Swedish Paediatric Society call it “child abuse” and say, “We consider it to be an assault on these boys”
                    http://www.thelocal.se/39200/20120219/
                    Why do two thirds of Swedish doctors refuse to perform circumcisions? Why is Tasmania considering outlawing it?
                    Why do Americans, who are circumcised in the majority, consume the most viagra per any population in the world?
                    The only study most men need to claim that the foreskin is the most sensitive part of the penis, is to feel it for themselves.
                    Then, it becomes obvious, to the vast majority of men.
                    You don’t share an opinion that circumcision is child abuse. OK. You are entitled to that opinion. How you can watch a video of a circumcision, and still hold that view, is, frankly, a little beyond my comprehension. The view that it is child abuse, and unnecessary child abuse, is not fringe. The Swedes and Dutch are not shy about expressing their view that it deprives the child of the basic right to keep all their healthy body parts. The Americans, British, New Zealanders, and Australians call it unnecessary. How does one argue in Practical Ethics, that it is ethical to remove a healthy body part from someone too young to give consent? I am afraid it is not very convincing.

                    • Jake says:

                      ‘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.

                    • Tony says:

                      … — 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.

                      You’re conflating harm and net harm. The former is indisputable of all circumcisions. Circumcision is surgery. Healthy skin is removed. A scar remains. Risks of further complications are inherent in the surgery. It is harmful. Your statement that circumcision is not inherently harmful is demonstrably false.

                      You draw your conclusion on the latter point, that of net harm, which is subjective to the consideration of factors you determine for yourself. That’s fine in the limited realm where it’s relevant (i.e. your foreskin). It is inexcusable in the broad realm of normal, healthy males, in general. You can’t make the subjective conclusion for everyone, unless… How do you weight the objective costs (i.e. harms) against the potential benefits? Please provide specific numeric values so we can understand the decisive, even if close, victory that non-therapeutic child circumcision allegedly provides. Please provide proof that your weighting of each factor for and against is the same as shared by every individual male on Earth, which is the obvious requirement to draw this as an objective, universal conclusion that may be imposed on a healthy male without his consent.

                      (Your subjective utilitarianism is the same thing I critiqued in my “May 27, 2012 at 1:56 pm” comment to you in response to your faulty analysis on the acceptability of death as a complication.)

                    • Jake says:

                      ‘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?

                    • Tony says:

                      … — no, I’m not. The two concepts are closely related.

                      You are, as you have in the past. Closely related is not the same thing. Harm is an input into net harm. Denying harms because you deem there to be no net harm is a mistake. This is denial:

                      … — so where is the “indisputable harm” that you mention?

                      Again, harm ≠ net harm. I am not making that mistake. I am describing an input into the decision an individual may make to determine his conclusion. (i.e. net harm, net benefit, …) Healthy skin is removed. That is harm. A scar remains. That is harm. Those harms result from every circumcision. Hence, indisputable. That you value something else more than those harms does not negate their status as indisputable harms.

                      … — if risk of future problems is harm, then not circumcising must be harmful. That seems a poor standard.

                      I did not say that no risk exists from a normal, intact foreskin. It is a factor that informs an individual’s determination of net harm for himself. Please cite where I said otherwise if you intend to ding my argument for this claim.

                      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? In that context, yes, it seems a poor standard for imposing non-therapeutic circumcision. So, you’ll be rethinking your position, right?

                      … — it’s subjective to an extent, but not exclusively.

                      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. (Here, implicitly at “May 25, 2012 at 9:10 am”. Elsewhere, explicitly.)

                      … — would you be kind enough to point me to where I said there was a decisive victory?

                      Ditto re: your statements on net harm. I also added the caveat “even if close”. Substitute “clear” for “decisive” if the word generates a semantic hang-up for you that implies “overwhelming”. Whatever word you want to use to mean “no net harm”. [50% + 1 uom or a draw, if you prefer]

                      “No net harm” is also implicit in any position that permits one person to impose non-therapeutic surgery on a person who does not consent. It requires the belief that there is no net harm in the action, lest you be the monster who deems non-therapeutic net harm to be an acceptable imposition onto a person. Your position is that non-therapeutic circumcision of male children is permissible (and advisable, given at least one of the papers to which your name is attached as a co-author). Ergo, you do not believe there is a net harm.

                    • Jake says:

                      ‘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.

                    • Tony says:

                      Jake,

                      … — shall we agree that they are indisputable consequences?

                      Because you are wrong, no. They are a consequence, but that’s a silly word you apply as a maximum limitation for the outcome. Harm is a consequence of surgery. That fact is what we should be able to agree on.

                      Since this is a very important fact underlying the flaw in your conclusion on your opinion as a universal fact, I think it’s best to focus here. If a person takes your money, is it a consequence that you have been harmed as a result of that action or is it merely a consequence that you no longer have that money? Consistency seems to require you to state that it’s merely a consequence, that we have to wait to draw a conclusion on the incident until the butterfly effect plays out, perhaps for a lifetime. Is this taking a harm?

                      Or, in context, is surgery removing a healthy, functioning finger harm? Would a cut to the skin on one’s face count as harm? Would a scar from that cut to the face constitute harm?

                    • psandz says:

                      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.

                    • Jake says:

                      ‘Because you are wrong, no. They are a consequence, but that’s a silly word you apply as a maximum limitation for the outcome. Harm is a consequence of surgery. That fact is what we should be able to agree on.’ — I’m afraid I can’t see why we should be able to agree on that.

                      ‘Since this is a very important fact underlying the flaw in your conclusion on your opinion as a universal fact, I think it’s best to focus here. If a person takes your money, is it a consequence that you have been harmed as a result of that action or is it merely a consequence that you no longer have that money?’ — it’s definitely a consequence. It may or may not be a harm, depending on the value of that money. For example, suppose the person took my accumulated stack of valueless Monopoly money which I wanted to dispose of: in such a situation, it’s more a benefit than a harm.

                      ‘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.

                      ‘Would a cut to the skin on one’s face count as harm? Would a scar from that cut to the face constitute harm?’ — and again, it depends on the circumstances. It might be a deliberate cut because the resulting scar is thought to be beautiful (as is done by some polynesian cultures, I believe). It seems difficult to reconcile that with the notion that it is a harm.

                    • Tom Tobin says:

                      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.

                    • Jake says:

                      ‘You are saying that having your foreskin removed is like being robbed of monopoly money?’ — no, I’m answering the question, ‘If a person takes your money, is it a consequence that you have been harmed as a result of that action or is it merely a consequence that you no longer have that money?’ Is it really too much to ask that you read my post before replying to it?

                    • Tom Tobin says:

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

                    • Jake says:

                      ‘You made the comparison with monopoly money. You backed yourself into a corner. I merely mentioned it.’ — would you be kind enough to quote my comparison with Monopoly money?

                    • Layla says:

                      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 says:

                      ‘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.’ — ah, you mean something with value and functionality that isn’t in dispute? That’s not such a good analogy, then. If having something taken is inherently harmful, then it ought to be so regardless of whether the thing was valuable or not. Otherwise it’s the loss of value that’s the harm, not the act of taking.

                      ‘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?’ — acceptable to whom? Has it occurred to you that comparisons that seem valid to you might be invalid to me, and vice versa?

                      ‘Why do you keep twisting things? Is it because of your bias created by your sexual preference for denuded and scarred male genitals?’ — why do you think you need to make personal attacks in order to debate?

                    • Tom Tobin says:

                      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.

                    • Jake says:

                      Have you finished, Tom, or would you like to sling a few more accusations around?

                    • Tom Tobin says:

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

                    • Layla says:

                      I’m not afraid to call him out. I don’t even have a problem with his sexual fetish- as long as the videos, story swapping, whatever- does not involve children or babies and only consenting adults.
                      But his motives, his bias, the psychology behind his motives needs to be clear to everyone.
                      It’s not a personal attack – its putting into light what fuels Jake. Full disclosure about who he is in the world of circumcision.
                      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.

                    • Jake says:

                      ‘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?

                    • Layla says:

                      It’s not an accusation if you are a known member of circ fetish groups.
                      Again, I have no problem with it but the conflict of interest should be known so that parents know exactly who they are getting information from.
                      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.
                      This is where the ethical sticking point comes – your “belief” about the male foreskin.

                    • Jake says:

                      ‘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.

                    • Hugh7 says:

                      “A few members seemed to have strange interests in the subject, certainly, but my impression was always that they were in a minority.”
                      Until June 2010, the Circlist website (http://www.circlist.com/news.html) inked to a Google discussion group that said:

                      “Circlist has always permitted, and will continue to permit, circumcision related fetish/sexual postings/materials, straight, gay or otherwise. Individuals may use CIRCLIST to make contact with one another, including for sexual purposes. The list is not just a medical interest list, but rather all things circumcision, including circ-fetish, sexual info, medical info and a place to meet up with fellow circumcision enthusiasts and proponents.”

                      “proposed functions are speculative at best.”
                      If a uniquely mobile, highly innervated structure near the end of the penis does not have an erogenous function, what was God/evolution thinking?

                    • Jake says:

                      ‘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?

                    • Jake says:

                      Found it. It looks as though that statement appeared on the circlist.com website, some time between Dec 15 2006 (where it wasn’t present: http://web.archive.org/web/20061215113359/http://www.circlist.com/resources/circlist.html) and Feb 2 2007 (where it was: http://web.archive.org/web/20070202032853/http://www.circlist.com/resources/circlist.html). It disappeared some time before the 7th of May 2010: http://web.archive.org/web/20100507033256/http://www.circlist.com/circlistgroup/circlistgroup.html

                    • Tom Tobin says:

                      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.

                    • Jake says:

                      ‘Genitals have erogenous functions. That is their nature.’ — I agree, but they also have other functions (urination, for example). And many individual parts of the penis have non-erogenous functions (for example, some nerve endings are there to signal potential harm, to cause the brain to take protective action.) Hence my point: it’s a mistake to think that a part of the penis must have an erogenous function, just because it’s a part of the penis.

                    • psandz says:

                      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.

                    • Hugh7 says:

                      And the relevance of the foreskin to urination is … ?
                      And the Meissner corpuscles concentrated in a ridged band inside the tip of the foreskin are there to signal potential harm to what?

                    • psandz says:

                      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 says:

                      ‘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.’ — on the contrary, I’d suggest that if pain is detected it may well be too late. An ideal “early warning” would detect light brushing (such as from a grass), perhaps even sudden changes in air pressure that precede impact of a larger object, and for that Meissner’s corpuscles are ideal.

                      ‘The mobility of the foreskin permits the Mesissner’s corpuscles to be continually re-stimulated, generating a tingling sensation, which is potentially extremely erotic’ — not so. once contact is made, they cease signalling, hence they have little plausible role in erotic sensation.

                      ‘Jake, you are opposed by a lot of “big guns”, who are better qualified than you to discourse on the foreskin!’ — that’s the fallacy of appeal to authority.

                      ‘I wonder if there are any bounds to your arrogance.’ — and that one’s argumentum ad hominem.

                    • psandz says:

                      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?

                    • Jake says:

                      ‘Meissner’s corpuscles quickly regain the ability to re-fire, as soon as the corpuscle has regained its shape’ — I agree, but that requires contact to be lost.

                      ‘Jake, I think that the conclusions of renowned neuroanatomists have a higher appeal than your opinions’ — repeating an appeal to authority doesn’t stop from being an appeal to authority.

                      ‘Do you have reason to disagree with, for example, Prof. Ken McGrath (Auckland university), Ashley Montague, and J.R. Taylor?’ — it depends what they’ve said, and on the basis of what evidence. Incidentally, I’m a bit puzzled: you seem to present these as examples of neuroanatomists, but McGrath and Taylor are/were both anatomists, and Montague was an anthropologist.

                      ‘Do you know of any neuroanatomists who REFUTE that view or claim?’ — I wouldn’t bother to look, firstly because I’m not interested in people’s opinions, and secondly, while neuroanatomists are well equipped to describe the nerves present, they may not be the best qualified to judge whether tissue is erogenous. If I was interested in opinions, I’d probably seek that of a sexologist instead.

                    • Jake says:

                      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”.

                    • psandz says:

                      Jake there was no mistake in your earlier post: Ken McGrath’s primary training is anatomy. He currently lectures in pathology at Auckland university. John R. Taylor is also an anatomist and pathologist. Both men are highly qualified in anatomy.

                    • psandz says:

                      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 says:

                      To reply to psandz, June 1, 2012 at 11:39 pm and June 1, 2012 at 11:51 pm:

                      ‘Jake there was no mistake in your earlier post: Ken McGrath’s primary training is anatomy. He currently lectures in pathology at Auckland university. John R. Taylor is also an anatomist and pathologist. Both men are highly qualified in anatomy.’ — you haven’t cited any evidence, so I’m afraid I’m not persuaded. (I don’t think it particularly matters, anyway, but I’m just pointing out that you haven’t persuaded me.)

                      ‘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.’ — I dislike watching online videos, so please give me a link and the approximate time in the video, so I can skip to the relevant section.

                    • psandz says:

                      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:

                      ‘Jake, would you accept evidence “straight from the horse’s mouth” that Montagu and Ken McGrath are/were anatomists?’ — sure. I’m not terribly surprised that McGrath says he trained in anatomy, since it would be impossible to practice or teach pathology otherwise, but Montague’s statement was a bit surprising, since various bios about him don’t mention it.

                      ‘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.’ — since I’ve never disputed the statement that there are nerves present in the foreskin, that’s a moot point: it’s probably true that I would agree with any statement about the anatomy of the foreskin (I’ve used the word “probably” since you haven’t identified specific statements, and as such I can’t be certain). 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, as I’ve already pointed out, so any appeal to the expertise of anatomists is doubly fallacious, because they aren’t even true authorities on the subject matter.

                      ‘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’ — both an appeal to authority and an ad hominem in the same sentence. Impressive! But, really, if I’m wrong then all you need to do is show me the evidence; the fact that you’re relying on fallacious arguments instead suggests that you cannot.

                    • psandz says:

                      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.

                    • Jake says:

                      ‘No, it isn’t, Jake. Nerve receptors affect the quality of our perceptions, so neuroanatomy is relevant to the discussion on erogeneity.’ — I didn’t say that neuroanatomy was completely irrelevant. I said that anatomy cannot answer that question. And I’m quite correct in saying so.

                      ‘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.’ — incorrect. “Bailey, a professor of epidemiology, thinks that circumcision reduces the risk of HIV” is an appeal to authority. 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.

                      ‘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)’ — amusingly enough, that helps illustrate the difference between evidence and appealing to authority: with evidence, anyone can examine it and judge its merits. Here you’ve done so. I think you’ve come to utterly irrational conclusions, but the fact that you were able to form your own conclusions is key.

                      ‘Your own willingness to empower parents to order the circumcision of their sons is nothing more than an appeal to their authority.’ — it’s nothing of the kind. Do you actually understand what the term 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. That would be illogical: “parents should have the right to decide because they have the right to decide”. Rather, 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).

                    • psandz says:

                      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?

                    • Jake says:

                      ‘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.’ — that’s changing the subject.

                      ‘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?’ — it wouldn’t make a lot of sense to me, I’m afraid.

