Follow up to the Circumcision Debate
As some of you may have seen over at A little Pregnant, there was a heated debate raging over circumcision. I had stated that in my personal opinion, the strongest reason to circumsize was because of the high association between not circumsizing and HPV and Cervical cancer (which I contracted, probably from my uncircumsized fiancee at the time). A few of the anti-circ crowd became very emotional and cited something supposedly posted on the American Cancer Society's website from 1996. Needless to say, that data, if it existed, would be quite outdated. It does not, however, exist. Instead of continuing the argument there, I promised that I would take the argument over to my own blog so as to stop the viciousness on Julie's site.I had asked Dr. G to help me find some empirical data on sites that could be accessed without subscriptions and he finally posted something over on Julie's site.
I doubt that many will actually see his comments though since I assume that people rarely go back and look at a comments section after several new posts have been added.
Ed, thank you for this. I know you didn't feel well this week and it was late when you got it done but the effort is so appreciated - even more so in light of all the info you have so diligently pulled together.
Below are the comments he posted on Julie's site:
~~~~~~~~~~~~~~~~~~~~~
Cautiously I wade into the shallow end of this topic of male circumcision, leery of the treacherous currents waiting to suck the unwary down the slippery slope of blogdom into the whirlpool of online opinion-mongers... Hmmm, the water seems rather hot.
As the foregoing posts show, opinions abound about the justification or lack thereof for circumcision. Unfortunately, some people seem so heavily invested in their position that half-facts and innuendo seem to be ruling the day. I don’t mean this as a slam, just an observation that while everyone is entitled to an opinion there should be a dividing line between one’s personal feelings on the topic, and the reasons for that opinion. So, I will cite my data for you and show you why I think that it is better to circumcise than not from a medical perspective. If you care about credentials (which you really shouldn’t in this case), I am a Ph.D. at Yale doing research on cervical cancer cell lines containing the human papillomavirus so I do have a passing knowledge of cancer, HPV and the medical literature. Susan asked me to weigh in this topic and I’m sorry that it has taken me this long. Before I post the info, I want to impress upon you that no scientific study is perfect and that a critic can always find something wrong. The issue is, is it wrong enough to invalidate the conclusion or just a cautionary note?
1). As larissa posted before there is a recent study in the New England Journal of Medicine showing that circumcision provides protection against HPV infection in general and protection of the monogamous female partner from cervical cancer. HPV comes in over 100 types and only a few types are actually associated with cancer (cervical, vulvar, penile, anal and some head and neck tumors). HPV is very different than HIV (which causes AIDS). Here is the link:
http://content.nejm.org/cgi/content/abstract/346/15/1105
[Editor's note: here's the conclusion of the study for those who don't have the time to read the whole thing: Conclusions Male circumcision is associated with a reduced risk of penile HPV infection and, in the case of men with a history of multiple sexual partners, a reduced risk of cervical cancer in their current female partners.]
And here’s a good synopsis:
http://www.cancer.org/docroot/NWS/content/NWS_1_1x_New_Study_Shows_Benefit_of_Male_Circumcision.asp
According to this large study, being circumcised reduces HPV infection some 63% in the man and cervical cancer some 68% in the woman. If I told you that having your kids' tonsils out would reduce their own infection rate and cancer in their lifepartner would you even hesitate to have the procedure done? The NEJM is an excellent medical journal and every article is peer-reviewed before publication. In fact, most uncircumcised scientists would happily get circumcised if it helped to get their papers accepted...
2). Elizabeth asserts, the American Cancer Society position in 1996 was that "Research suggesting a pattern in the circumcision status of partners of women with cervical cancer is methodologically flawed, outdated, and has not been taken seriously in the medical community for decades."
First, this statement does NOT appear on the ACS website NOW and googling this phrase only pulls up vitriolic anti-circumcision websites that are apparently quoting each other. Hmm... Even if the ACS actually wrote this letter, 1996 is just too long ago in this rapidly advancing field to place much merit on those dated opinions, especially when hard evidence to the contrary exists.
If you look at the Current ACS site and search for “circumcision” you will find the above link favorably reviewing the 2002 study showing a link between cervical cancer and circumcision and also describing the benefits of reducing male infant urinary tract infections. Now the ACS does say “Whether circumcision is a risk factor [for penile cancer] is a controversial issue.” in another section of their website but see the following study which clearly evidences a major effect for invasive penile cancer:
http://pediatrics.aappublications.org/cgi/content/full/105/3/e36
3). The National Cancer Institute is probably the gold standard for any discussion concerning the accepted state of the art in cancer research and treatment and they show a likely inverse association between circumcision and penile cancer.
