Is circumcision in line with the Hippocratic Oath?

[carlosc1dbz]

I am just curious what you guys think. I have been reading on how so many medical students mess up circumcisions and babies needing skin grafts, the list goes on. Is this procedure a justified one according to the regulatory powers here in the US?

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[Sol Rosenberg]

Sure, why not?

 

[cpants]

I am just curious what you guys think. I have been reading on how so many medical students mess up circumcisions and babies needing skin grafts, the list goes on. Is this procedure a justified one according to the regulatory powers here in the US?

Please link to literature regarding botched medical student circumcisions. I've never seen a medical student allowed to perform a circumcision.

Circumcision is certainly justifiable as long as parents are informed of the risks and benefits of the procedure. Risks include screw-ups requiring skin grafts, infection, hemorrhage, even loss of penis and death. Minor complications of circumcision are rare, and severe complications are extremely rare. Benefits are reduced risk of UTI, reduced risk of penile cancer (although this is exceedingly rare to begin with), decreased risk of HIV, and cosmetic.

 

[badasshairday]

Circumcision is certainly justifiable as long as parents are informed of the risks and benefits of the procedure. Risks include screw-ups requiring skin grafts, infection, hemorrhage, even loss of penis and death. Minor complications of circumcision are rare, and severe complications are extremely rare. Benefits are reduced risk of UTI, reduced risk of penile cancer (although this is exceedingly rare to begin with), decreased risk of HIV, and cosmetic.

Well said.

 

[carlosc1dbz]

Please link to literature regarding botched medical student circumcisions. I've never seen a medical student allowed to perform a circumcision.

Circumcision is certainly justifiable as long as parents are informed of the risks and benefits of the procedure. Risks include screw-ups requiring skin grafts, infection, hemorrhage, even loss of penis and death. Minor complications of circumcision are rare, and severe complications are extremely rare. Benefits are reduced risk of UTI, reduced risk of penile cancer (although this is exceedingly rare to begin with), decreased risk of HIV, and cosmetic.

Hello, I as far as students, I am considering residents still as students. I guess I should of made that more clear. You dont need literature to know that everyone has or knows of a person that has messed up a circumcision.

What I am thinking is that regardless of whether or not the parents know about the risks, the patient is still the baby. I feel like circumcision is a cosmetic procedure that is not practiced much around the world. I am not sure the logic behind statements like, less likely to get UTI. Guys hardly ever get UTIs. The other statement about cancer, and how circumcision is performed because you are less likely to get penile cancer. You cant just chop something off of someone to prevent cancer later on. Those statement much like the other statement sound more like an excuse for doing a circumcision than a reason. One of the funnier ones is the HIV excuse. Less likely to get HIV. Look if someone is doing it with hookers or has a partner with HIV, they are going to get HIV, either way because they are having sex with either many people, or they are not using condoms. They are probably going to get and STD. What do you tell the parents about reducing the risks of HIV? "Well parents, circumcision reduces the chances of him getting infected with HIV, when in the future he is having unprotected sex with prostitutes or with college girls."

 

[cpants]

Hello, I as far as students, I am considering residents still as students. I guess I should of made that more clear. You dont need literature to know that everyone has or knows of a person that has messed up a circumcision.

What I am thinking is that regardless of whether or not the parents know about the risks, the patient is still the baby. I feel like circumcision is a cosmetic procedure that is not practiced much around the world. I am not sure the logic behind statements like, less likely to get UTI. Guys hardly ever get UTIs. The other statement about cancer, and how circumcision is performed because you are less likely to get penile cancer. You cant just chop something off of someone to prevent cancer later on. Those statement much like the other statement sound more like an excuse for doing a circumcision than a reason. One of the funnier ones is the HIV excuse. Less likely to get HIV. Look if someone is doing it with hookers or has a partner with HIV, they are going to get HIV, either way because they are having sex with either many people, or they are not using condoms. They are probably going to get and STD. What do you tell the parents about reducing the risks of HIV? "Well parents, circumcision reduces the chances of him getting infected with HIV, when in the future he is having unprotected sex with prostitutes or with college girls."

The reason I asked for literature is because in your original post you claimed to have been "reading on how so many medical students mess up circumcisions". I guess that was untrue.

Your post was barely coherent, but what I got out of it is you don't approve of routine circumcision. That's fine, and I may even agree with you, but the procedure can certainly be justified under the Hippocratic oath. It's a very safe procedure, and does confer certain medical benefits which I outlined in my post above.

I don't know why you consider decreased risk of HIV transmission to be funny. We can and do promote condom use, but the reality is that people don't use them. Circumcision significantly reduces the risk of getting HIV, especially in endemic areas. Your argument reminds me of parents who refuse Guardasil because they think their daughter won't have sex until she marries another virgin some day. Wishful thinking.