                      ‘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.’ — that’s not an appeal to his authority. It’s my own assessment of the study, having read and understood it.

                      ‘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.’ — it is surgical. It reduces the risk of disease, just as vaccines do. Seems a reasonable description to me.

                      ‘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.’ — I know you hold that opinion, but it has nothing to do with appeals to authority.

                      ‘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?’ — yes, I do. Several problems. First, I don’t believe it is appropriate to create special rules for surgery: it is much more logical to have a single standard for all parental decisions, surgical or otherwise. My general principle applies equally well to everything from circumcision to ear piercing to choosing a child’s diet. Second, decisions such as this may involve both medical and non-medical factors, all of which need to be considered to determine the right decision. Your approach would, therefore, fail to consider all of the relevant factors.

                    • psandz says:

                      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 says:

                      ‘The question is WHY anyone should have confidence in trial findings (the RCTs) which are based on self-selected participants?’ — This doesn’t seem a very realistic objection. I think most trials have self-selected participants; I can’t see how it would be ethical to do otherwise.

                      ‘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.’ — If the problems are bad enough for them to be eager for therapeutic circumcision, the men would probably have been excluded from the trials. To quote from Bailey et al, the exclusion criteria included “Absolute indication for circumcision”, and to quote from Gray et al: “Men who had medical indications for surgery (eg, severe phimosis) were excluded from the trial and were offered circumcision as a service.”

                    • psandz says:

                      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.

                    • Waskell the Liar says:

                      The other side knows it’s a street fight, and deals with you as such. You’re way too nice. They’d cut your dick in a heartbeat.

                    • Tony says:

                      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.

                    • Waskell the Wimp says:

                      Anthony, I’m grateful for your work with Intaction. You’re wasting your breath with Gas Bag Waskell, you’re more likely to convince a Hyena to become a Vegan. Peace.

                    • psandz says:

                      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.

                    • Jake says:

                      ‘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’ — as I pointed out, these data allow us to place an upper bound on the number of men who entered the trials with these conditions, simply by making the extreme assumption that all of these conditions were preexisting. In reality, the numbers were doubtless smaller, but whatever assumptions you make, it’s difficult to escape the conclusion that there were relatively few cases of these conditions, contradicting your hypothesis that they would be overrepresented.

                      ‘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?’ — ulcerative STIs could potentially increase susceptibility but, to quote from Auvert et al: “Potential participants with genital ulcerations were temporarily excluded until successful treatment.” I think you’re grasping at straws here.

                      ‘Note that many of the men were recruited form STD clinics (see “Study design and methods”).’ — from Table 2 of Auvert et al, roughly 10% of men had attended a clinic for a health problem affecting the genital area in the past 12 months. Tests for STIs are shown in Table 1 of Bailey et al, and do not give the impression that STI prevalence was abnormal.

                    • Cut To The Chase says:

                      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)

                    • psandz says:

                      To Jake:

                      Happy Jubilee! You say:
                      “as I pointed out, these data allow us to place an upper bound on the number of men who entered the trials with these conditions, simply by making the extreme assumption that all of these conditions were preexisting. In reality, the numbers were doubtless smaller, but whatever assumptions you make, it’s difficult to escape the conclusion that there were relatively few cases of these conditions, contradicting your hypothesis that they would be overrepresented.”

                      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). 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?

                      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. Men who were diffident or embarrassed at having their penis checked could do so with their face screened. The exam would have to be documented for each person. There’s no other way of carrying out such a medical trial responsibly.

                      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. It proabably represents a few documented self-reported cases, and may only include some particularly severe ones. The only way to know is if the participants’ penises had been checked and any conditions documented.

                      I maintain that the study design of the RCTs was too crude to present a true picture of what their findings signify.

                      You say: ” ulcerative STIs could potentially increase susceptibility but, to quote from Auvert et al: “Potential participants with genital ulcerations were temporarily excluded until successful treatment.” I think you’re grasping at straws here.”

                      Do you really believe that Bailey knew the total number of participants affected by genital ulcerations? Just how?
                      Moreover, predisposition to HIV infections is fairly well established for at least the following STDs: Chlamydia, Syphilis, Gonorrhoea, Herpes, Trichomoniasis, in addition to penile ulcers (this is the CDC source: http://www.cdc.gov/std/hiv/stdfact-std-hiv.htm).

                    • Jake says:

                      ‘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.

                    • psandz says:

                      To Jake:

                      Jake says: “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.”

                      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.
                      Provide documented evidence that only 0.7% of the participants had balanitis amd phimosis (no more appeals to authority please!), based on medical examination of all the men’s penises (or just the Control men’s).

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

                      Is there documented evidence that all the Control men had their foreskins medically checked at those times?

                      I asked: “Do you really believe that Bailey knew the total number of participants affected by genital ulcerations? Just how?’
                      Jake replied: “His Table 1 presents baseline results for HSV-2, syphilis, T vaginalis, gonorrhoea, chlamydia, and chancroid.”

                      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?
                      From memory, Bailey did not have the foreskin of most of the men examined or tested.

                      I have Auvert’s RCT. There is no evidence that such medical examination occurred.

                    • Jake says:

                      ‘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.

                    • jakeeewwww says:

                      The problem with intellectuals against circumcision is they don’t understand the gutter tactics of its advocates. In the instant case, an additional compounding factor is that the pro-circumcision guy spending all his time here, well, how do I say it, this debate is his foreplay, if you get my drift. Very sick.

                    • Tony says:

                      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.

                    • God says:

                      You shall keep my Law, you and your children after you throughout their generations. This is my Law, which you shall keep, between me and you and your offspring after you: Every male among you shall be circumcised. You shall be circumcised in the flesh of your foreskins, and it shall be a sign of the contract between me and you. He who is eight days old among you shall be circumcised. Every male throughout your generations, whether born in your house or bought with your money from any foreigner who is not of your offspring, both he who is born in your house and he who is bought with your money, shall surely be circumcised. So shall my Law be in your flesh an everlasting Law. Any uncircumcised male who is not circumcised in the flesh of his foreskin shall be cut off from his people; he has broken my Law.

                    • psandz says:

                      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.

                    • From God to Psandz says:

                      tell Me again… what’s wrong with a buffet?

                    • psandz says:

                      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.

                    • psandz says:

                      To Jake:
                      You don’t seem to grasp how bias or confounding of self-selection of participants could have impinged on the RCT findings.

                      The RCT findings are being projected epidemiologically onto the African general population, and even on a global scale. It is important to probe whether they are reliably representative of general populations rather than just the self-selected subgroup. The RCT results show a relatively small numerical difference between the Control and the Intervention groups. Taking Bailey et al.’s results as an example, we see that 47 men in the Control ended up infected with HIV vs. 22 men in the Control. This numerically small difference is highly susceptible to confounding in terms of epidemiological usefulness, unless the study design is of sufficiently high quality or strength to cover it, or at least to allow us to assess limitations. Interestingly, none of the RCT authors even mentions self-selection in their discussion as a possible limitation or bias of the trials. I believe self-selection to be their major potential limitation.

                      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. In the USA, for example, there is evidence that about 90% of men who elect circumcision do so in response to foreskin problems. Impaired foreskin tends to be more vulnerable to HIV infection than normal foreskin.

                      To assess the trials’ limitations or strengths, let’s start by looking at the exclusion criteria. For Auvert’s RCT, there were just two: 1) Being already circumcised. 2) Contraindication to circumcision.
                      So we can see that men with cuts or impaired foreskin were accepted. Such conditions affecting the men were not documented. An exception was made for men with genital ulcerations, who were temporarily excluded from the trial until successful treatment. Bailey’s RCT exclusion criteria were slightly more sophisticated, including “foreskin covering less than half the glans”, bleeding disorders, contraindication to surgery, and “absolute indication for circumcision”.

                      Now the issue here is whether the participants were representative of the general population in terms of foreskin health and conditions. To assess this, two investigations are necessary:
                      1) A random sample of the male population at large needs to be genitally examined in the same way as the trial participants. The exam would need to be a careful visual exams undertaken by medical experts (not just by casual nurses) and penile swabs taken for laboratory analysis. This population sample (say of 300 men) would need to be randomly invited to participate, not self-selected like the RCT participants. Since the population sample would only involve a one-time exam, it shouldn’t be too difficult to carry out.
                      This type of investigation was not performed for any of the RCTs!
                      2) In the same way, trial participants also need to be given a thorough visual genital scrutiny by experts, and swabs taken for analysis. There is no documented evidence in any of the trials as to how meticulous the “screening” of the men was, and whether undertaken by experts; no foreskin impairments are documented, except (in the case of Bailey’s RCT) the incidence of STDs.

                      Jake, in expecting me to believe that the screening of the participants was thorough or performed by experts, you are only making an appeal to the RCT author’s authority.
                      But in any case, without a comparison with a non-selected population sample, we can’t know whether the trial participants can accurately or reliably represent the general population in terms of susceptibility to heterosexual HIV infection. Without reliable experimental data, we can’t even begin to know whether a large-scale circumcision programme in Africa – or anywhere – is of utilitarian benefit.

                      It is a point of concern that the trial authors have ignored in their discussions of their trial weaknesses this most important potential confounding factor. Why would they ignore it?

                    • Jake says:

                      ‘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.

                    • Bareback Rider says:

                      You Einsteins can debate ethics for black people all day. The cool thing about being cut is we don’t use condoms anymore.

                    • psandz says:

                      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.

                    • psandz says:

                      To Jake:

                      I’m not sure where your last comment ended up. 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. Go on written evidence! Just using common sense, it is extremely unlikely that just one man out of several thousand had phimosis! (NB. Doesn’t Brian Morris estimate that 10% of men have it? I estimate it at about 1%).

                      Jake asks: “so according to your theory, these men were suffering from foreskin-related problems to a sufficient degree that they were eager to obtain a free circumcision, and then attempted to hide their condition during genital examinations? That doesn’t make any sense.”

                      You’re right it doesn’t make any sense, which is true of most strawman arguments. The men didn’t hide their conditions. 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 investigators weren’t instructed to check comprehensively for foreskin problems anyway. Phimosis would be acceptable as long as it wasn’t “severe” (probably severe enough to prevent sex altogether). Incidences weren’t even recorded.

                      I said “STIs are not a very good indicator of motivations to elect circumcision, unless men are aware they are infected.”
                      Jake replied: “now you’re contradicting your earlier argument”.
                      No, because only if men know they have them will they be motivated to get circumcised. In particular, Herpes simplex 2 (the commonest infection in Bailey’s RCT) is usually latent. However, it’s still important to document, since it may increase susceptibility to HIV infection.

                      Jake says: “the prevalence of HSV-2 was 26.1% among Kenyan men tested in KAIS 2007.”

                      You have eyes like a hawk, I think! 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. How about documented foreskin cuts and tears, and foreskin inflammation and infections? How did they compare to the general population? How many men had phimosis in ANY of the RCTs? NB. I don’t have evidence that phimosis predisposes to HIV, but it will affect the quality of sex.

                    • Jake says:

                      ‘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.

                    • psandz says:

                      Jake says: “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”.

                      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? Where does their vested interest lie, do you think? That would certainly help to account for such sloppy, lackadaisical documentation, unbefitting of a scientist.
                      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. Don’t go on your clairvoyance please.

                      Jake says: “They [the participants] could do whatever they liked, and it is reasonable to suppose that they took advantage of the free medical care given to them.” – I agree!

                      “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.”

                      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?

                      The more men with foreskin problems entering the trials, the better the result for the study designers and investigators.
                      Jake, you must admit that those Krieger, Bailey, Moses etc. guys have made a lot of money out of this, not to mention the investigators. So, there’s your motive question answered nicely, though not kindly.
                      By creating slipshod trials, those designers lay themselves open to doubt.

                      Perhaps they should have asked someone like Van Howe to make some contribution to the design! At least that would have introduced some balance, since they’re all about equally biased, although in fairness to Van Howe, he has far less financial motive to be so. Van Howe might have been able to save Krieger’s trial (the silliest RCT of them all) from keeling over.

                    • Jake says:

                      ‘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.

                    • God_to_Waskell says:

                      Son, you’ve been a disappointment to Me. If you were the Exemplar, I’d start mankind all over again. It would indeed have been a tedious waste of my time, except fortunately you and your ilk are the primitive fringe of My creation.

                    • psandz says:

                      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?

                    • psandz says:

                      I don’t know where your last comment ended up, but it’s so irrelevant to anything under discussion that it probably doesn’t matter.

                      You said: “now I see you’ve resorted to misrepresenting our conversation — something that seems a little unwise given that one only has to scroll a little to see what was actually said. I actually quoted three sentences before my reply. I haven’t misrepresented you.”
                      I haven’t misrepresented you. I’m far too taken with trying to show how pointless your recent comments have been:

                      First, ” a standardized medical history and physical examination, plus a personal interview to obtain sociodemographic and health information” doesn’t imply any genital examination! There’s no protocol there apart perhaps from a “standardized medical history and physical examination”. The latter may be no more than blood pressure check and the application of a stethoscope!
                      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. I mean, if you’re just going to be silly, let’s stop this futile discussion in its tracks. The cases of balanitis and phimosis may be nothing more than self-reporting. We’re given no protocol for genital investigation, are we? We have no idea of how many men were affected by genital conditions and nothing in the population at large to compare anything with. So what is your point?
                      Who cares whether the men may have reported various conditions to the investigators? They’re obviously not all documented anyway.

                    • Bull$h!t in Bull$h!t out says:

                      the RCTs are a hoax, funny stuff!

                    • psandz says:

                      My last comment was to Jake, by the way.

                    • psandz knocks out the waskell says:

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

                    • I Only Regret That I Have But One Foreskin To Give For My Cause says:

                      It’s been fun, everybody! Now go out and save a dick for the world.

                    • Jake says:

                      ‘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.

                    • psandz says:

                      To Jake:

                      Jake says: “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. Where’s the protocol for genital checking, and where’s the evidence of the results? Please understand what “protocol” means in clinical medicine.
                      I apply my criticism to all the RCTs, not just Krieger’s.
                      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.
                      Remember, the RCT results only indicated a relatively small number of HIV-infected men from either arm. Therefore, they are very vulnerable to confounding (especially relating to epidemiological usefulness) .

                      Other sources of information: 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. Those findings should not be dismissed.”Within country” comparative observational findings are more reliable than cross-country comparisons, and less open to investigator bias.

                    • Jake says:

                      ‘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.

                    • The doctor and the foreskin says:

                      Symposium organized by the Royal Dutch Medical Association, parallel to the conference of the International Association of Bioethics in Rotterdam . Researchers, ethicists and representatives of professional physicians’ organizations will be discussing circumcision of boys and men.

                      Surgical removal of the foreskin from young boys is a centuries-old practice. It is part of many different cultures and is carried out for many different reasons. The last decade, there seem to be changes in attitude around the world on this practice. There is an increasing emphasis on children’s rights and a growing concern regarding complications, in the short and the long term, which can occur as a result of circumcision. Many professional doctors’ organizations have adopted declarations stating that circumcision is not associated with any medical benefits sufficient to justify the intervention. In 2010, the Royal Dutch Medical Association published a position paper stating circumcision of minors is a violation of children’s rights.