http://www.cancer.gov/cancertopics/pdq/treatment/penile/HealthProfessional
4). Male urinary tract infections are also about 9 times higher in uncircumcised males:
http://pediatrics.aappublications.org/cgi/content/full/105/4/789
5). Circumcision reduces the chance of getting HIV (yeah, that’s right, AIDS) some 8 fold, at least in India
http://dx.doi.org/10.1016/S0140-6736(04)15840-6
Admittedly, the chances of getting penile cancer or a serious UTI as an infant are pretty low so you have to ask yourself if performing 900 circumcisions to prevent one invasive tumor or hospital visit with a UTI is worth the downside for you and your son. Personally, I see few negatives with circumcision and a number of possible benefits that may or may not ever matter for me or any boys I might make (but then again my parents made that same decision for me so maybe I’m biased?). While we might want to believe that our children will always be responsible with their sexual decisions wouldn’t you be willing to inoculate your child with some magic vaccine that had the above properties JUST IN CASE? So why the fuss over snipping off some unnecessary skin? Would you be as concerned over someone piercing their infant daughter’s ears?
posted by suzinalexa @ 1/07/2005 10:00:00 AM
23 Comments:
Hhhhm thought provoking, thanks for posting this.
Thank you for posting this! I saw all the debate over on A little pregnant and was shocked to see how emotional people got, especially when the best reason they could give for doing it or not doing it was "to look like daddy." You would think people would use medical facts instead of opinion for something like this, but I guess not.
Great post.
I had no idea. I saw the argument on ALP and for that reason I'm posting anonymously. But thank you for this otherwise I would have gone on believing that there was no medical necessity for it.
I just posted once at Julie's, didn't realize the raging debate. However, I still disagree with this invasive procedure. I appreciate the time put into the entry here, but I do not think it is without serious bias.
Circumcision is not of 'extra' skin and it is not akin to piercing a daughter's ears. Do you have the stats which demonstrate that? It is pretty condescending a thought about earnest parents.
Further-
"If I told you that having your kids' tonsils out would reduce their own infection rate and cancer in their lifepartner would you even hesitate to have the procedure done?"
No, this isn't sufficient a reason for invasive surgery. I prefer having my tonsils, thanks. I could have screens done to moniter the situation, but I don't need to go under a knife-happy surgeon with knife-happy opinions.
"JUST IN CASE?" is just not good enough. That's the only thing you've proven.
(I REALLY enjoy PCB and I hope honest opinions are welcomed. I'm currently waging a blogging etiquette battle on my own front and I hope I didn't cross any lines disagreeing with your expert and his lines of thought.)
Like Cricket, I wouldn't inflict a painful, invasive procedure on an infant because there is a possibility of a benefit that could be achieved in another way.
Circumcisions can go wrong, and even when they don't, they are painful to babies, although people may not always recognize a response as a reaction to pain because such responses are different in infants.
And I don't approve of piercing infants' ears.
Slim
Hi guys and thanks everyone for posting.
Cricket - I'm so glad you did post. I do appreciate opposing views and would never blog on personal or controversial thoughts if I wasn't looking for discussion to ensue.
And I agree with your position in some respects. I for one will never put ear tubes in my kid unless I am presented with OVEWHELMING evidence that it actually helps stop severe ear infections.
I also have a really hard time with women who get their breasts removed because they have a high incidence of breast cancer in their family. I would never do something "just in case."
I don't think the evidence that was presented represents a "just in case" argument though. For me (and that's all this part is - my opinion) the evidence is compelling enough to make me want to circumsize if, God willing, I ever get that far in the baby game to have to make this decision.
For you, it's not compelling enough and that's totally fair and reasonable.
Thank you for posting. I was hoping someone would post for the other side, too. And thank you especially for doing it intellectually and with courtesy to anyone else who feels just as strongly on their position.
Bottom line is this is a very controversial topic. Iwas not trying to get anyone to change their minds. I did however want to get some factual info into the mix so that anyone who wanted the facts could find them easily.
Cheers!
I'm going to cop out and do this anonymously too. Sorry...I just don't want the emails from the other side.
After reading these links below (and I admit that some of them are way too scientific for me), I would have to hear a pretty compelling argument NOT to circumsize, other than it's the way God made us. Because God also gave us tails a long time ago, and we still have appendixes (whatever the plural is of that) and we still have tonsils and yet it's common to remove both of those when recurrent infections cause problems.
So, does this mean that we should wait until there are re-current infections to have the circumsizion? Maybe, but I think if I had a son, I would probably not want him to have to go through that pain over and over again before I fixed the problem, especially if I could fix it in advance knowing he'll only having the pain once.
So, SMT had things to say in response to this post, although he did it over on Julie's site instead of here. While I do appreciate everyone's opinion, I sincerely hope we can keep this conversation to the level of opposing information offered versus attacking the writer personally.
SMT, when you ask if Ed is sure he has a PhD., not only is that condescending and arrogant, it begs the question - what, exactly are your qualifications for weighing in so heavily on this subject?
You are certainly entitled to your opinion but, so is everyone else. And for your information, because Ed will not blow his own horn, not only has he made study of HPV his life's work, he also has patented a technology using parts of his studies that major pharmaceutical companies use today to treat cancer. He's not just blowing smoke up anyone's ass here. He's got years of study and work in this field backing him up.
What do you have?
Also, your first line here reads, "I could address each medical issue you brought up, but I think that has already been done by virtually every major medical organization in the world..."