                      The increasing criticism of routine circumcision has led to a falling incidence of circumcision in many countries. On the other hand though, there are currently large scale campaigns going on throughout Africa promoting circumcision as a possible means of preventing HIV-infections. Questions remain however, as to the scientific evidence backing these campaigns, their moral acceptability and their cost effectiveness.

                      During this symposium, organized by the KNMG, the Royal Dutch Medical Association, researchers, ethicists and representatives of professional physicians’ organizations will be discussing circumcision of boys and men. What are the medical consequences of circumcision, both in the short and the long term? Is there enough scientific evidence to implement circumcision campaigns in Africa? Can circumcision of young boys for religious reasons be morally justified? What is more important, religious freedom or the right to physical integrity of the child? And should parents decide, or should doctors?

                      We offer live streaming for those who cannot attend the conference in person:
                      http://www.knmg.nl/livestream

                    • psandz says:

                      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!

                    • psandz says:

                      My comments no longer seeem to appear (e.g. my 2 of 2 rebuttal to Jake, which focused on his Weiss et al. study). Maybe this will appear:

                      To Jake,

                      You ask: “then why did you say (June 3, 2012 at 10:32 am): “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?” (emph added). Why ask about something and then say (to paraphrase) “it doesn’t matter” when you get an answer?”

                      I wish you were more attentive to what I write! I said that STD documentation is particularly important because STDs predispose to HIV infection. There are two different themes in my argument, in case you still haven’t realised:
                      1) self-selection bias on account of foreskin abnormalities (and high risk sexual behaviours in men who have been led to believe that circumcision will protect), and
                      2) foreskin abnormalities that predispose to HIV.

                      I wrote: “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”.
                      Jake replied: “surely you mean “in circumcised men..”

                      No, I meant the uncircumcised men in the general population being recruited for the trial (obviously, circumcised men were not eligible). I didn’t express myself clearly enough.

                    • Circular Logic says:

                      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.

                    • Tony says:

                      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. Please define significant. That seems quite the subjective word to apply to non-therapeutic cutting on a non-consenting individual. It implies that you’re willing to justify a net harm imposed by parents from non-therapeutic cutting on their non-consenting child son as long as it isn’t “significant”. I’m curious to know how you justify that ethically. It seems to not sync with anything I’ve heard from you before.

                    • Jake says:

                      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.

                    • Tony says:

                      I didn’t misunderstand. I see the relationship between the two, and in your context here. If I’d misunderstood, I would’ve said something to the effect that you’d earlier said parents may make decisions where there is “no net harm”. That was my initial reaction. But I stopped and thought and realized you hadn’t said that. You’d only said you think non-therapeutic circumcision on a child is not a net harm. That suggests but doesn’t state your position on the bounds of parental authority.

                      “…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)” states your position. But it’s not a good position. Significant is a subjective term. Non-trivial is a subjective term. They fail to clarify. It’s probably not possible to get to a concise statement perfectly applicable to any and every decision. But some proxy decisions are clearer than others, like non-therapeutic cutting on a non-consenting individual.

                      I’m sure my objection to your standard is obvious. Significant to whom? Non-trivial to whom? This loose fluidity across individuals permits substituting one person’s judgment for another’s in effectively arbitrary ways. Of course that describes parenting to a large degree. I hope no one is making the mistake of assuming I think individuals should be emancipated upon birth. But your standard is not a limiting principle. It’s not a guide to boundaries that include the subordinate as an individual with his (or her) own rights, needs, and preferences. It’s compounded and much more relevant when the consequences of the subjectivity are applied to permanent, irreversible decisions like non-therapeutic circumcision.

                    • Jake says:

                      ‘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.

                    • Tony says:

                      I forgot to reply to the specific comment again. It’s at June 2, 2012 at 4:43 pm.

                    • Lying Waskell says:

                      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.

                    • Tony says:

                      I’m trying to be decent. If you don’t value that, that’s your choice. But if you value protecting children from unnecessary circumcision, being decent is an excellent first step in convincing those on the fence or loosely in favor of circumcision that they should listen to you. And, more importantly, that they should listen to me. If you antagonize people just because it makes you feel good, it makes the goal we both ostensibly want more difficult to achieve. Please stop making it more difficult. Engage on the facts and ethics, since they’re on our side. Or don’t join the conversation. Either choice will help. Something else, such as your comments here, won’t.

                    • Lying Waskell says:

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

                    • Tony says:

                      This isn’t a street fight.

                    • Tom Tobin says:

                      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.

                    • Tom Tobin says:

                      As a pathologist from Manitoba, John R. Taylor had training to be a doctor, at a minimum. MB, ChB, MRCPEd, and FRCPC were mentioned in his obit. Perhaps someone will be kind enough to translate for us.

                      n 1956, John qualified in medicine at the University of Birmingham Medical School, England followed by junior hospital positions in Birmingham, Sheffield and Liverpool, culminating in his acceptance as a member of the Royal College of Physicians of Edinburgh in 1962 and his decision to specialize in Pathology.
                      Always interested in a new experience John accepted a position as a Pathologist at University College Hospital, Ibadan, Nigeria in 1963, supported by the British Overseas Development Corporation. The combination of hospital duties, research and teaching occupied much of John’s time but the introduction to West African sculpture ignited a passion that equaled his devotion to medicine. His study and love of Yoruba sculpture was undiminished over forty years, leading to an understanding of the artistic value, ethnic variety and expertise of the Yoruba carvers that was phenomenal.

                      When John was offered a position as Pathologist at the Medical Research Laboratory, Kenyatta National Hospital, Nairobi, Kenya in 1967, he accepted a new challenge and an opportunity to experience East Africa. He took his family camping in game parks, boating up the Nile, driving into Ngongoro crater and exploring Olduvai gorge.

                      John’s special contribution in Kenya was his medical treatment of hemophilia. He was the only doctor at the time making cryoprecipitate that would halt the bleeding episodes in his young patients. The effect was so stunning the nurses referred to it as ” Dr. Taylor’s magic stuff”.

                      John spent 27 years at the HSC as a forensic pathologist, teacher and researcher and was an Associate Professor of Pathology at the University of Manitoba. His heart research, which included a special interest in the development of the human heart from embryo to adult, was published in the Canadian Journal of Cardiology.
                      However, the research that gave John international recognition was the work he did to support a growing opposition to routine infant circumcision. His publication in the British Journal of Urology was a courageous and creative effort to secure the genital integrity of infant boys born today and in the future.
                      Dr. John Taylor was the ultimate scientist, always meticulously thorough in his work. His interests were many and varied. He found joy in music, art, antiques, photography, history, all a result of an instinctive curiosity.

                      I would say that this qualifies him on circumcision, considerably more than, say that Australian guy with the great connections to publicity.

                    • Tom Tobin says:

                      “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?

                    • Snake Charmer says:

                      Amen, Tom

                    • Snake Charmer says:

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

                    • Hugh7 says:

                      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”ll put my cut-and-paste (and islaywhisky’s earlier one, here: http://forums.ivillage.com/t5/The-Circumcision-Debate/Circlist-comes-out/td-p/20936833 – he provides a link that was presumably then live) against Jake’s memory.

                      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.

                    • Jake says:

                      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.

                    • Hugh7 says:

                      Circlist is still going at http://www.circlist.com/. If CircList was distinct, few woud have noticed, so intimately were they connected, and Inter-Circ seamlessly took its place as the fetishist arm.

                      “Perfectly plausible”? Would Jakew’s foreskin blink when dust got under it (until he had it cut off)? Mine never does – nor can I ever remember it giving me any kind of early warning (though it has encountered its share of twigs and long grasses when I wasn’t wearing clothing).

                      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

                    • Jake says:

                      ‘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:

                      Okay, it looks like the correct URL is http://www.circumstitions.com/remondino.html

                      As for your argument, I think I’ve worked out what you’re saying, and I want to share it, because it’s hilarious.

                      You’ve noted that there are vague similarities between Remondino’s argument that “In those days, but for the protecting double fold of the preputial envelope that protected it from the thorns and cutting grasses, the coarse bark of trees, or the stings and bites of insects, the glans penis of primitive man would have often looked like the head of the proverbially duel-disfigured German university student” and my argument that “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.”

                      Yes, there are similarities, but apparently you’re unable to accept the possibility that two people can independently think of the same thing. I must, therefore, be “channelling” Remondino. (Perhaps I held a seance?)

                      Not satisfied with this burst of illogic, you apparently feel the need to be even more extravagantly so, because you continue:

                      “Not the most reliable or desirable source: http://www.circumstitions.com/remondino.html#rape” [URL corrected]

                      Here we have a textbook example of the fallacy of poisoning the well: attempting to establish that argument A is invalid by pointing to argument B from the same author. This can only be justified by assuming that all people can be divided into two categories: a) those that always make correct statements, rational to the modern eye, and b) those that always make incorrect statements, absurd to the modern eye. It should be self-evident that this notion is incorrect: most people make a mixture of true and false statements, so clearly both arguments A and B must be judged on their own merits.

                    • psandz says:

                      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.

                    • Tom Tobin says:

                      Your words echo those of Paul Remondino, from the 19th century, regarding twigs.
                      He was an early rationalist for circumcision.
                      The CircList discussion group didn’t close of its own will in 2010. As I understand it, Google closed it.

                    • Tom Tobin says:

                      “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.

                    • Tony says:

                      Jake,

                      …— it’s definitely a consequence. It may or may not be a harm, depending on the value of that money. For example, suppose the person took my accumulated stack of valueless Monopoly money which I wanted to dispose of: in such a situation, it’s more a benefit than a harm.

                      I’m going to give you credit here. I expected an evasive answer. I did not expect this attempt. Bravo for such creative evasiveness. 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? Not, can you think of an alternative solution to still play, thus allegedly explaining away the taking. Do not beg the question you want to answer rather than the question asked. Are you harmed by what was taken?

                      But, to clarify, even though it wasn’t necessary: Actual money. British pounds, in your case. A sum of legitimate, spendable currency issued by the British government. Your life’s savings. If it’s taken from you without your consent, either physically or electronically, is it harm to you?

                      … — again, it depends on the circumstances. It might be a sixth finger … It might be a deliberate cut because the resulting scar is thought to be beautiful …

                      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. (The scar is thought to be beautiful by whom, for example?) That’s quite convenient. It’s also quite wrong. My questions stand as they can and should be easily understood. Are you willing to answer them?

                      To hopefully speed this up, though, I’ll quote something with your name attached (BMC Pediatr. 2012 Feb 28;12:20.):

                      … Since erections would place the most tension on the wound during healing, erections likely contribute maximally to pain scores.

                      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)

                    • Jake says:

                      ‘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.

                    • Tony says:

                      I mistakenly posted my comment to the entry rather than as a reply. It’s above with – May 30, 2012 at 1:47 am – as the time stamp.

                    • Frank OHara says:

                      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

                    • Tom Tobin says:

                      No medical society of any country states that the benefits of circumcision outweigh the risks.

                    • psandz says:

                      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.

                    • Tom Tobin says:

                      Why don’t you ask the Swedish Paediatric Society why they consider it “child abuse” and “assault”?
                      You can’t imagine that ripping apart the synchia which connects the foreskin and head with a blunt probe, and tearing the most sensitive tissue on a human body, except for possibly the eye, is considered assault? Really?
                      I guess you haven’t heard the screams. I have.
                      The Swedish doctors are not incorrect. This is child abuse and assault of the highest order. Why is the removal of genital tissue of females almost universally condemned, but removal of genital tissue of males tolerated?
                      It is a hypocrisy I have never understood.

                    • Tom Tobin says:

                      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?

                    • Jake says:

                      ‘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?’ — I wish people would address what I’ve actually said rather than attacking strawmen. If you look at my post dated May 25, 2012 at 7:52 am, you’ll see that I raised the issue of penile cancer in response to another person who discussed circumcision deaths. My point was not “circumcision is a really good idea because it prevents cancer”. Rather, it was “the deaths caused by circumcision should be considered alongside those that it prevents”.

                      ‘No one is talking about results of genital surgery, when discussing the sexism inherent. They are talking about ethics.’ — are you sure about that? Surely the question “Is it considered no net harm for females?” is about results?

                      ‘Do you have difficulty grasping that the owner of the body should ethically be the one who decides which healthy body parts to keep?’ — I understand that you and other intactivists hold this viewpoint.

                    • Tom Tobin says:

                      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?

                    • Jake says:

                      ‘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?’ — I don’t think that’s analogous. There is a difference between doing something against someone’s will and doing it when they are too young to form and express a will.

                      ‘Can you understand that for most people, this is not considered ethical behavior, because the person having the part removed cannot consent?’ — I think that if such a view were as widespread as you suggest, it would be reflected in the laws: infant circumcision would be illegal.

                  • Richard Russell says:

                    @Jake Waskett. Regarding deaths from circumcision, Jake Waskett said: “the numbers are smaller than the deaths due to penile cancer’” Please state clearly in real numbers how many deaths there are from penile cancer. Please state clearly WHERE these deaths occur (in which country or countries, worldwide, and so on). Please state clearly for which year or years the number of deaths you provide occurred. Please provide reference to article or articles in professional journals that provide any statistics you provide in response to this request. I am doing research on this subject; I have not been able to find reliable data on deaths from penile cancer, and will appreciate receiving the data you appear to have.

              • eshu21 says:

                ‘Several babies die each year from circumcision.’ — this is true, although the numbers are smaller than the deaths due to penile cancer, HIV, etc., if the same number of babies were left uncircumcised.

                Firstly, babies do not get penile cancer. Secondly, your generic statement about the number of babies dying from HIV makes no distinction between HIV transmitted to an infant due to sexual activity of the parent (and no distinction between cut and intact parents), and HIV transmission due to drug use or contaminating medical procedures, for example.

                As for your unsupported numerical conclusion of relative deaths – really? By what mechanism can you prove that assumption? Can you point to a study that follows two groups of children in the same culture, same economic level, cut and intact, and follows them lifelong to demonstrate that the intact group indeed has higher rates of penile cancer, HIV, etc.?

                And how do you explain the similar rates of penile cancer between the (circumcising) USA and non-circumcising Netherlands? Your response is simply a statement of personal belief and preference, not verifiable facts.

                • Jake says:

                  ‘Firstly, babies do not get penile cancer’ — agreed, though I did not say otherwise.

                  ‘Secondly, your generic statement about the number of babies dying from HIV’ — correction: males of any age dying from HIV.

                  ‘As for your unsupported numerical conclusion of relative deaths – really? By what mechanism can you prove that assumption?’ — Okay:

                  Suppose we take two million boys, and circumcise half. That means we’ve got one million circumcisions. Given a risk of death of 1 in 500,000, that means we should expect two deaths due to circumcision.

                  We should also expect some deaths due to penile cancer — to estimate their number, we’ll use the most conservative estimate of the relative risk in uncircumcised males (2x), the overall lifetime risk in the US (1 in 1,437), and the prevalence of circumcision (79%). (If you want citations for these, just ask.) We can therefore calculate the risk in circumcised males using algebraic manipulation; it’s 0.058%, or 575 cases. Using a conservative 5% mortality rate, there are therefore 29 deaths due to penile cancer, plus two due to complications of circumcision.