Please SMT - I invite you to cite even one medical journal here that refutes this evidence so we can all benefit from your extensive research on the subject.
I think it would add to the debate and give us all a healthy "other" perspective based in fact, not opinion.
Also, you mention "risky sexual behavior" several times and this is a myth. A woman can have sex with only one partner in her life and he can be her husband; if he is uncircumsized and had more than 1 sexual partner (also not that risky unless it's hundreds, but you see the point is that it doesn't even have to be- more than 1 is sufficient) the chances of him having HPV are high enough to put her at severe risk for contracting HPV and subsequently maybe cancer.
Let's try and stay away from broad generalizations like that plelase. It also takes a blame the victim attitude that I think is unproductive - to assume that anyone who gets HPV has practiced "risky" sexual behaviors.
~~~~~~~~~~~~~~~~~~~~~
Here are SMT's comments from Julie's site:
I could address each medical issue you brought up, but I think that has already been done by virtually every major medical organization in the world. None have determined that the benefits of circumcision outweigh the risks. It is not just enough that there are "some benefits" from infant circumcision. There is a burden of proof that is on the one wanting to cut up a child's gentials. There MUST be a proven benefit that outweighs all the risks.
I think it is more important to address it from an ethics standpoint. A boy is born with a normal, healthy, functional foreskin. At this point, none of his rights have been infringed upon. If there is no absolute indication that a circumcision is necessary, how do you ethically justify unnecessarily removing his foreskin and violating his rights?
This isn't just a matter of "opinions". The existence of this boy's foreskin is a physical fact. The medical ethics of modern medicine already exist. There MUST be a proven benefit that outweighs the risks to justify ANY medical procedure. It is impossible to justify unnecessarily removing a boy's foreskin without clear proof that it is necessary to do so.
Ok, I'm going to touch on the medical issues anyway...
1) HPV: Having a foreskin does not cause HPV. Risky sexual behavior is the reason that HPV is spread. How can you ethically justify Human Genital Modification on an infant when they may not even choose to be involved in risky sexual practices? This is even more relevant when you consider the fact that a guy can choose circumcision as an adult and gain the same benefit without infringing on the rights of any other guys.
"If I told you that having your kid’s tonsils out would reduce their own infection rate and cancer in their lifepartner would you even hesitate to have the procedure done?"
Of course I would hesitate. If there was no proof that the benefits of the procedure outweighed the risks then I would not consider subjecting my child to a harmful procedure. Are you sure you have a PhD? Just curious, do they teach medical ethics at that school? Just having a benefit is not sufficient to meet the ethcal criteria. The procedure must be weighed against all available benefits and risks and evaluated with evidence based research.
2) Penile Cancer: How many unnecessary surgeries can you ethically justify to prevent one case of penile cancer? 1? 20? 100? 300? Let's try 600. That is the number of boys that will have to undergo unnecessary surgery to prevent one case of penile cancer. The majority of those that do get penile cancer will also have been able to experience the majority of their life with a normal, healthy, functional foreskin. This rights violation is even more obvious when you consider that practicing proper hygiene is thought to reduce penile cancer similar to the reduction from circumcison. Let's also not forget that penile cancer is one of the rarer cancers. What other functional body parts should we start cutting off before we need to worry about penile cancer?
BTW, the ACS does currently say this on their website [with my comments]: "However, penile cancer risk is low in some uncircumcised populations [really? how do you explain this?], and circumcision is strongly associated with other socioethnic practices that are associated with lessened risk [you mean penile cancer may be do to confounding factors?]. The consensus among studies that have taken these other factors into account is that circumcision alone is not the major factor preventing cancer of the penis [or perhaps not responsible at all?]. It is important that the issue of circumcision not distract the public's attention from avoiding known penile cancer risk factors -- having unprotected sexual relations with multiple partners (increasing the likelihood of human papillomavirus infection) and cigarette smoking."
http://www.cancer.org/docroot/cri/content/cri_2_4_2x_what_are_the_risk_factors_for_penile_cancer_35.asp
3) Penile Cancer and HPV: Hey, what do you know??? HPV has a link in penile cancer. Time to curb those risky sexual practices instead of just unnecessarily cutting off body parts.
4) UTIs: Sure, a 9x less chance of getting a UTI sounds great... until you consider that you would have to unnecesarily circumcise 99 boys to prevent one UTI that is treatable with a $6 antibiotic. This benefit also only applies to the first year of life. Infant girls also get more UTIs than boys. What part can we cut off of girls to help them not get so many UTIs? BTW, I love that Schoen uses so many references to Wiswell who has proven flawed studies using the only available intact babies he could find... many being premature babies that were not healthy enough to undergo their circumcision and... guess what... have a higher rate of UTIs! Despite Schoen being the chairman of the AAP's circumcision task force, even he couldn't convince the rest of the group to give a recommendation for circumcision as valid away to prevent UTIs.
5) HIV: Plenty of inconclusive studies there for sure. Once again, the ethical question... How do you justify removing an infants normal, healthy, functional foreskin when he may not even choose to be involved in risky sexual practices? Does a child have any rights or not?
So what is the conclusion from all of this? No major medical organization in the world recommends that infants be circumcised. Even the most recent major medical organization to release a circumcision policy says this:
"Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention." COLLEGE OF PHYSICIANS & SURGEONS OF BRITISH COLUMBIA - June 2004
Posted by: smt at January 7, 2005 05:30 PM
I really should have commented on this, too:
"So why the fuss over snipping off some unnecessary skin? Would you be as concerned over someone piercing their infant daughter’s ears?"
'Unnecessary' by who's definition? Isn't it up to the individual to determine what parts he considers necessary?
Personally, I am against any unnecessary, permanent alteration to a child's body without their consent. Ear-piercing is not subject to the same criteria as medical procedure which are covered by medical ethics. Perhaps a better comparison would be your concern (or lack there of) over having your daughter's genitals cut.
Ok, is the water hot enough now? :)
Well, what a curious debate. And what a lot of information to digest this late on a Friday night.
After taking about 40 minutes to read all of this, I have to say that there is quite a lot of factual information FOR circumcision and not a whole lot for the anti-circ side.
Can someone (because I don't have the patience or skills) bring some links to factual articles from CREDIBLE sources (3rd party established organizations) that support the anti-circumcision debate?
I took about 15 minutes to look but couldn't really find anything - which in itself says a lot.
Posting anonymous too, sorry
I have posted a comment over at my site:
http://mamchenkov.net/blog/item/circumcision_again
Susan, I'm fairly sure you will refute this comment in short order. But for those who have posted anonymously and have not been able to find info on why NOT to circumcise one's child: here's a link. http://www.infocirc.org/facts.htm
It actually makes me tired just to put this out there, thinking of what will come next onto my email head.
I'm for circumcision, and I'm also glad that it's illegal to burn circumsising bottle feeding parents at the stake.
had to comment re ear tubes. My daughter had 25 serious ear infections. Doc v. conservative, resisted ear tubes. Me: in danger of losing job. Daughter, crabby all the time, poor sleeper, constantly on antibiotics, speech development impaired. Called doc sobbing that if he wouldn't give ear tubes I'd do it myself (kidding of course) Referral immediately to ear specialist. Ear specialist so horrified @ condition of daughter's ears that they put her in a "board" and pierced them with only local anesthesia right then and there, say dtr was a few steps away from hospitalisation from severe infection. Oh yeah baby I am for those ear tubes. dd now 6, never had another infection, disposition improved overnight, speech normal, etc.
Hi all- I had a rough weekend getting ready to move. Sorry to take so long to get back.
To the person who said I'd refute what he posted, please don't think that my intention here was to refute anything. I'm happy to have someone who took time to research and post a link coming to the party - so thanks!
Please realize that my intention with this post was not to try and convince anyone how to decide this very personal issue.
This whole thing started because someone posted (on A Little Pregnant) some very blatant misinformation under the guise of "medical info" claiming that it was posted on the American Cancer Society's website, when in fact it was not.
I am new to blogging but feel that even in a personal journal, if you comment on something you should maintain your integrity and not try to pass off opinion or un-truthful info as fact.
This post was an attempt to put some empirical data and real facts into the mix so that anyone who wanted to make an informed decision EITHER WAY would at least not be doing so based on the misinformation that was offered on the other site.
I would never try to sway someone else's decison on something so personal. But I do try to make informed decisions myself and thought others might benefit from further discussion on the topic.
So Cheers everyone! Thanks for coming on over to my site. Hopefully you'll stick around and we can bounce other topics around with candor and curiosity and humor.
Now that I have been introduced to some new sites, I'll come over to yours as well!
Oh, I forgot to mention. I want to thank smt for his re-post on ALP retracting his cheap shot at Ed.
And so I'll hope he'll forgive me for getting snarky above in response. While I do appreciate open debate, it's hard to not take it personally when someone attacks the man o' my dreams.
;o)
Hi, Ed the irritated scientist here.
I'm responding to Leonid Mamchenkov's comments which he referenced above in a link to his own blog. I want to keep this discussion here because spreading it out over three blogs is silly and a waste of everyone’s time. Below are Leonid’s comments and my responses:
“Circumcision again
Aparently, the circumcision discussion that I mentioned the other day is still hot and kicking. There was an expert opinion posted here with a couple of links to medical resources. I've read it through and I have only a couple of points to bring out.
• Resources. I have checked both of the links provided by the expert. The reference to the The New England Journal of Medicine requires a subscription to access the article. Subscription is not free, and I am not yet convinced that I should spend any money on it. In any way, I have to dismiss it as it is not a "public enough" information and peer review that those articles recieve is questionable. The second article seems to be based on the first reference, so I don't see much point in it either.
• Safe sex. The medical reason provided by the expert suggest that circumcised penis is less likely to harbour all sorts of infections. I have difficulty believing it considering safe sex in general, and condoms in particular. Circumcision deals with the part of the penis which is isolated by the condom. Medical studies of those people who practice sex with "multiple partners" without condoms do not concern me. Unless those are brain studies.