                  Now, in the uncircumcised group, we should expect twice the number of penile cancer cases: 1,150, and 58 deaths. This is slightly less than twice the number in the circumcised group: circumcision saved 27 lives.

                  ‘And how do you explain the similar rates of penile cancer between the (circumcising) USA and non-circumcising Netherlands?’ — that’s easy: there’s different exposure to other variables. 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.

                  • eshu21 says:

                    Firstly, babies do not get penile cancer’ — agreed, though I did not say otherwise. – please reread your initial statement, the implication (presumably a grammatical implication rather than a real-world one) is there.

                    Thank you for the correction about the second statement.

                    You said::Suppose we take two million boys, and circumcise half. That means we’ve got one million circumcisions. Given a risk of death of 1 in 500,000, that means we should expect two deaths due to circumcision.

                    We should also expect some deaths due to penile cancer — to estimate their number, we’ll use the most conservative estimate of the relative risk in uncircumcised males (2x), the overall lifetime risk in the US (1 in 1,437), and the prevalence of circumcision (79%). (If you want citations for these, just ask.) We can therefore calculate the risk in circumcised males using algebraic manipulation; it’s 0.058%, or 575 cases. Using a conservative 5% mortality rate, there are therefore 29 deaths due to penile cancer, plus two due to complications of circumcision.

                    Now, in the uncircumcised group, we should expect twice the number of penile cancer cases: 1,150, and 58 deaths. This is slightly less than twice the number in the circumcised group: circumcision saved 27 lives.”

                    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”, and the evidence that any such numbers come solely from being intact (as opposed to say poverty and lack of proper health care, which may as an unrelated issue also involve greater numbers of intact men, as in the United States – please see the logical fallacy, “Post hoc ergo propter hoc”)?

                    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

                    • Jake says:

                      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.

                    • James Mac says:

                      It’s peculiar that circumcision advocates use cancer prevention to support their arguments, while cancer prevention organisations themselves do not:-

                      “Given the lack of evidence to support circumcision as a cancer control measure in Australia, in Cancer Council Australia’s view it is inappropriate to complicate the debate on circumcision by suggesting the procedure could contribute to reduced cancer burden in Australia.” ~Cancer Council of Australia, March 2012.

                    • Joe says:

                      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 OHara says:

                      Joe wrote: “It’s especially peculiar considering there is a very good vaccine available for both boys and girls”

                      When Guardasil was announced in 2004 (2005?), I predicted that circumcision advocates would totally ignore it and continue to push circumcision for HPV and cervical cancer. I have not been proven wrong. Here 7 or 8 years later, they purposely ignore this advent and continue to push circumcision.

                      Circumcision has proven to be a totally worthless intervention with 80% of American men circumcised and an estimated 70% HPV infection rate. These two figures contradict each other if circumcision had any value at all.

                      Circumcision advocates such as Jake purposely ignore this advancement to push male circumcision and do so at the risk of women’s lives due to cervical cancer.

                      The vaccines are highly effective and have few suspected counter effects. In addition, no one loses important parts of their genitalia with the vaccines. They are available at any doctor’s office and only take seconds. In addition, there is no recovery period.

                      This should cause all readers to evaluate the postings by Jake and any others here defending circumcision and their intent. It appears to me the intent is clear.

                      .

                    • psandz says:

                      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.

                    • Frank OHara says:

                      psandz says: “Circumcision is redundant.”

                      Indeed it is and also borders on abusive. It’s like carrying 6 spare tires in your automobile. There is little significant pain with the vaccine and no loss.

                    • eshu21 says:

                      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 says:

                      (Responding to eshu21, May 27, 2012 at 9:40 am)

                      ‘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’ — that doesn’t make any sense. If I understand your argument, you’re saying that because HPV rates were similar between circumcised and uncircumcised men in New Zealand, then HPV rates must be similar between different countries.

                      In any case, it’s extremely unwise to extrapolate from a single observational study. Dickson’s paper is just one study of circumcision. Albero et al included 21 studies in their recent meta-analysis. Albero G, Castellsagué X, Giuliano AR, Bosch FX. Male circumcision and genital human papillomavirus: a systematic review and meta-analysis. Sex Transm Dis. 2012 Feb;39(2):104-13.

                    • Frank OHara says:

                      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.

                      .

                  • Frank OHara says:

                    Jake wrote: “We should also expect some deaths due to penile cancer — to estimate their number, we’ll use the most conservative estimate of the relative risk in uncircumcised males (2x), the overall lifetime risk in the US (1 in 1,437), and the prevalence of circumcision (79%). (If you want citations for these, just ask.) We can therefore calculate the risk in circumcised males using algebraic manipulation; it’s 0.058%, or 575 cases. Using a conservative 5% mortality rate, there are therefore 29 deaths due to penile cancer, plus two due to complications of circumcision.

                    Now, in the uncircumcised group, we should expect twice the number of penile cancer cases: 1,150, and 58 deaths. This is slightly less than twice the number in the circumcised group: circumcision saved 27 lives.”

                    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 did find one woman whose father had a cancer (successfully treated) but his cancer was directly on his circumcision scar. With the prevalence you claim, it would be very unlikely that there would be none.

                    Likewise, there are virtually no case histories of these to be found. Apparently, they only exist in your mind.
                    e
                    But, you make the jump that penile cancer is fatal in your calculations. Penile cancer (squamous cell carcinoma in situ) is but one of five types of penile cancer and the only one that could possibly be influenced by circumcision. You also make no distinction here.

                    “Given a risk of death of 1 in 500,000,”

                    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. In medical research, 3 studies that find essentially the same thing establish the research as fact. Do you have 3 (or more) research projects that back your claim of 1:500,000? I suspect not as I have been involved in this issue for years and have never seen anything legitimate that backs the figure. Yes, I’ve seen claims of that number but never any legitimate research.

                    .

                    • Jake says:

                      ‘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.

                    • psandz says:

                      Jake, evidence indicating that circumcision reduces penile cancer is actually flimsy, since studies haven’t demonstrated that foreskin is the causative agent. Socioeconomic factors (and possibly lifestyle) are far more significant contributors. The same goes for cervical cancer.
                      The Canadian Paediatric Society says under “neonatal circumcision revisited”:
                      “The annual rate of penile cancer is 0.3 to 1.1 per 100,000 men in developed nations. In the USA, the annual rate is about 1 per 100,000 men. This is similar to the rates in Norway and Sweden, where circumcision is rare”.

                • Frank OHara says:

                  eshu21 says: “Several babies die each year from circumcision.’ — this is true, although the numbers are smaller than the deaths due to penile cancer, HIV, etc., if the same number of babies were left uncircumcised.”

                  No, the incidence of penile cancer is 1:109,000 (at worst). That’s just those who have the cancer, not deaths. The incidence of infant death from Circumcision is approximately 1:7,000. Thus, about 15 infants die in an effort to save them as old men. Penile cancer is among the easiest cancers to treat. At first appearance, the cancer presents as a match head sized lesion. The treatment is to remove it in an in-office procedure and it’s gone. The treatment is that simple and virtually always successful.

                  However, there is an even better way. Penile cancer is caused by the human papilloma virus. There are two recently developed vaccines against this virus that are both very effective and safe. Which is better, a vaccine or amputative surgery? That seems to be a no-brainer.

                  • eshu21 says:

                    Frank OHara, I agree with you! The statement you are refuting was a quote from another poster. For some reason, the “Reply” button is not posting the replies made next to their original comments. Sorry about the confusion!

                  • Joe says:

                    Frank said: “The incidence of infant death from Circumcision is approximately 1:7,000.”

                    Frank, could you please provide a reference to support this figure?

                    • Frank OHara says:

                      Joe says: “Frank, could you please provide a reference to support this figure?”

                      This number is not available per se. I figured it my self. But it came from reliable sources at http://www.cirp.org.

                      In 1979, Robert Leon Baker found that 229 infants died as a result of their circumcisions. http://www.cirp.org/library/general/baker1/

                      Ten years later, another study was done that found the same number of deaths. This site names names: http://www.cirp.org/library/death/

                      Then in 1998, Bollinger again found about the same number of deaths: http://www.icgi.org/articles/bollinger4.pdf

                      When the circumcision rate fell by about 50%, the death rate also fell by a corresponding percentage from 230 to 117.
                      Given the numbers of circumcisions performed (about 1.6 million in the early 1990’s) and the birth rate, it was just a matter of mathematics to figure the !:7,000 death rate.

                    • Jake says:

                      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!

                    • James Mac says:

                      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?

                      I say zero boys harmed and zero boys killed due to unnecessary circumcision surgery is the only acceptable number.

                    • Jake says:

                      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.

                    • James Mac says:

                      “that is, the number of deaths [of healthy, defenceless babies] caused by circumcision would have to be at least equal to the [imagined] number of [adult, behaviour-related] deaths prevented by circumcision.”

                      It’s highly doubtful that anyone has ever died from not being circumcised. Conversely, the tragic (real-world – real children with real names and real families) evidence of circumcision deaths is a matter of historical record.

                      It is wrong to strap or pin down children and cut them. It is wrong to spread misleading information with the intention of deceiving naive parents into thinking that cutting off a significant part of their son’s penis is in the child’s best interests.

                    • psandz says:

                      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.

                    • Frank OHara says:

                      James Mac says: “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?”

                      Great question, James Mac! Apparently, Jake is willing to throw babies under the wheels of the bus to advance circumcision. I’m anxious to see Jake’s answer to this.

                      .

                    • Frank OHara says:

                      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.

                      .

                    • Jake says:

                      ‘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’ — Perhaps you’d care to explain, then, why Bollinger clearly states that it is an estimate based on assumptions (p82): “Though the data previously cited are insufficient to establish a definitive death rate on their own, there is enough available information to calculate an estimate. … Gender-ratio data can help extrapolate a figure. … Assuming that the 59.6% portion is unrelated to gender, we can estimate that 40.4% of the 35.9 deaths were circumcision-related.”

                  • Jake says:

                    This is a reply to Frank OHara’s comment of May 26, 2012 at 10:56 pm:

                    ‘No, the incidence of penile cancer is 1:109,000 (at worst).’ — that’s the annual incidence, ie., the risk per year. It’s more meaningful to compare the lifetime risk, which is 1 in 1437.

                    ‘The incidence of infant death from Circumcision is approximately 1:7,000.’ — actually 1 in 500,000.

                    • Frank OHara says:

                      Jake wrote: “that’s the annual incidence, ie., the risk per year. It’s more meaningful to compare the lifetime risk, which is 1 in 1437.”

                      No, what you are espousing is taken from Edgar Schoen whose intent is to scare. 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?

                      Penile cancer is among the rarest of all cancers.

                      “‘The incidence of infant death from Circumcision is approximately 1:7,000.’ — actually 1 in 500,000.”

                      Your figure is taken from either The AMA or AAP who have a vested interest in hiding the deaths. Four separate studies by four separate authors have established the actual death rate at approximaately 1 per 7,000 procedures. It may be even higher than that as these deaths are often attributed to other causes when the initializing cause was the circumcisision procedure. If the child hadn’t been circumcised, the attributing cause would not have been any factor.

                      For instance, if a child bleeds to death after circumcision, the cause of death might be listed as “exsanguation” (sp?). The thing that caused the exsanguation was the circumcision. If the child had not been circumcised, there would be no wound to bleed. Children don’t just spontaneously start bleeding uncontrolably.

                    • Jake says:

                      “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.

              • Frank OHara says:

                Jake wrote: “on the contrary, there’s strong evidence that it provides multiple benefits in terms of reduced risk of a number of conditions.’

                It’s curious that you (a computer programmer) have been able to find these “strong multiple benefits” while the medical profession has not.

                “this is true, although the numbers are smaller than the deaths due to penile cancer, HIV, etc., if the same number of babies were left uncircumcised.”

                I’d like to see some support for this. Penile cancer (squamous cell carcinoma in situ) is a vanishingly rare cancer and can always be successfully treated if treatment is sought in a reasonable time. Also, the victims get to lead a full life as it is a cancer that strikes old men. The American Cancer Society scoffs at the notion circumcision provides any protection at all.

                The connection of circumcision and HIV has not been made as The US has both a very high circumcision rate and a high HIV rate. There are other areas of the world where this same situation exists. If circumcision had the protective effects claimed, these contradictions simply would not exist. There would be stark differences in infection rates.

                .

              • Tom Tobin says:

                It is not several babies who died from circumcision each year. James L. Snyder, M.D., F.A.C.S., retired President of the Virginia Urological Society, estimates 200 babies die every year in the United States from circumcision, most from hemorrhage. He states that medical personnel always put something else on the death certificate, such as excessive bleeding, but those deaths would not have occurred if the infant had not been circumcised.
                http://www.youtube.com/watch?v=XrcMYq0ASB8

                Please present evidence that the number of babies who die from circumcision is less than the number who would be lost due to penile cancer, HIV, etc, if the same number of babies were left uncircumcised.
                With penile cancer, the American Cancer Society does not recommend circumcision as a preventative. In fact, the Christopher Maden study in Washington State showed that 37% of the men who got cancer of the penis were circumcised as babies.

                The number of second surgeries to correct a problem from circumcision has risen 110% in the US.

              • Richard Russell says:

                Regarding deaths from circumcision, you said: “the numbers are smaller than the deaths due to penile cancer’” Please state clearly in real numbers how many deaths there are from penile cancer. Please state clearly WHERE these deaths occur (in which country or countries, worldwide, and so on). Please state clearly for which year or years the number of deaths you provide occurred. Please provide reference to article or articles in professional journals that provide any statistics you provide in response to this request. I am doing research on this subject; I have not been able to find reliable data on deaths from penile cancer, and will appreciate receiving the data you appear to have.

          • Joseph4GI says:

            Is there a “right amount of science” that would convince you to advocate for female circumcision?

            What if it were conclusive “beyond reasonable doubt?”

            What if “health benefits” were acknowledged for female circumcision? Would it still be “morally wrong” or a “violation of basic human rights?”

            Is the difference between “circumcision” and “mutilation” alleged “health benefits?”

            Never.

            There would never be enough “science” or “benefits” that would ever justify the forced genital cutting of girls.

            EVER.

            Genital mutilation, whether it be wrapped in culture, religion or “research” is still genital mutilation.

            It is mistaken, the belief that the right amount of “science” can be used to legitimize the deliberate violation of basic human rights.

          • eshu21 says:

            Funny how all of the non-circumcising world (that is, outside of the US, Middle East and parts of Africa) find the supposed claims of health benefits to be utterly false; their own studies and statistics find no benefit to circumcision. The medical bodies in Australia, New Zealand, Holland, UK, Canada, South Africa, and Sweden HAVE looked at the HIV data and concluded that the supposed benefits to adults don’t warrant routine infant circumcision. Perhaps you might widen your research to include them? Try as a start:

            Male circumcision in Britain: findings from a national probability sample survey
            Dave SS, Fenton KA, Mercer CH, Erens B, Wellings K, Johnson AM.
            Sex Transm Infect 2003;79:499-500

            and

            Circumcision in Australia: prevalence and effects on sexual health.
            J Richters, AM Smith, RO de Visser, AE Grulich, and CE Rissel
            Int J STD AIDS, August 1, 2006; 17(8): 547-54.

            and from the US military:

            Prevalence of male circumcision and its association with HIV and sexually transmitted infections in a U.S. navy population
            A G Thomas, L N Bakhireva, S K Brodine, R A Shaffer
            Naval Health Research Center, DHAPP, San Diego, CA, United States

            As for evidence of harm, just as a sample try:

            http://ije.oxfordjournals.org/content/early/2011/06/13/ije.dyr104.abstract
            http://sciencenordic.com/male-circumcision-leads-bad-sex-life
            http://www.hani.co.kr/arti/english_edition/e_national/180947.html

            • eshu21 says:

              Why are these replies not showing up in the appropriate places? My post above (“Funny how all of the non-circumcising world”) was meant to reply to:

              JimmyWang says:
              May 24, 2012 at 7:53 pm

              There is no right amount of science that would convince you
              no matter how conclusive.

              If the health benefits were acknowledged, people
              would not be able to say circumcision is morally wrong or a
              violation of human rights.

          • psandz says:

            Jimmy Wang, the science is not on your side!
            Maybe circumcision offers protection against certain STDs under certain conditions in certain third-world countries. Maybe…
            There is no medical consensus that circumcision offers a net health benefit. For example, the Royal Dutch Medical Asociation clearly states (2011), following their research, that infant circumcision is not associated with medical benefit, but IS associated with significant risk of complications. They urge doctors to “actively and insistently” warn parents against the procedure. The Swedish Paediatric Society calls for a “BAN” on infant circumcision (2012). The South African Medical Association calls infant circumcision “unethical”, and disputes that circumcision offers useful protection against HIV transmission. Science is not necessarily on your side.

            Btw, net health benefit for circumcision could only be established on the basis of a GENERAL HEALTH PROFILE comparing the health of circumcised vs. uncircumcised males. Your (and Jake’s) cherry-picking just a few health issues (e.g. UTIs, penile cancer) to compare between circumcised and uncircumcised men doesn’t cut the mustard. No health insurance company seems to be aware that circumcised men suffer fewer health issues than uncircumcised men. They don’t care or want to know whether their male clients are circumcised or not, although they do require information on many other personal details. Circumcision evidently makes no difference to health.

          • Hugh7 says:

            There are undoubted health benefits of castration. Castrati live longer than intact men. Their risk of STDs is much lower (virtually nil if penectomy is included). From memory they suffer much less from prostate cancer. Castration of healthy boys would still be morally wrong and a violation of their human rights. “Health benefits” have to be weighed against other deficits, but in any case human rights inhere to all humans by right, by definition, and the right to security of the person, freedom from unreasonable seizures and equality of the sexes are among those guaranteed by e.g. the Universal Declaration of Human Rights.

        • JimmyWang says:

          Derick, you can say it as much as you want. It doesn’t make it true
          just because you say so.

          The science is on my side. It’s very clear there are life-long health benefits
          to being circumcised.

          • Joe says:

            And it is also clear that there are risks to the procedure, some with life long consequences. The only person who can realistically weight the risks against the potential benefits is the individual being circumcised.

          • Joe says:

            To JimmyWang May 24, 10:06

            And it is also clear that there are risks to the procedure, some with life long consequences. The only person who can realistically weight the risks against the potential benefits is the individual being circumcised. (repeated to put back into context)

          • eshu21 says:

            There are life-long health benefits to removing infant girls’ breasts at birth – far more than from removal of the foreskin. When we we see you agitating for the worldwide institution of infant mastectomies?

      • Henry says:

        The world needs anger. The world often continues to allow evil because it isn’t angry enough.

        - Bede Jarrett, The House of Gold

      • Tom Tobin says:

        Was Germany having an angry rant, when they outlawed circumcision?
        http://uk.news.yahoo.com/german-court-outlaws-religious-circumcision-162728176.html
        I’m certain that the parents of the four year old who got maimed felt they were making the right decisison.
        I am not so certain the four year old will agree as an adult. Just another lifelong benefit, eh, Jimmy?

    • JimmyWang says:

      Another comment for Henry:

      “This has needed to be said. No amount of data would convince them that circumcision is good because they think it is morally wrong. That’s a very acceptable position. I don’t think we should be circumcising children either.”

      If you believe this, then why bother denying the health benefits?

      You’d have a lot more credibility if you acknowledged the health benefits.

      Instead you come across like an unscientific zealot.

  • bo says:

    These are pre-planned timepoints to do a data-analysis to see if the study should be continued. These are very common in large clinical trials. These are done to see if the study should be stopped because the result is clearly positive, clearly negative, or clearly too toxic. This is very common.

  • Melissa says:

    Foreskins do not cause or transmit HIV/AIDS. Having sex with an HIV positive person does! All circumcision will do is give men a false sense of security so that they will engage in higher risk sexual activities more often. Condoms, abstinence, and monogamy are the only way to prevent the spread of HIV/AIDS. There are multiple countries where 90% or more of men are not circumcised and those countries have LOWER HIV rates than the USA. Examples include Mongolia, Japan, and Denmark.

    • bo says:

      Despite availability and knowledge of condoms, people keep having sex with HIV+ and contracting the virus themselves. These studies wouldn’t be done if people wore condoms. We’ve already discussed how the epidemiologic studies you refer to aren’t very helpful here. There are too many confounding variables. Particularly in northern Europe, approximately 10% of people have genetic mutations that provide some resistance to contracting HIV.

      • JimmyWang says:

        Bo, I absolutely agree that if people used condoms all the time,
        there wouldn’t be an AIDS epidemic. In spite of years of effort trying
        to get people to do that in Africa, it hasn’t happened.

        It’s kind of like saying these studies wouldn’t be necessary if people
        stopped having sex.

        It’s not going to happen.

      • Joe says:

        In reply to Bo on May 24, 2012 11:04

        Actually Bo, I might differ with you on the point of availability of condoms. According to AVERT, whose figures com from the UNFPA records, the number of donated condoms only reaches about 15 % of the need. The number of condoms available per man per year in these parts of the world is about 15. With such a raging epidemic, that is a scandalously low number; there is no reason that the continent can’t be saturated with condoms. Whether they are used or not is a different story but I am not convinced that they’ve ever been available in sufficient quantity and I am also not convinced that the knowledge is there either.

        In reply to JimmyWang:

        With the low availability of condoms, I am not convinced that there has been a meaningful effort to get people in Africa to use them. How could you when there are so few available? Just making condoms available is the first step and we’ve failed at that year after year.

        • bo says:

          You make a good point on condoms, particularly in regards to the overall effort to prevent HIV transmission. However, in the studies, condoms were offered at every visit. I don’t understand why, but people don’t use them enough, even when they are free. We see this problem here in America in the MSM community, and that is why there are prophylactic trials of antiretrovirals. Why would someone rather have surgery or a daily medication with side effects over a condom? I don’t know.

          So, they did have condoms in the study, but I think regarding the overall effort in these countries, you are probably right. A lot more should be done on the condom front, before circumcision is really part of the strategy. In reality, HIV shouldn’t be touching the foreskin or lack of foreskin.

          • Joe says:

            I know that the provision of condoms was part of the study, I was speaking more toward their availability in the wider population which as far as I can tell is, as I said, scandalous considering the scale of the problem. Getting them to be used is the hard part but saturating the continent, making them available to anyone, anywhere and anytime should be relatively easy, a number one priority, and it seems we can’t even manage that. (And this discussion is meandering every which way, we do have to be specific about the context we’re talking about. ;-) )

            As a matter of policy and resource allocation in those countries, I’d prefer to see limitless condom distribution, widespread testing (possibly mandatory after a certain age), and HAART drugs available to any of those infected. Circumcision, even in those places where the studies where done, I’d put toward the bottom of the heap in terms of strategy, only permitted by informed individual consent.

          • Joe says:

            Bo, I do agree with this: “Why would someone rather have surgery or a daily medication with side effects over a condom?”

            I also don’t understand why someone would consider circumcision or daily medication over a condom. I suspect it might be because people are looking for a silver bullet, quick fix.

    • JimmyWang says:

      Um, I beg to differ. The evidence shows that foreskins DO allow for
      easy access of HIV.

      Once again, in the US, HIV is transmitted mostly through being anal receptive
      and IV drug use. Circumcision is not going to help that group of people.

      • Joseph4GI says:

        Jimmy, evidence please?

        I’m afraid that as of yet there is no demonstrable causal link, only debunked hypotheses and cherry-picked statistics with empty assertion that correlation equals causation.

      • eshu21 says:

        Actually Jimmy, the only study that purported to show a connection between foreskins and HIV (I am referring to a direct connection, rather than those attempts to infer a connection as in the African RCTs) occurred years ago, when a study of severed foreskins in the lab led researcher­­s to believe that “specializ­­ed cells” (Langerhan­­s cells) were a portal for HIV; about four years ago it was discovered that these same cells produce a substance called Langerin that attracts and binds HIV, preventing it from entering the body. It was this attracting and binding process that misled the first group of researchers, a misunderstanding and error still repeated in mainstream media today. Circumcisi­­on removes that defense.

        • Jake says:

          I’m afraid you’re incorrect, eshu21. Multiple studies have found evidence of mechanisms by which the foreskin increases risk. For a good review see Dinh MH, Fahrbach KM, Hope TJ. The role of the foreskin in male circumcision: an evidence-based review. Am J Reprod Immunol. 2011 Mar;65(3):279-83

          The situation involving Langerhans cells isn’t as black-and-white as you seem to suggest. Langerhans cells play a defensive role through Langerin, but also act as a portal for the virus. As de Witte et al put it: “recent data demonstrate that LCs prevent HIV-1 transmission by clearing invading HIV-1 particles. However, this protective function of LCs is dependent on the function of the C-type lectin Langerin: blocking Langerin function by high virus concentrations enables HIV-1 transmission by LCs.” and as de Jong and Geijtenbeek put it: “LCs express the LC-specific C-type lectin Langerin that efficiently captures HIV-1, which prevents HIV-1 transmission. However, immune activation of LCs changes these protective cells into HIV-1-transmitting cells, which indicates that the antiviral function of LCs depends on several factors including co-infections.”

          • eshu21 says:

            Since DeWitte was the source of the original incorrect study of severed foreskins in the lab, he is hardly unbiased; further, he conflates the inability of Langerhans cells to continue blocking HIV with actual transmission as a greater portal of entry than other cells occurring throughout the penis. There is simply no evidence for this; any cell overwhelmed by HIV in essence becomes an HIV transmitting cell; neither DeWitte or de Jong and Geijtenbeek demonstrate that this is at a higher rate in Lnagerhans cells than in others, or that they therefore create a greater risk.

          • Jake says:

            “Since DeWitte was the source of the original incorrect study of severed foreskins in the lab, he is hardly unbiased” — I’m afraid you’re incorrect. de Witte was the lead author of “Langerin is a natural barrier to HIV-1 transmission by Langerhans cells.” If that makes him biased, he’s surely biased in favour of the LCs-as-protection hypothesis.

      • CB says:

        Circumcision also does nothing to prevent male to female transmission, so you can add that to the list of those unprotected by this surgery.

    • Frank OHara says:

      Melissa says: “Foreskins do not cause or transmit HIV/AIDS. Having sex with an HIV positive person does!”

      Yes, the infection is transmitted when the man ejaculates his semen that is a carrier for the infection. A man is going to ejaculate regardless of whether he still has his foreskin or not. The foreskin has nothing to do with that.

      “All circumcision will do is give men a false sense of security so that they will engage in higher risk sexual activities more often.”

      This has been found to be true. The circumcised men are engaging in risky practices believing they are invincible.

      “Condoms, abstinence, and monogamy are the only way to prevent the spread of HIV/AIDS.”

      Yes again. Condoms have been found to be 98% effective virtually eliminating the risk. Condoms alone would defeat the epidemic. The US has sent untold numbers of condoms to Africa. However, it has been found that circumcised men are resistant to using condoms.

      “There are multiple countries where 90% or more of men are not circumcised and those countries have LOWER HIV rates than the USA.”

      Yes, The US has both the highest rate of circumcision and the highest rate of HIV infection among the industrialized nations. If circumcision is so effective, how can this be?

  • admin says:

    A gentle reminder to our commenters: the policy of the Practical Ethics blog encourages fierce, passionate debate. But it prohibits ad-hominem abuse, name-calling and personal attacks. Kindly do your best to stay on the right side of that line. We greatly prefer not to delete and block people from participating, and we rely on our commenters to moderate their own behaviour.

    • De Pietro says:

      This is actually a good topic for debate. The last three articles on circumcision were afflicted by a very heated discussion, bordering mutual insult. A point was reached where there was no intellectual profit whatsoever and one did not even read the comments anymore. This is undesirable.

      The question is: should the blog decide to never again write about circumcision, so as to prevent this from happening? Formulated in another way: “Should society/the scientific community refrain from addressing certain topics, on the grounds that discussing them only creates chaos and rage?”. In this respect, concepts accepted as unquestionable truths, such as freedom, democracy, and human rights, are what come to my mind right now.

      *. I’m assuming that people won’t change and correct their behavior, of course.

      • Jake says:

        There are other options. For example, if the blog software has this facility, the owners of this blog might consider subjecting comments to pre-moderation. Comments containing personal attacks could, quite simply, be deleted.

        I’d hesitate, however, before recommending such a course of action. I think an intelligent reader can learn a great deal about the participants in a debate from their behaviour. Nauseating as they are, personal attacks are informative, usually indicating the weakness of the attacker’s arguments.

        (Since the ‘reply’ functionality seems to be malfunctioning at present, this is a response to De Pietro’s comment dated May 25, 2012 at 12:27 am.)

      • Joseph4GI says:

        Not discussing circumcision has been the problem all this while, either because parents don’t want to discuss what they see as a “parental right,” or because Jewish people claim “antisemitism.”

        The fact is that “parental choice” and religious immunity have lost their validity, and now, more than ever, people grope for a “scientific” sounding alibi. In essence people are disguising their biases with a feigned interest in “medical benefits” and/or “public health.” But it seems even “medical benefits” are enough anymore; they now seek to make it an indispensable imperative for all men in the world.

        The very idea of “studying” the devaluation of the human body and the legitimization of its deliberate destruction ought to be scrutinized. Usually, medical science seeks to preserve bodily integrity. Circumcision “research” is unique in that it is the only kind seeking to necessitate, and not avert surgery in healthy, usually non-consenting individuals.

        Science is always trying to improve itself; to make itself obsolete. Progress is marked by the replacement of the old with the new and better. Instead of seeking out newer, better, less invasive method of preventing disease, why are people seeking to necessitate an ethically problematic procedure?

        Using all that “knowledge” that “researchers” claim we’ve acquired from “all those studies,” why havn’t the come up with a way to achieve “benefits” WITHOUT genital cutting? Why is the end result always the same? (…and hence everyone should be circumcised?”

        In the hypothetical situation that the same “research” that exist for male circumcision, existed for female circumcision, could there be a similar “debate” as the one the exists for male circumcision? Would people debate the “pros and cons” of female circumcision? Supposedly what separates male circumcision apart from “mutilation” is all the “medical benefit.” So if “benefits” could be established for female circumcision, would it stop being “mutilation?”