• "Just in case". I find it very surprising to hear the phrase "Just in case" from a Ph.D. in medical science. I do not think that this is a good enough reason to do anything at all in general, and cutting pieces of skin off the penis in particular.
Resume: I am still far away from being convinced that the procedure is necessary. “
-----------------------------------------------
1) I make no claims on being a “circumcision expert”. I am but a hard-working scientist with the skill-sets necessary to research, digest and discuss many biomedical topics. I happen to do research on HPV and was aware of the link with circumcision which got me interested in this topic. I was only trying to show that there is, indeed, some medical rationale for circumcision. I’m not trying to promote the practice, or prove that it is necessary; I’m merely trying to give parents additional information upon which to base their decision.
2) “Resources”: I apologize that the link to the New England Journal of Medicine didn’t work for you as it did for me on the lab computer. If you get to the NEGM site, you can register for FREE (lower right corner) and get any article over 6 months old. You can also find the journal at almost any major public library or college/university. The reference is Volume 346 issue 15 pages 1105-1112 published on April 11, 2002. In any case, the second reference, which apparently DID work for you, is an excellent synopsis of the first article by the jolly folks at the American Cancer Society. If you feel compelled to “dismiss” the most available and respected medical journal in the world and a review by an expert organization, just what kind of evidence DO you acknowledge? If you are unwilling to even consider the science on this topic we have nothing to discuss other than our opinions based on personal experience and beliefs. Personally, I’ve got better ways to waste my time...
3) “Safe Sex”: I really don’t understand your point here other than the suggestion that people who don’t practice safe sex should have their heads examined (perhaps you should post this notion on the blogs dealing with rape and see how far it gets you). Circumcision only protects against CERTAIN types of HPV and apparently HIV based on my references. This is though to be due to the types of cells which preferentially populate the foreskin. I don’t know of evidence showing protection against other viruses. By the way, though a condom will help reduce the changes of HPV infection, it doesn’t do such a hot job because there are plenty of other sites not covered by the condom which can be actively producing HPV. Yikes
4) “Just in Case”: Leonid takes issue with my suggestion that protection against some serious but unlikely events is a reason to consider circumcision. He also casts personal dispersions that a Ph.D. in “medical science” could even SUGGEST such a thing (actually, its “molecular biology and microbiology” but I’ll let that slide). Well Leonid, I’m in some pretty good company with that one so I’ll accept your criticism with pride. There are quite a few Nobel Prize winners who cheerfully and correctly made the same argument about a wide variety of accepted practices. Surely, you’re not advocating that we stop vaccinating our children against polio and the like, eliminate fluoridation and chlorination of drinking water and forget about pap smears? [Of course not, and don’t call me Shirley] All of these more or less invasive practices confer a DIRECT benefit to only a few of the people that undergo them. For example, though the incidence of Polio was less than 1 in a thousand aren’t we happy that we got vaccinated, even if we would have been in the 999 who wouldn’t have gotten it anyway?
The real question is the balance between the positive and negative aspects of circumcision. I’ve only presented the science of the situation so parents can make an informed decision. My opinion is that though there are benefits to circumcision, they are not compelling enough to urge parents to have the procedure done, rather parents need to balance the benefit with the pain and cost and whatever ethical or religious issues they have.
Ouch!
And THAT my friends is what we like to call a "smack down."
Its 3:30 in the morning... Do you know what your scientists are doing?
Hi,
Ed again.
Man, this is turning into a freakin JOB! Now I’m responding to several posts by “SMT” who, fair props, does raise some very good points. He also gets a leetle bit snarky with me so given the late hour and the fact I just got worked up dealing with the arguments of someone from Cyprus cut me a little slack if I toggle testy mode {ON}. [Oh, I make a little circumcision joke, see testy=>teste, though not foreskin but close. [Oh, I did it again. Man, I do entertain myself...]].