        What if female circumcision could be performed in a way that wasn’t detrimental to a woman’s sexuality? (Actually, there are studies that show that even women who have undergone infibulation, which is the worst kind of female genital cutting, are still able to orgasm.)

        Is there a magic number of “studies” and “benefits” that would allow us to have a “debate” about the “pros and cons” in a scientific setting? Or is this unique to male circumcision only?

        Or would the scientific community forbid discussion so as to not rouse the wrath and rage of anti-FGM /pro female genital cutting advocates?

      • Joseph4GI says:

        Not discussing circumcision has been the problem all this while, either because parents don’t want to discuss what they see as a “parental right,” or because Jewish people claim “antisemitism.”

        The fact is that “parental choice” and religious immunity have lost their validity, and now, more than ever, people grope for a “scientific” sounding alibi. In essence people are disguising their biases with a feigned interest in “medical benefits” and/or “public health.” But it seems even “medical benefits” are enough anymore; they now seek to make it an indispensable imperative for all men in the world.

        The very idea of “studying” the devaluation of the human body and the legitimization of its deliberate destruction ought to be scrutinized. Usually, medical science seeks to preserve bodily integrity. Circumcision “research” is unique in that it is the only kind seeking to necessitate, and not avert surgery in healthy, usually non-consenting individuals.

        Science is always trying to improve itself; to make itself obsolete. Progress is marked by the replacement of the old with the new and better. Instead of seeking out newer, better, less invasive method of preventing disease, why are people seeking to necessitate an ethically problematic procedure?

        Using all that “knowledge” that “researchers” claim we’ve acquired from “all those studies,” why havn’t the come up with a way to achieve “benefits” WITHOUT genital cutting? Why is the end result always the same? (…and hence everyone should be circumcised?”

        In the hypothetical situation that the same “research” that exist for male circumcision, existed for female circumcision, could there be a similar “debate” as the one the exists for male circumcision? Would people debate the “pros and cons” of female circumcision? Supposedly what separates male circumcision apart from “mutilation” is all the “medical benefit.” So if “benefits” could be established for female circumcision, would it stop being “mutilation?”

        What if female circumcision could be performed in a way that wasn’t detrimental to a woman’s sexuality? (Actually, there are studies that show that even women who have undergone infibulation, which is the worst kind of female genital cutting, are still able to orgasm.)

        Is there a magic number of “studies” and “benefits” that would allow us to have a “debate” about the “pros and cons” in a scientific setting? Or is this unique to male circumcision only?

        Or would the scientific community forbid discussion so as to not rouse the wrath and rage of anti-FGM /pro female genital cutting advocates?

        • Frank OHara says:

          Joseph4GI wrote: “Using all that “knowledge” that “researchers” claim we’ve acquired from “all those studies,” why havn’t the come up with a way to achieve “benefits” WITHOUT genital cutting?”

          That would derail the money train, Joseph. Give a simple pill instead of performing surgery? Not likely to happen. Put off the profits for years? Not likely to happen. Let another medical professional (pediatrician?) get the business? Not likely!

          “they now seek to make it an indispensable imperative for all men in the world.”

          I fear that is the real agenda.

          “Circumcision “research” is unique in that it is the only kind seeking to necessitate, and not avert surgery in healthy, usually non-consenting individuals.”

          I’ve never thought of it that way but it makes sense!

          “why are people seeking to necessitate an ethically problematic procedure?”

          I suspect it is because of humans intrinsic fascination with the genitals.

          “Using all that “knowledge” that “researchers” claim we’ve acquired from “all those studies,” why havn’t the come up with a way to achieve “benefits” WITHOUT genital cutting? Why is the end result ”

          Apparently they don’t want to find those methods. The methods are already there and sitting on the shelf ready to use.

          “In the hypothetical situation that the same “research” that exist for male circumcision, existed for female circumcision, could there be a similar “debate” as the one the exists for male circumcision? Would people debate the “pros and cons” of female circumcision?”

          WEll, you see, they have already found those but they choose to ignore them. The female genitalia has “protected status” that the male genitalia isn’t perceived to have.

          “So if “benefits” could be established for female circumcision, would it stop being “mutilation?”

          Interesting question! Certainly medical treatment for medical conditions is not regarded as mutilation but as a prophylactic treatment?

          “(Actually, there are studies that show that even women who have undergone infibulation, which is the worst kind of female genital cutting, are still able to orgasm.)”

          Yes and I have seen those studies as well. However, when they are posted on a site such as this, they are routinely and universally rejected. The same for males is accepted.

          “Is there a magic number of “studies” and “benefits” that would allow us to have a “debate” about the “pros and cons” in a scientific setting? Or is this unique to male circumcision only?

          “Or would the scientific community forbid discussion so as to not rouse the wrath and rage of anti-FGM /pro female genital cutting advocates?”

          Many internet discussion sites will ban you instantly if you post about the positive side of female circumcision while you can write anything you want about male circumcision. Is that misandrist or what?

          .

      • Joseph4GI says:

        Not discussing circumcision has been the problem all this while, either because parents don’t want to discuss what they see as a “parental right,” or because Jewish people claim “antisemitism.”

        The fact is that “parental choice” and religious immunity have lost their validity, and now, more than ever, people grope for a “scientific” sounding alibi. In essence people are disguising their biases with a feigned interest in “medical benefits” and/or “public health.” But it seems even “medical benefits” are enough anymore; they now seek to make it an indispensable imperative for all men in the world.

        The very idea of “studying” the devaluation of the human body and the legitimization of its deliberate destruction ought to be scrutinized. Usually, medical science seeks to preserve bodily integrity. Circumcision “research” is unique in that it is the only kind seeking to necessitate, and not avert surgery in healthy, usually non-consenting individuals.

        Science is always trying to improve itself; to make itself obsolete. Progress is marked by the replacement of the old with the new and better. Instead of seeking out newer, better, less invasive method of preventing disease, why are people seeking to necessitate an ethically problematic procedure?

        Using all that “knowledge” that “researchers” claim we’ve acquired from “all those studies,” why havn’t the come up with a way to achieve “benefits” WITHOUT genital cutting? Why is the end result always the same? (…and hence everyone should be circumcised?”

        In the hypothetical situation that the same “research” that exist for male circumcision, existed for female circumcision, could there be a similar “debate” as the one the exists for male circumcision? Would people debate the “pros and cons” of female circumcision? Supposedly what separates male circumcision apart from “mutilation” is all the “medical benefit.” So if “benefits” could be established for female circumcision, would it stop being “mutilation?”

        What if female circumcision could be performed in a way that wasn’t detrimental to a woman’s sexuality? (Actually, there are studies that show that even women who have undergone infibulation, which is the worst kind of female genital cutting, are still able to orgasm.)

        Is there a magic number of “studies” and “benefits” that would allow us to have a “debate” about the “pros and cons” in a scientific setting? Or is this unique to male circumcision only?

        Or would the scientific community forbid discussion so as to not rouse the wrath and rage of anti-FGM /pro female genital cutting advocates?

  • David says:

    Great article, Mr. Earp. You’ve provoked a firestorm. Rarely does this topic bring out the pro-circumcisionists quite like your piece has. We need more research on the psychological impact of circumcision and why it causes some men to wish to impose it on others. The ethics seem pretty clear to most that imposing a primarily cosmetic (and damaging) procedure for some marginal medical benefit is wrong. What is less clear is why some men seek to subordinate human rights when, as we’ve read above from Robert Darby, it is not necessary to do so to achieve said marginal benefit.

    • Joseph4GI says:

      It’s called Sour Grapes; the foxes with no tails want everyone to be tailless like they are because they don’t want to feel there is anything the matter with them.

    • JimmyWang says:

      David, no one is trying to “impose” circumcision on others.

      All I want is for accurate scientific information to be available so
      parents and men can make an educated decision.

      If you were to acknowledge that circumcision is not just
      “a primarily cosmetic (and damaging) procedure for some marginal medical
      benefit” but actually a vaccination with life-long benefits, then perhaps
      you wouldn’t see it as wrong.

      Since you mentioned ethics, you should follow these links which have been
      around before:

      http://www.circs.org/index.php/Library/Benatar2
      http://www.circs.org/index.php/Library/Benatar

      • Tony says:

        JimmyWang says:
        May 26, 2012 at 12:37 pm

        David, no one is trying to “impose” circumcision on others.

        That’s not accurate. Anyone circumcising their son imposes it on him. Anyone advocating for parents to circumcise is trying to impose it, or at least encouraging its imposition. The word has a specific meaning that applies to non-therapeutic child circumcision. You can’t assume a child’s consent for a non-therapeutic surgery. Without consent – and lack of consent is not assent – circumcising a healthy person imposes circumcision on him.

        All I want is for accurate scientific information to be available so parents …

        See, that’s imposition, which you’re endorsing. There’s more to the debate than just scientific information for circumcision.

        If you were to acknowledge that circumcision is not just “a primarily cosmetic (and damaging) procedure for some marginal medical benefit” but actually a vaccination with life-long benefits, then perhaps you wouldn’t see it as wrong.

        That’s not targeted at me, but I’ll answer. I think there are valid reasons to be skeptical of the findings, but I am also happy to fully acknowledge that they all exist as advertised. So? That acknowledgement doesn’t change the ethical issues, which I think were explained well in Mr. Earp’s prior post on the question. It’s wrong to impose it on a healthy, non-consenting individual because it violates the recipient’s rights (i.e. bodily autonomy) in pursuit of someone’s else goals and preferences. I can also assume it is not imposed for malicious reasons. Believing that parents act in what they believe is their child’s best interest can coexist with the fact they are imposing something obviously unethical and indefensible.

        The utilitarianism you seem to favor (and Jake favors) is relevant to your personal evaluation of the net effect and whether circumcision is good or bad. But that’s your personal conclusion. All individual tastes and preferences are unique. To impose circumcision ignores the evaluation a child might make for his own (healthy) body under the mistaken belief that the child will appreciate and want any decision his parents make on the matter.

        What about the person who believes the (short-term) and “life-long” harms from circumcision outweigh these “life-long” benefits? Is he wrong because he draws a conclusion different than yours or his parents about how that should be applied to his body? Is your subjective opinion the only valid opinion, thus rendering it an objective conclusion? If so, what criteria and weighting are you using for the different subjective factors involved to draw this allegedly objective conclusion?

        Jake made this same mistake when he wrote “if there’s no net harm, on average, then what’s the problem?” (May 25, 2012 at 9:10 am) The Benatars make the same mistake in the two papers you link. We are discussing individuals capable of evaluating factors to determine the net effect to themselves, not utilitarian lumps of flesh waiting to be molded according to what they “should” want because someone somewhere values something in a specific way.

        • JimmyWang says:

          Okay, parents “impose” everything on their infants
          including vaccinations, religion, education.
          Good parents do this things with the best interest of the
          infant in mind.

          If there are life-long health benefits and no net harm,
          then parents no only have a right but an obligation to do
          what they think is best.

          I’m not the one “imposing” anything. Like I said, all I
          want is to give people accurate scientific information
          so they can make an intelligent decision.

          • Tony says:

            The standard “parents make many decisions” argument is flawed. Circumcision is not like religion, education, bed times, movie watching privileges, etc. It is a permanent, unnecessary imposition. A male can change his religion, get a different education, and generally alter or adjust to virtually every decision his parents make for him. He can’t change circumcision. It is, in effect, his parents continuing to parent him every day of his adult life.

            The vaccination argument is related, but has enough to distinguish it. Vaccines work with the body’s immune system to protect the individual against diseases that are communicable through no means other than quarantine. Circumcision removes a part of the body to protect against diseases that are more easily prevented or treated without surgery. (I acknowledged that parents inexcusably impose circumcision with good intentions.)

            If there are life-long health benefits and no net harm, then parents no only have a right but an obligation to do what they think is best.

            “No net harm” is an opinion, not an objective conclusion. It’s based on the mistaken belief that everyone values everything the same way. I do not share your opinion on the net result of circumcision. Each of our conclusions is a subjective analysis based on our own preferences for the potential benefits, potential harms, and guaranteed harms. Your position is that your opinion is good enough for me. (Or, at least, parents’ opinion is good enough for their healthy son.) That is wrong. We don’t apply that simplistic logic to all parenting decisions. It’s only somehow acceptable with male genital cutting.

            I do not value the life-long health benefits you cite because I prefer to engage in safe sex, refrain from smoking, bathe regularly, and so on. Circumcision is unnecessary for me. I’d prefer to have my foreskin and a slightly higher risk of certain ailments because I value my opinion more than yours or my parents’ about how I experience my life. Why am I wrong?

            Do you like coffee? I don’t. Do you enjoy hockey? I do. Do you prefer ’80s music? What about comedies over dramas? Or how about sedans instead of SUVs? And so on. We’re all unique individuals with our own preferences. The purpose of parenting is to raise independent individuals capable of functioning in the world. It is not to create carbon copies of themselves who share every opinion and wear every decision permanently and unchangeable. You’re advocating control, not parenting. Parents manage to raise their daughters successfully without prophylactic surgery to reduce their risk associated with being alive. We don’t criticize that lack of action, and we wouldn’t permit it under the theory that parents have an obligation to intervene if an action might reduce the risk of something. Yet, males are different to the point that we may (or should?) disregard that they can volunteer for circumcision as consenting adults and instead surgically alter them in childhood based on speculation? No.

            I’m not the one “imposing” anything. Like I said, all I want is to give people accurate scientific information so they can make an intelligent decision.

            I addressed that when I wrote “or at least encouraging its imposition”. You are encouraging its imposition. That is not imposing it, but it is very closely related. You are encouraging surgery on a healthy person who does not consent. When you give inaccurate incomplete information, such as your subjective “no net harm”, you are participating in its imposition.

            But what about this scientific information: The child is healthy when he is born. No genital surgery is indicated, just like no heart surgery, brain surgery, or any other surgery is indicated. Health is science, too. The process that has helped us develop preventions and treatments is also science. Antibiotics are science. Condoms are science. The issue is full of science. I love science!

            Why is the science supposedly encouraging circumcision – the science convenient to your position – the only science you want people to focus on?

          • Frank OHara says:

            Jimmy Wang wrote: “Okay, parents “impose” everything on their infants including vaccinations, religion, education. Good parents do this things with the best interest of the infant in mind.”

            We would hope they do these things with the best of intentions but how about those who eschew the professional recommendations of medical professionals?

            “If there are life-long health benefits and no net harm, then parents no(t) only have a right but an obligation to do what they think is best.”

            What if they rely on a computer programmer (Jake) for their medical advice instead of a medical professional/organization? What are the “life long health benefits?” How significant are they? Can they be achieved by less invasive means?

            Clearly, most expectant parents do not have the sophistication to be able to read research studies and understand them and come to their own conclusions. Should they be permitted to make a change to another person’s body on the basis of this not understood information? What if they make a decision that conflicts with the information provided by the world’s professional medical organizations? Should they be able to circumcise their daughters? There is evidence that female circumcision has benefits if you want to believe them. Why should parents not be allowed to circumcise their daughters if they believe the information? Why should it be different for boys?

            “all I want is to give people accurate scientific information so they can make an intelligent decision.”

            So, do you make the decision as to what is “accurate scientific information” or does someone else get to make that decision? Who would that be? The world’s medical associations, maybe? None of them support infant circumcision. NONE! Do you have better qualifications? Is your knowledge superior to theirs? Do you maybe have an agenda?

            .

          • Tom Tobin says:

            Removing half the skin from a child’s genitals is not “a lifelong benefit”.
            It is an immediate, and lifelong harm.
            Humans, and the animals they evolved from, have had foreskins forever.
            Foreskins go back 120 million years on mammals.
            A brain might evolve with a few quirks, but you can be certain that if there was any problem with the reproductive system, the genes have been pretty well weeded out of the human race by now.

      • Frank OHara says:

        JimmyWang wrote: “All I want is for accurate scientific information to be available so
        parents and men can make an educated decision.”

        And so that is why you posted a link to Jake Waskett’s site? Jake will not publish anything on his site that shows a negative to infant circumcision. Further, Jake started the site as a counterpoint to http://www.cirp.org which publishes all research either pro or con. Circs.com is simply a site to deceive parents who are trying to make an informed decision.

        “but actually a vaccination with life-long benefits, then perhaps you wouldn’t see it as wrong.”

        This is pure propaganda from Brian Morris and Edgar Schoen. It provides no “life long benefits” at all, only destruction.

        • Jake says:

          ‘as a counterpoint to http://www.cirp.org which publishes all research either pro or con’ — perhaps you’d be good enough to provide a link to the Benatars’ article at CIRP.org, then?

        • JimmyWang says:

          Frank, Jake didn’t write the Benatar articles.

          From what I can tell cirp.org is pull of anti-circ propaganda.
          Let’s start with the word “intact” instead of uncircumcised.
          That’s a give away right there what they’re about.
          Funny, I couldn’t find anything pro circumcision there or
          any links to research showing the health benefits of circumcision.

          Jake’s website in fact does have a topic for anti circumcision.

          Just because you say there are no “life long benefits” doesn’t
          make it true. There’s plenty of scientific evidence showing that
          you are wrong.

          • Frank OHara says:

            JimmyWang says: “Frank, Jake didn’t write the Benatar articles.”

            I clearly understand that.

            “From what I can tell cirp.org is pull of anti-circ propaganda.”

            Since when is publishing research studies “anti-circ propaganda?” These are studies originally published in the world’s medical journals. Are the world’s (respected) medical journals propaganda organs? The owner of the site does not publish his own work. He occasionly appends but that’s it. When he does append, he makes it clear that is what is happening. There is no deception.

            “Let’s start with the word “intact” instead of uncircumcised. That’s a give away right there what they’re about.”

            So a girl with her breast is “unmastectomised?” A person with their appendix is “unappendectomized?” “Uncircumcised” is intended to infer something hasn’t been done that should be done. “Intact,” has become correct through popular use and is accurately descriptive.

            “Funny, I couldn’t find anything pro circumcision there or any links to research showing the health benefits of circumcision.”

            That is not unexpected. There is virtually nothing that supports routine infant circumcision and those pages/site reflects that. It is in total agreement with the world’s medical associations. The “health benefits” are in the imagination of those who push circumcision only. The world’s medical associations pretty much eschew any notion of significant health benefits. If they do indeed exist, they are characterized as “Potential,” ie. not confirmed or known to exist.

            “Just because you say there are no “life long benefits” doesn’t make it true. There’s plenty of scientific evidence showing that
            you are wrong.”

            I’ve been diligently researching this topic for more than a decade and have yet to find these “life long benefits.” I’ve seen them claimed often but no one has been able to offer proof. Maybe you can do better? Or are they only in your imagination?

            .

            • JimmyWang says:

              I think you’ve been diligently ignoring the research showing
              the life long benefits. There’s plenty of high quality
              large scale studies showing the benefit.

              Many of the anti-circ studies are published in obscure
              journals eager to get submissions.
              And instead of just accepting the studies you need
              to evaluate them along with the comments.
              This would be very similar to what has been done with
              the 3 African RCT’s. There have been many attempts
              to discredit them but when you see the rebuttals, it’s
              pretty clear that the studies are valid.
              In the case of the anti-circ studies, if you read the comments
              you’ll see what’s wrong with the studies.

              As for not expecting any pro-circ information on cirp.org,
              then how can you claim it gives a “balanced” view?
              It’s clearly anti-circ.

              • Tom Tobin says:

                They stopped routine circumcision in Australia in 1980. The genital health of the Australians got better.
                Where are these lifelong benefits? Are the people of Europe suffering, because in general they keep their foreskins? The answer is “no”. The people who are most strident about the lifelong benefits…are they medical doctors? Typically, no. One of the most outspoken is Dr. Brian Morris of Australia. He is a molecular biologist, who makes all kinds of absurd pseudo-scientific claims, such as ‘Circumcision of males represents a surgical “vaccine” against a wide variety of infections, adverse medical conditions and potentially fatal diseases over their lifetime, and also protects their sexual partners’, and ‘The benefits vastly outweigh risks.’, and my personal favorite, ‘Most women prefer the circumcised penis for appearance, hygiene and sex.’.
                There is no widely accepted medical basis for any of these statements. In fact, they run counter to the advice of the medical society of every country whose medical society has voiced an opinion.

                Where did you expect to get a ‘balanced’ view? Everyone has their particular slant on it, and that includes you and me. Did you think that organizations would be somehow different?

              • psandz says:

                Jimmy Wang, please spare us your repetitious waffle! No research so far has established that there are net benefits associated with non-therapeutic circumcision. To even begin to demonstrate this, you would need to be able to weigh up established benefits against at least reasonably reliable evidence of the risk of complications or harm associated with it. There is no medical consensus on either likely benefits associated with non-therapeutic circumcision or on the degree of risk of harm. And that’s not even broaching the subject of the neuroanatomy of the foreskin, as demonstrated by neuroanatomists, or of its function. Quite apart from its dense sensory innervation, its rich vascularisation (capillary network) attests rich functionality.

                Medical peer-reviewed journals have published studies finding circumcision benefit and studies finding none, as well as studies which attest to harm associated with circumcision. I have plenty of peer-reviewed studies finding no benefit, just as you can doubtless refer to others finding benefit. Either way, medical study findings don’t provide proof, unless they are corroborated by empirical evidence at large.

                Is it too much to ask you to contribute something of substance to this discussion?

              • Hugh7 says:

                It wouldn’t matter if there were some benefit. There’s some benefit to almost anything you can imagine. Did you know castrated men live longer than non-castrated? Properly analysed, the cost/benefit ratio of circumcision comes down against it.

                Circumcision began in the mists of time before human history, as some kind of blood/sex/magic ritual, and it’s status has changed very little since. It has always been an intervention in search of an excuse, a “cure” looking for a disease.

      • Hugh7 says:

        Interesting you cite the Benetars. David Benetar has now written a book called The Second Sexism in which he argues that infant circumcision is one of the remaining ways males are discriminated against. He may have had a road-to-Damascus experience.

      • Layla says:

        “life long benefits” ? Really?
        Has anyone gone back to Africa to do follow up on all of the men cut for the research? What are the stats now? How many of them now have HIV/AIDS?

        • Frank OHara says:

          Layla wrote: “Has anyone gone back to Africa to do follow up on all of the men cut for the research? What are the stats now? How many of them now have HIV/AIDS?”

          That’s a major problem. A large number of the participants were “Lost to follow-up. Those lost to follow-up could completely change the outcome.

          Now, I ask, were they intentionally lost? Would they have materially changed the outcome? I can’t imagine these men would go far away from their tribes. The tribes would be their family and their support group and important to them. Did the (so called) researchers actually try to account for them? Did they try at all to find them? Did they arrainge the situation NOT to find them?

          Inquiring minds wanna know especially with the research ended less than half way through. Maybe I smell a rat?

          .

  • Scientific Instruments says:

    Took me time to read All the comments, but i really enjoyed the article. It Proved to Be Very useful to me and I am sure To All the commenters here! It’s Always Nice When You Can Not Only Be Informed, entertained goal Assisi! I’m Sure You Had joy writing this article.

  • Joseph4GI says:

    What is the foreskin?

    What does it do?

    Why are males born with it?

    Is it a dead part of the body, like a nail or umbilical cord?

    Or does it have blood vessels and nerves?

    What does it do?

    Let’s talk about these questions first before addressing the so-called “pros and cons” of destroying a normal, healthy part of the body.

  • Lon Strickland says:

    The loss of foreskin creates tightening / less elasticity of the penis which increases friction during intercourse. More friction means more bleeding. Understanding anti-circumcision requires simple common sense. Understanding pro-circumcision is where it gets complex. Your talking about mass delusion, cultural banality, and ancient religious rituals. The “pro” rabbit hole just gets deeper and weirder the farther you go.

    • JimmyWang says:

      More bleeding? Nonsense. The foreskin is likely to tear and bleed.
      Care to tell us where you got your information?

      To understand pro circumcision you need to understand science.

      • Lon Strickland says:

        Having your foreskin during intercourse provides a self contained means to ejaculate. Same with masturbation. It’s why uncut people don’t need lubricant to jerk off. The skin does it for you. Without it, the penis is partially handicapped, and relies more on the vaginal walls to ejaculate. I assure you, a circumcised penis is far more likely to bleed during intercourse due to the friction that would have been prevented by the foreskin. It’s the ring of scar tissue around the glans that is most likely to bleed. There’s nothing natural about it. Sex is much smoother and less painful if you have your foreskin.

        • JimmyWang says:

          Assure all you want. It’s not true. And circumcised guys don’t
          need lube to jerk off.

          • Tom Tobin says:

            You are speaking for yourself. You are not speaking for all circumcised men.
            I assure you, many, if not most American men use lube, both to jerk off, and for sex.

            • Lon Strickland says:

              Yes, the degree of genital handicap is not a black and white issue. It depends on how much was cut from your penis as to whether lube is essential, helps a lot, helps some, or is not needed at all. I have a friend who had an insignificant amount of foreskin removed. As if the doctor knew how damaging it was, and performed a completely pointless and painful surgery only to sever a small ring of flesh off the top to appease the parents request, but to secretly protect the child. What a glaring problem we have in our culture when informed doctors must go to ridiculous lengths to secretly protect children from their parent’s unwarranted (and unconstitutional) decision, while preserving their guilt free outcome. Why can’t we just admit it’s wrong, and start educating people properly about the normal healthy male genitals? Not sure about current high school biology text books, but all the ones I grew up with always portrayed penises as mutilated. As if that’s the normal biological state of our genitals. The foreskin is complex, and could take up a full chapter in any text book. From infant retraction to primary source of ejaculation, general sex education behaves as if it doesn’t even exist.

      • Tom Tobin says:

        I get it, from hearing men talking about their erections being so tight that the skin breaks and bleeds.
        Most of these men are desperate enough to be looking into foreskin restoration, to stop the constant pain of erections. This is after exhausting doctor visits, moisturizers, and other things which provide no relief. It is another unintended consequence of circumcision, like skin bridges and meatal stenosis…one that most men are very unlikely to talk about, unless it is behind the anonymity of the network.

        • Lon Strickland says:

          Yes, tightening is another common side effect I’ve heard of. It’s so completely tragic we not only fail to stop this insane barbaric ritual, but our government works to protect it such as with California’s recent ruling to put a ban and banning circumcision after San Fransisco rallied to outlaw it. That’s right, a “ban on banning” in the name of religious freedom. It should also be noted that circumcision is the number one cosmetic surgery performed in the unites states, making it a billion dollar industry. To make matters even worse, the prepuce amputated from defenseless baby boys are sold to bio-engineering and cosmetic companies to be used as an ingredient in expensive anti-aging creams. Research for yourself. Our children’s genitals are being mutilated and exploited for profit. Great job, America!

          • Tom Tobin says:

            Isn’t it saddening how quickly doctors and medical societies can turn a blind eye, when there is money to be made.
            The firs thing to to is the Hippocratic Oath: First, do no harm. California may be reactionary enough to have pandered to a ban on banning circumcision, but at least they don’t allow Medicaid to pay for it. The rates are dropping very rapidly in the West, with Nevada down to 20%. There are 18 states where Medicaid refuses to pay anymore, because circumcision is elective. Most recently, the decision was upheld by a slim margin in Colorado, despite a doctor/Senator spearheading the efforts.
            I write letters to the heads of the AMA, AAP, Johns Hopkins, the CDC. The AAP is infuriating. They hired Dr. Douglas Diekema, medical ethicist, to head the Task Force on Circumcision. Why, if their policy is that circumcision is unnecessary, do they create a Task Force? Why put the man who was advocating for female circumcision in the US, on two separate occasions, as the head of it? He is the man made famous, by advocating for a nick in the female genitals being legalized, to prevent parents from taking their child overseas for a more amputating circumcision. This is the state of American medical ethics. I find it most disturbing, indeed.
            As a foster parent to many children, I have unintentionally seen more kids’ genitalia than most. One boy came in to use the toilet while I was shaving. He appeared circumcised on one side, but not on the other. Another slept nude on hot summer nights. He was so tightly circumcised, there was no way his erections were not painful.
            Genital cutting on healthy kids is wrong, whichever gender they are.
            I have a meeting with a Senator, to discuss defunding circumcision in Medicaid. Medicaid was never designed for optional, elective surgery.

            • Jake says:

              ‘The AAP is infuriating. They hired Dr. Douglas Diekema, medical ethicist, to head the Task Force on Circumcision. Why, if their policy is that circumcision is unnecessary, do they create a Task Force?’ — to write an updated policy, obviously.

              • Tom Tobin says:

                They are in a position where they cannot change the policy. With circumcision rates dropping so rapidly, coming out in favor would raise massive protests. They know that.
                There are intactivist groups in every state. State legislatures are defunding the payment for circumcision by Medicaid. No one believes that the African studies, whether they were scientifically conducted or not, apply to the US. Besides, AIDS is not the threat it once was.
                It is very difficult to change a policy, unless studies are done. The US has no intention of conducting studies, because if they were to find that circumcision is not helpful, as multiple smaller scale studies have done, they would kill the goose that lays the golden eggs. They cannot change their policy either way. If they say that circumcision is beneficial, they would have to prove it, and that would run contrary to the science of Canada, the UK, Australia, New Zealand, and almost all of Europe. If they say that it is wrong, and shouldn’t be done, they have to admit that they have been allowing a useless surgery to be performed on children since 1870. That would open the floodgates of lawsuits.
                The CDC would have to change its policy, and start attributing problems arising from circumcision, to circumcision. No more “death by exsanguination”. They would have to count the skin bridges, meatal stenoses, and the surgeries to correct incorrect circumcisions.
                Why Dr. Diekema, when he has already been lambasted twice by the public for his suggestions to allow a nick of the female genitalia?