1). “I could address each medical issue you brought up, but I think that has already been done by virtually every major medical organization in the world.” Well gosh, don’t hold back on my account; have at it! Come on now, you’ve got to admit that this argument is just a TAD weak. I sure couldn’t get away with it in ANY scientific journal so if we’re going to talk science then LETS TALK SCIENCE and not just say “because”. Deal? Obviously, if “every major medical organization in the world” felt this way, these studies would have been torn to shreds. Instead some very reputable organizations basically say that there are plusses and minuses to circumcision and parents need to balance the various issues. Here is a remarkable ambivalent statement to that effect from the American Academy of Pediatrics:
http://www.aap.org/pubed/ZZZJZMEMH4C.htm?&sub_cat=1
To Quote: “Scientific studies show some medical benefits of circumcision. However, these benefits are not sufficient for the American Academy of Pediatrics (AAP) to recommend that all infant boys be circumcised. Parents may want their sons circumcised for religious, social and cultural reasons. Since circumcision is not essential to a child’s health, parents should choose what is best for their child by looking at the benefits and risks.” This is pretty much what I said in my earlier response. We have no argument here. I resent the implications that I “want to cut up a child’s genitals”. This is a blatant misrepresentation of my position and is a “straw man” type sophistry. In penance, I now require you to read up on the straw man argument so YOU WILL NEVER DO IT AGAIN. Here is a fun site to do just that:
http://www-personal.umich.edu/~lilyth/strawman.html
2) We agree that ANY medical procedure, no matter how small, needs to be justified and the costs and benefits need to be addressed. [BTW, did you actually READ and THINK about my post or did you just get your back up over the notion that someone would DARE present actual data showing that there are some valid medical reasons to consider circumcision? (whoops, there’s that afore mentioned testyness).] You touch on the ethics of making a medical decision for someone who is unable to make that decision for themselves. We also are in absolute agreement that the benefits need to outweigh the risks. In fact, you’re getting tedious about stating the obvious. What we are NOT in agreement about is that this somehow calls into question my “concern (or lack there of) over having your daughter's genitals cut”. Whoops, there’s that straw man again AND an ad hominem argument to boot (due props: nasty combination, though wildly inappropriate). As penance for insulting me and bringing my daughter’s genitals into the argument I require that you now read this torturous discussion of the sophistry of ad hominem arguments so that YOU WILL NEVER DO IT AGAIN:
http://en.wikipedia.org/wiki/Ad_hominem
In other words, don’t make personal attacks, you prick, thinking that it supports your argument (Interestingly enough, insults are not considered ad hominem attacks, but I digress...).
Since you raise the issue of the ethics of involuntary beneficent medical treatment, and take the time to insult me regarding your low estimation of my educational background, please take the time to read the 2003 review in the American Journal of Bioethics Vol 3, issue 2 pages 35-48, titled “Between Prophylaxis and Child Abuse:
The Ethics of Neonatal Male Circumcision“ in case the following link doesn’t work for you:
http://muse.jhu.edu/journals/american_journal_of_bioethics/v003/3.2benatar.html
For those of you at home, their conclusion is “We conclude that nontherapeutic circumcision of infant boys is a suitable matter for parental discretion.” Gosh, isn’t that what I’ve been saying? So what’s the problem SMT? I know that there are a zillion anti-circumcision websites out there but surely you were warned about uncritically accepting everything you read on the web. After all, there must be a website “Space aliens ate my dog”. Wait a sec, I’ll check... minutes pass of tangential, whimsical surfing... Ok, so I WAS WRONG, there is no such website but there are multiple “Space Aliens Ate My Homework” sites so I’ll expect partial credit.
3) You assert that the HIV and UTI studies I cite, from reputable journals, are flawed. One because he cites former work done by someone else that you happen, for some unknown reason, not to like. How about providing something like, oh I don’t know... a reference or something to these accusations. After all, citing other peoples work is what we scientists do to show the state of the field. If you want to diss Schoen’s study, then please take the time to tell us why. The HIV study was elegant and survived a storm of controversy in LANCET, all of which you can read and judge youself. The UTI study looked at large numbers of kids and scored those who were hospitalized so I don’t think that your suggestion that all they needed was $6 of antibiotics holds much water. I doubt that Kaiser put those kids up in the hospital (where they could catch nasty secondary infections) just for the hell of it.
4) You do raise the excellent question of where should one draw the line on a medical treatment that only benefits some of the treated patients. What level of significance is required? Does the severity of the potential harm from non-treatment outweigh the potential harm in treating, and in this case, making treatment decisions for an infant who cannot make those decisions himself? These are tough and important public health questions. In my earlier response to Leonid I pointed out that we routinely make these decisions for our children by immunizing them against rare but dire threats like polio. I recall that for every 900 circumcisions 1 case of penile cancer and 1 serious UTI (requiring hospitalization) is prevented. There is an 8 fold less risk of HIV infection but I have no idea of what that corresponds to in a per person risk so lets say that it also has a 1 in a 1000ish rate. Now, these are certainly pretty long odds and about 997 out of a 1000 guys would be getting circumcisions that wouldn’t do them any direct benefit. But, I wouldn’t want my son to be 1 of those three guys. Naturally, I would stress the importance of safer sexual practices and avoiding situations where bad decisions could be made to reduce the chances of penile cancer, cervical cancer in a partner and AIDS. But, I, personally, would still make the decision that reducing the risk of these DIRE diseases is worth the risks of circumcision. I respect the fact that other parents may not feel this way. SMT, you correctly point out that “risky” sexual practices contribute to several of these diseases.
So SMT, I’ll make a deal with you. I’ll spot you the UTIs, and if you can GUARANTEE that my sons and nephews won’t screw up and engage in risky practices (despite the best warnings and education from concerned and nurturing parents) I will cheerfully join the anti-circumcision bandwagon. Surely you don’t believe that ONLY bad kids get STDs or pregnant...
Cheers,
Ed
Hi Ed,
It's Leonid Mamchenkov, the guy with comments in the other blog. I am replying here to keep the discussion in one place, but this might cause me to forget to check back later.
Firstly, let me appologize for irritating you. It wasn't intentional. If nothing else, please write it off at English not being my first language and me not being located in the English-native speaking country.
Thank you for pointing out that the article at NEJM was free after registration. I haven't noticed this when I was there the first time. On the other hand, please understand me not taking your word on what was written in the article. That was because:
1. I don't know you.
2. Your word was apparently shorter than the article. ;)
Now that you have shown me the way to access the article (interesting read by the way), my point with resources does not have anything more to it and should not be further discussed.
My point about "safe sex" was in regard of cervical cancer. In my understanding (please forgive my non-medical background), cervix is pretty deep inside the woman and a man will have to use his penis to deliver HPV in there. Hence my point about condoms.
I was a bit overreacting to "Just in case", but that was mostly caused by my imagination. I started picturing gall bladder sergeries on infants and all sorts of things. Certainly "just in case" is a valid reason in some situations, but I fail to see how it is valid in circumcision.
Oh, and don't worry, I won't call you Shirley (is it a way to call Sherlock Holmes, or am I missing something again). You are wrong on a number of issues you raise about my beliefs. I understand that you would be right maybe with the majority of other people, but just not with me. I don't believe in doing something "just in case". In the same way I don't believe in total vaccination or "eliminate fluoridation and chlorination of drinking water". I do come from the place where drinking water didn't have any chemical process performed at it and I am glad that it was like it was.
Anyway, vaccinations and Pap smears are far away from surgery. One thing is to inject a small amount of virus in a controlled environment for a body to develop and enhance its immune system. Same one thing is to "scratch off" some cells off any part of the body, be that a hand or a vagina. And a totally different thing would be to "cut off" bits and pieces of the body.
What do you lose if Pap smears are proven useless tomorrow? Nothing. Just a few cells. What do you lose if circumcision is proven useless tomorrow? A lot. (I do have my foreskin, and I would surely miss it if it was gone).
In any way, thank you for sharing the your opinion and resources with me. I appreciate the input.
Hey Ed, I wish my professors were as funny as you are. I've learned more here than I ever did in med school on several forms of cancer and HPV (though to be fair, I did go into dentistry instead of oncology). It's good to see someone retaining their sense of humor over all of this.
This has been a great discussion. Thanks for taking so much time to pull credible resources and links together so that everyone can read as much or as little as they want before making this decision.
I saw the original debate on the infertility site and didn't bother to comment because it was clear that most of the responders were just into enganging in heated debate over opinion, not fact. And when real facts were introduced, instead of using credible sources as a rebuttal, they got personal and attacked the messenger instead of the information.
Thanks again. My sister is preggers now with a boy and she happened to ask my opinion on this topic, which led me to the first site. She's overwhelmed with the info right now but it'll be interesting to see what she does in the end.
Dr. Bob
(What gives? In order to post non-anonymously, it's asking for a sign in and I don't have one.)
Wow, thanks Dr. Bob!
I'm getting all misty eyed here. Good luck to your sister. I do think that the expanding story of HPV and its association with cancer has really provided us with some amazing molecular insights into how normal cells get reprogrammed into cancer cells and what genes are required to keep those cells in their transformed state. As a dentist you might be interested in the link between head and neck cancer and HPV. Here's a recent review that I just got off medline:
http://lysander.ingentaselect.com/vl=2427902/cl=170/nw=1/rpsv/cw/tandf/00016489/v124n4/s39/p520
Please note that this review only deals with HPV16, which is involved in the majority of cases, but there are other high-risk HPVs involved too. This is the same HPV type most often associated with cervical cancer.
Anyway, see what a little flattery will get you! You should see what Suze gets, heh.
Hey, wait a minute , Suze actually "got" me spending my Saturday helping with her tag sale and somehow convinced me to drag a $25 table across the city to the legendary wrong side of the tracks with a FREE mattress lashed to the roof of my car with old telephone cords. Maybe I need to aim a little higher. Damn, I must love that woman.
Cheers,
Ed
Aww, now *I'm* getting all misty.
You had me worried there . . . for a minute I thought you two were going to start the Ed and Bob Mutual Admiration Club. E&B MAC.
The MAC Daddy's of Post-Coital Babble.
Put that on your resumes.
;o)
um, Dr. Bob? Just to clarify....your sister asked you - a Dentist - about circumcision?
I didn't know you guys did that now! Cool!
Do you use a special chair or just have the guys hang upside down on the regular one?
Do they get the nitrous?
I LOVE the gas!
I tell you what, I wanna be your new bestest friend. Kay? You could bring the gas to our parties.
Tahoodle dee doodle if I do say so myself.
Hi- I've been digging out of the mud for the past week so I will just scan through the posts and make some quick comments.
> Anonymous said...
> and we still have appendixes (whatever the plural
> is of that) and we still have tonsils and yet
> it's common to remove both of those when recurrent
> infections cause problems.
Please note the ethical criteria has been met by treating an actual problem.
> So, does this mean that we should wait until
> there are re-current infections to have the
> circumsizion?
Yes, the ethical thing to do is to use the least invasive options first.
> I think if I had a son, I would probably not want
> him to have to go through that pain over and
> over again before I fixed the problem, especially
> if I could fix it in advance knowing he'll only
> having the pain once.