                • Lon Strickland says:

                  Yes, exactly. It’s too huge a fuck up, spanning too many years with too many victims to take responsibility for. Then you introduce the “billion dollar industry” aspect and that is why it remains “a private matter the government has no place in”. Keep everyone stupid, don’t talk about it, and do not educate. They depend on our cultural banality and ignorance to keep things the way they are, and every so often pull some PR stunt that advocates it. It’s just completely despicable. We need to keep speaking out against it, because the victims are helpless babies with parents who are conditioned to believe they’re making a healthy and normal decision for their kids. It’s a battle for informed consent. I can’t think of a more relevant ideological struggle to speak out against than this. It’s such a clear violation of fundamental human rights happening in complete contrast to what is supposed to be a progressive and modern society.

                  • Tom Tobin says:

                    Eloquently written. Thanks, Lou.
                    This is why I write letters to anyone I think can make a difference.
                    This is why I am meeting with my Senator tomorrow.
                    It really has to stop.
                    There is so much to admire about our society, and then you turn around, and see this atrocity.
                    Any society, any nation, is judged on the basis of how it treats its weakest members ; the last, the least, the littlest, the most defenseless.

  • psandz says:

    All the commentators are overlooking the MAIN weakness of the African RCTs. Their main weakness lies in the fact that the participants were not randomised from the general population (they selected themselves), but only at the experimental level. So we cannot have any confidence that the trial findings are representative of the men at large. Men with defective foreskin would have gravitated to the trials to be circumcised, attracted by the optimal medical conditions provided.
    So you can see the fatal problem of the trials: men with foreskin problems or abnormalities (such as cuts, abrasions, infections) would be over-represented in the RCTs. We know that defective foreskin is much more susceptible to HIV transmission than normal foreskin.
    On arriving at the trials, were they randomised into Intervention and Control groups.
    So the men assigned to the “Control” got to KEEP their defective foreskin, whilst circumcised men had their defective foreskin REMOVED. This would make the trial findings impossible to project onto the general population (which would have a much lower statistical incidence of men with foreskin abnormalities).
    Probably, all that the trials provide evidence of is that defective foreskin is more susceptible to transmitting HIV than normal foreskin, which we already knew! The trial design is too crude to provide more information than that.

    • Tom Tobin says:

      The sad part is that, though what you say is true, the propaganda machine of the WHO and UNAIDS has blessed these defective studies as the gold standard. This way, they can perpetuate the slaughter of foreskins, and justify their existence. A side benefit is that people in places such as wikipedia can point to them, as if they are real science, conducted with the utmost of controls, and use them as verification. They become part of the bedrock of medical studies…all based on something other than good science.

  • psandz says:

    All the commentators are overlooking the MAIN weakness of the African RCTs. Their main weakness lies in the fact that the participants were not randomised from the general population (they selected themselves), but only at the experimental level. So we cannot have any confidence that the findings are representative of the men at large. Men with defective foreskin would have gravitated to the trials to be circumcised, attracted by the optimal medical conditions provided.
    So we can see the fatal problem of the trials: men with foreskin problems or abnormalities (such as cuts, abrasions, infections) would be over-represented in the RCTs. We know that defective foreskin is much more susceptible to HIV transmission than normal foreskin.
    On arriving at the trials they were randomised into Intervention and Control groups.
    So the men assigned to the “Control” got to KEEP their defective foreskin, whilst circumcised men had their defective foreskin REMOVED. This would make the trial findings impossible to project onto the general population (which would have a much lower statistical incidence of men with foreskin abnormalities).
    Probably, all the trials provide evidence of is that defective foreskin is more susceptible to transmitting HIV than normal foreskin, which we already knew! The trial design is too crude to provide more information than that.

    • JimmyWang says:

      What exactly is “defective foreskin”?

      If the trials were so fatally flawed, why has the circumcision in
      S. Africa been so successful at reducing the risk of HIV.
      Turns out the risk is reduced by 76% even better than what the trials
      showed.

      • psandz says:

        Jimmy Wang, I explained what a “defective foreskin” is. It would include any foreskin pathology, e.g. cuts, abrasions, foreskin infections, phimosis. All these abnormalities appear to make the foreskin more vulnerable to STD infection.
        You claim that it “turns out that the risk is reduced by 76% than what the trials showed”.
        Your claim is unfounded. Once the trials were stopped, they cannot continue under randomised Control conditions. They STOP for good!

      • Frank OHara says:

        Jimmy Wang wrote: “If the trials were so fatally flawed, why has the circumcision in S. Africa been so successful at reducing the risk of HIV.”

        As of yet, there has been no reduction in the new HIV infection rate in any of Africa. It may show some success eventually but that time has not yet arrived. Now, if the rate of new infections falls by 60%, I’ll take my lumps and admit I was wrong. Heck, even if it falls by 40%, I’ll admit I was wrong! I don’t expect I will be offering any apologies any time soon.

      • Hugh7 says:

        “the risk is reduced by 76%”
        Hardly. That claim was made at a conference, and does not seem to have been published yet, but the part that it was a difference between intact and circumcised men seems to have been added by reporters. There was an campaign against HIV at Orange Farm, South Africa, involving circumcision and the HIV rate went down. They surely promoted every other safe-sex intervention that’s going. To say that circumcision did it is spin.

      • Tom Tobin says:

        Why do multiple trials in the US and UK, show no statistically significant difference, in the infection of any disease, between circumcised and foreskinned men?
        http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102282676.html

        http://journals.lww.com/stdjournal/Abstract/2011/11000/Circumcision_and_Acquisition_of_Human.16.aspx

        When the London School of Hygiene and Tropical Medicine has to bring in a marketing man from Proctor & Gamble to sell circumcision, that is pretty bad.

        http://www.lshtm.ac.uk/newsevents/events/2011/05/getting-men-to-part-with-their-foreskin-a-case-study-on-male-circumcision-communication-and-promotion

        A doctor who performs circumcision says:
        “Circumcision is a brutal surgery. If you treated an animal the way we treat babies, you would be arrested for animal cruelty. We never remove a mole or a lump without lidocaine.” She said circumcision without something to numb the pain would be “like removing your lips — squeezing the skin of your lips with Vise-Grips and cutting across that squeezed area. Very tender.”

        http://www.miaminewtimes.com/2012-02-16/news/circumcision-activists-square-off-against-thousands-of-years-of-tradition/

  • James Mac says:

    The ‘playbook’ of those promoting circumcision is patently clear:-

    1) Keep releasing new and recycling ‘studies’ pointing to the mostly-discredited medical benefits of circumcision (perpetuating the fake ‘debate among experts’).

    2) Frame the debate as an issue of ‘parental rights’ (as if parents choosing elective surgery for their children is somehow a right or valid parental choice).

    3) Never, ever discuss the value and function of the male foreskin.

    4) Dismiss out of hand the losses and harm caused by circumcision along with the voices of damaged and resentful men.

    5) Avoid the topic of human/children’s rights – and if it comes up – compare circumcision to everyday food, education and vaccination choices parents make for their children.

    6) Avoid discussion of the fact that medical benefits of circumcision exist only in (biased and self-interested) studies and never in real-world settings.

    The *real* story of circumcision can be found by seeking to understand the true motivations of its proponents. It’s a story that needs to be told. It is a story of a massive medical, scientific, financial and human rights scandal and is set to blow up in the faces of many organisations and individuals.

    • JimmyWang says:

      James, once again the anti-circ conspiracy theory comes up.
      There are many reputable doctors and researchers who have put
      their names on these studies.

      Please continue with your theory and tell me why they’d put
      their reputations on the line.

      And just when do you think this about to “blow up”?

  • psandz says:

    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 nations. National health policy or strategy is ALWAYS formuated on the basis of internal evidence of efficacy, i.e. within the country considered. 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.

  • admin says:

    Sorry everybody. Clearly the system is not designed to deal with such a large comment thread, and they are now appearing out of order. I’m looking into it, but don’t hold your breath.

  • psandz says:

    Jake:
    Aa meta-analysis study can produce no more reliable results than the individual studies it is based upon. The available evidence does not justify the circumcision of babies to reduce cancer or any STD. HPV studies tend to lack robustness in their design, usually failing to test all parts of the penis or genitals for HPV. Accordingly, they don’t produce evidence that can evaluate an alleged protective effect for circumcision. Thus, if the shaft of the penis tends to carry most of the HPV load (which from memory I think is correct), whereas the foreskin only carries a minor part, then circumcision may not be a useful intervention strategy. Van Howe is right to criticise many HPV studies for failing to investigate the entire penis (as well as following variable collection techniques). There are many HPV studies, besides Fergusson’s, finding no benefit for circumcision. Halperin’s “urethral swab” tests for HPV (in his African study) represent shoddy methodology, and many other HPV studies are no more robust.
    The fact that the HPV vaccine is generally available gratis for girls in most countries (and its efficacy is likely to keep improving), and there are sophisticated screening methods for cervical cancer detection, makes infant circumcision even less useful.
    HPV studies that follow the protocol of testing the entire penis usually find no circumcision benefit. Here is an example of a study following reasonably sound protocol (finding no circumcision benefit):
    http://ukpmc.ac.uk/abstract/MED/14767822 (“Evaluation of genital sites and sampling techniques for detection of human papillomavirus DNA in men” by Weaver et al). Another reeasonably sound HPV study is by Aynaud et al. (France, 1997). They put to shame Halperin’s study.
    It is quite likely, as Catellsague’s large (but flawed) 2002 study found, that circumcision offers some protection against HPV in the case of highly promiscuous men. This should not surprise since there will come a point when foreskin’s intrinsic immunological capacity can be overwhelmed by viral load, and at that point, the foreskin would present as extra surface area for infection. But what normal parent will presume that their baby son is likely to find himself in this high risk category on reaching sexual maturity? Children should be taught responsible behaviour.
    International comparative studies give no reason to believe that there is a causal relationship between circumcision and cervical or penile cancer. For example. Finland, and much of South East Asia (which all have low circumcision rates) have no more cervical cancer than Israel. See http://www.phac-aspc.gc.ca/publicat/ccsic-dccuac/pdf/chap_2_e.pdf
    (“epidemiology of cervical cancer”), see fig.4.

  • Claire says:

    Informative and well written article. My intact boys and I thank you :-)

    Jake, all that Wiki re-writing seems very lonely. Have you considered taking up a hobby, like fishing or bowling?

  • Tony says:

    Jake:

    May 27, 2012 at 8:18 am

    … — 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.

    There are at least two problems in your analysis. First, you’re relying on estimates of deaths “prevented” by circumcision. It’s possible to draw estimates, but they rely on various factors and not everything relevant is or can be included. Is there a way to get better, more consistent condom use within a population? Are there ways to get people to cut their risk of various ailments without circumcision? Are there new treatments and/or preventions coming in the future before the large majority of those estimated deaths actually occur? (e.g. an actual HIV vaccine) And so on. Life is complicated. Your estimate is only a best guess prediction that you attempt to balance against actual, confirmed deaths.

    Second, more importantly, the timing of the deaths matters a lot, unless you buy into David Benatar’s absurd notion that it’s better to never have lived than to live at all. These infant deaths are when these children have lived barely days (or sometimes, months or a few years). Contrast those with the deaths you estimate will be prevented by circumcision. Those all occur after the individual has lived for several decades, at least, and potentially for much of their projected life expectancy if they were to eventually die of some other malady or of natural causes. (It’s also not verifiable that circumcision alone would prevent the malady, either. Some circumcised males will get HIV, and some will get penile cancer. Hooray for circumcision?) Your utilitarian analysis gives equal value to many decades of life and to no life, with the only true judgment being made on circumcision status: circumcision safe, foreskin dangerous. Essentially, for those individual children who die, your approach to the question suggests it’s the same to have no life and to be intact and eventually die of something circumcision may have prevented. Is that what you’re saying? Because that absurdly ignores people, treating them like statistics and nothing more. Are the intervening years that infant deaths would’ve lived worth anything to them?

    You also assume a combination of the two, that every male either considers it no different or would rather be circumcised than live with his foreskin until he got some malady later in life presumed to be instigated by his foreskin. You’ve encountered enough evidence to know that is a faulty assumption.

  • Lon Strickland says:

    Remember, the moment you begin to apply “science” to the removal or clitorises or foreskins, you’ve missed the point completely. You could talk about the scientific pros and cons to having noses, breasts, eye lids, and ears removed as well. The difference is there wasn’t an ancient ritual perpetuating the removal of these body parts thousands of years ago. There’s no history or reason to feel we must to justify this needless assault on our bodies. To promote circumcision is solely about a blood sacrifice to god. It is “for the land of Canaan”. It has no place in hospitals… no place in science. Once more people begin to open their eyes, I do believe we’ll see it fade away. The internet has been instrumental in waking people up this cultural error. That’s all it is in the end. A mistake. It’s time to admit that as opposed to tricking a third world country into genital mutilation. Fucking disgusting.

  • psandz says:

    The starting point is that circumcision creates injury. Now how do you justify that injury?
    With regard to ethics, parents are presumed to give “proxy” consent for the circumcision of their child. But what is the basis for believing that the child WOULD give informed consent to having part of his penis removed, if he were able to? Clearly, there is no valid reason to believe that he would consent to it.

  • Layla says:

    So, leave boys/men whole and intact and teach them proper hygiene and safe sex practices OR remove a part of their genitals and still teach them proper hygiene and safe sex practices?
    Even in the African studies, the cut men were educated and advised to use condoms after their wound healed.
    The newly released advertisement posters for circumcision clinics themselves have, in small print, a disclaimer saying that men still need to use condoms and practice safe sex in order to protect themselves.

  • James Mac says:

    It is only to be expected apotemnophiles perceive their elective surgical outcomes as favourable, regardless of the loss of tissue and function and resultant scaring. Anyone who had wished for their foreskin to be surgically removed since childhood and then acted upon this desire in adulthood cannot possibly offer rational and unbiased opinions on the subject of amputating/excising the foreskin of others. That such people lurk in online parenting forums promoting the ‘medical benefits’ of circumcision to well-intentioned but naive parents is truly frightening.

    The community is finally awakening to the fact that circumcision advocates are invariably seeking to advance thier own agendas, which have nothing to do with public health or the interests of the child.

  • Layla says:

    So Jake, you don’t believe that the owner of the body gets to decide which healthy body parts to keep?
    Why not?

    • Jake says:

      ‘So Jake, you don’t believe that the owner of the body gets to decide which healthy body parts to keep? Why not?’ — because I don’t think there’s a compelling reason why that has to be the case, and it has some troubling consequences. Consider, for example, a child born with extra fingers. It may well be beneficial to remove them while the child is young: her hands will develop normally, there will be less scarring due to the amazing healing ability of the infant, no trauma that she remembers, she can grow up without feeling abnormal, etc. From her point of view, removing the digits in infancy is preferable. The only situation in which it isn’t preferable is if she grows up and resents the removal of those digits. Perhaps this seems an easy decision to you, but I think it’s more complicated, requiring balancing of the possible outcomes.

      Now, I’m not saying that the foreskin is a 6th digit; I’m just questioning the principle that others have proposed.

      • Tom Tobin says:

        So, how about normal, healthy body parts? Should a person be allowed to decide which normal, healthy body parts they get to keep? If the decision belongs to someone else, why should their authority trump the judgment of the person whose body it is?
        Do you really think that someone else should be allowed to cut healthy parts off, because they decide, “It’s for their own good”?

      • Frank OHara says:

        Jake, why did you totally ignore Layla’s question? You completely changed the subject. Was the question too hard?

        .