So, with one infection, you would start cutting off body parts? What other body parts would you apply that same concept to? Wouldn't you first like to know what the odds are of getting an infection? Or getting recurrent infections? Of course every parent want's to avoid their child being in pain. It seems like supporting routine infant circucmision without adequate data to support that position is only guaranteeing that your child will have a painful circumcision as in infant, where it is very likely that the vast majority of boys will never need to be circumcised later in life.
> suzinalexa said...
> SMT, when you ask if Ed is sure he has a PhD.,
> not only is that condescending and arrogant,
> it begs the question - what, exactly are your
> qualifications for weighing in so heavily on
> this subject?
I have not stated that I have any specific qualifications. I presented a case against circumcision and welcome any rebuttals or corrections to what I have said. I am also willing to clarify my position if that is needed.
> Ed will not blow his own horn, not only
> has he made study of HPV his life's work, he also
> has patented a technology using parts of his studies
> that major pharmaceutical companies use today to
> treat cancer.
I applaud his work. Is he involved in the HPV vaccine? That vaccine might make some of this discussion irrelevant.
> What do you have?
I'm not claiming any special knowledge other than what I have already written here.
> Please SMT - I invite you to cite even one
> medical journal here that refutes this evidence
> so we can all benefit from your extensive
> research on the subject.
Why don't you pick a specific benefit of circumcision and we will discuss that one. When we are done with that then we can move on to others if you would like. Please understand that just because there is a "benefit" does not mean a procedure is justified. The benefits must be weighed against all risks and disadvantages. I have not said there is no benefit at all from circumcision. What I have said is that there is no benefit that has been proven sufficient to justify infant circumcision. That really is the bottom line, right?
> Also, you mention "risky sexual behavior" several
> times and this is a myth. A woman can have sex with
> only one partner in her life and he can be her
> husband; if he is uncircumsized and had more than 1
> sexual partner (also not that risky unless it's
> hundreds, but you see the point is that it doesn't
> even have to be- more than 1 is sufficient) the
> chances of him having HPV are high enough to put her > at severe risk for contracting HPV and subsequently
> maybe cancer.
What is the myth? The ACS specifically lists risky sexual behavior as a primary risk factor of getting HPV. Specifically they say "having unprotected sexual relations with multiple partners". Your exact same argument can be applied to circumcised men because they too *could* pass HPV. Let's consider this from the ethics perspective. You are basing a case for circumcision on the ability of an intact penis passing HPV to the partner. This assumes that the benefit of circumcising an infant is sufficient to take away a healthy, functional part of his body for some type of sexual behavior he may not choose to take part in. How is that ethical? He can choose to be circumcised when he becomes sexually active if he thinks that will lower his risk of getting/transmitting HPV.
> Let's try and stay away from broad generalizations
> like that plelase.
Well, you need to talk to the ACS. I don't just make this stuff up. Risky sexual behavior is a risk factor for HPV. No one is saying it is the only way to transmit HPV. Along the same lines I think it is best to not put all the blame for HPV on the foreskin. An intact penis can transmit HPV, too.
> Anonymous said...
> Can someone (because I don't have the patience
> or skills) bring some links to factual articles
> from CREDIBLE sources (3rd party established
> organizations) that support the anti-circumcision
> debate?
If you conisder that the burden of proof for a medical procedure is on the one proposing it you would understand that the anti-circ side does not have to prove anything. It is up to the pro-circ side to prove that there are benefits from circumcision that outweigh the negatives. This has yet to be proven. So, what are some third party organizations that say there is no proven benefit that outweighs the risks?
AAP: Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.
AMA: Supports AAP's statement
ACOG: However the data are not sufficient to recommend routine neonatal circumcision.
RACP (Australia): After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision
BMA (UK):The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it.
CPS (Canada): Recommendation: Circumcision of newborns should not be routinely performed.
*Some might say that the policy statements are outdated. Here is the most recent major medical organization to release a circumcision policy statement*
CPSBC (British Columbia): Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention. June 2004
> suzinalexa said...
> I would never try to sway someone else's decison
> on something so personal.
Who is this personal to? The parents? Or the child with the penis? Why wouldn't you try to sway someone's decision from performing unnecessary human genital modification on an infant?
> "And so I'll hope he'll forgive me for getting snarky above in response."
I don't mind a little snarkiness :)
> Anonymous said...
> The real question is the balance between the
> positive and negative aspects of circumcision.
Exactly.
> I’ve only presented the science of the situation
> so parents can make an informed decision.
And this is why the procedure should not be performed when there is no medical indication of a problem. IMO, the typical parent has no way to evaluate the medical facts without doing extensive research. Most major medical organizations have already done the work and none of them have concluded that the benefits of infant circumcision outweigh the risks. How can we expect a parent to come to any different conclusion? I guess it doesn't really matter because currently parents can have their son's genitals cut up just because they don't like the way the foreskin looks. The medical community is not being held accountable to modern medical ethics.
Ed has brought up some good stuff to discuss... I will have to save my response to Ed's post for my next available opportunity.
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