 

[VA Hopeful Dr]

Hello, I as far as students, I am considering residents still as students. I guess I should of made that more clear. You dont need literature to know that everyone has or knows of a person that has messed up a circumcision.

What I am thinking is that regardless of whether or not the parents know about the risks, the patient is still the baby. I feel like circumcision is a cosmetic procedure that is not practiced much around the world. I am not sure the logic behind statements like, less likely to get UTI. Guys hardly ever get UTIs. The other statement about cancer, and how circumcision is performed because you are less likely to get penile cancer. You cant just chop something off of someone to prevent cancer later on. Those statement much like the other statement sound more like an excuse for doing a circumcision than a reason. One of the funnier ones is the HIV excuse. Less likely to get HIV. Look if someone is doing it with hookers or has a partner with HIV, they are going to get HIV, either way because they are having sex with either many people, or they are not using condoms. They are probably going to get and STD. What do you tell the parents about reducing the risks of HIV? "Well parents, circumcision reduces the chances of him getting infected with HIV, when in the future he is having unprotected sex with prostitutes or with college girls."

Yes, in fact you can. Ever hear of preventative mastectomies?

 

[FutureDoc4]

It's true more women do get UTIs due to having a shorter urethra. However, this does not mean that boys don't ever get UTIs. It has been pretty well studied that circumcision leads to decreased UTIs for boys. Here is just one random article I got from a pubmed search, but there is lots on the subject:

http://www.ncbi.nlm.nih.gov/pubmed/11793114

Honestly, it seems to me from your post you are just trying to argue against circumcision (and are fishing for any reason why).

And yes, circumcision has been shown to decrease the incidence of HIV in men. Here is ONE (of many) articles showing an explanation for this phenomena:

http://www.ncbi.nlm.nih.gov/pubmed/20395432

Your bias against circumcision I hope is not being passed onto patients.

 

[ml66uk]

Preventative mastectomies aren't performed without the patient's consent. About one in eight women develop breast cancer, and we could prevent that with two simple snips on a baby girl, but that would be unethical.

Penile cancer is rare. Really rare. Rarer than vulval cancer, and rarer than breast cancer in men. Penile cancer also happens to be even rarer in some countries that don't circumcise, than in the USA.

Girls get more UTI's than boys. Even if we could reduce their risk of UTI's by cutting off their inner labia though, it wouldn't make it acceptable to do so.

Trying to prevent HIV is one of the worst reasons to circumcise. In Europe, almost no-one circumcises unless they're Muslim or Jewish, and they have significantly lower rates of almost all STI's including HIV. Even in Africa, there are six countries where men are *more* likely to be HIV+ if they've been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms. . 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".

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

The British Medical Association has a discussion of whether or not male circumcision is actually legal: http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp

Also worth looking at:

Canadian Paediatric Society
http://www.cps.ca/english/statements/fn/fn96-01.htm
"Recommendation: Circumcision of newborns should not be routinely performed."

http://www.caringforkids.cps.ca/pregnancy&babies/circumcision.htm
"Circumcision is a 'non-therapeutic' procedure, which means it is not medically necessary."
"After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions."

Royal Australasian College of Physicians
http://www.racp.edu.au/index.cfm?objectid=B5610716-9E3E-6C97-A8D87880FD002E3B
"After extensive review of the literature, the Paediatrics & Child Health Division of the Royal Australasian College of Physicians has concluded that there is no medical reason for routine newborn male circumcision."
(their bolding. Almost all the men responsible for this statement will be circumcised themselves, as the male circumcision rate in Australia in 1950 was about 90%. "Routine" circumcision is now *banned* in public hospitals in Australia in all states except one.)

 

[mwppa]

How about circumcision for the sake of your future son's sex life because, quite frankly, many women are repulsed by an uncircumcised penis. It may not be a "medical benefit" but it is something that he may thank you for later. If he decides to have the procedure done later in life because he is facing rejection from women, the process is much more horrific. At least as an infant, he won't be traumatized (despite what the quacks say.)

Also, there seems to be a correlation between uncircumcised men and their female partners having a higher risk of cervical cancer. Just something to think about.

 

[ml66uk]

How about circumcision for the sake of your future son's sex life because, quite frankly, many women are repulsed by an uncircumcised penis. It may not be a "medical benefit" but it is something that he may thank you for later. If he decides to have the procedure done later in life because he is facing rejection from women, the process is much more horrific. At least as an infant, he won't be traumatized (despite what the quacks say.)

Also, there seems to be a correlation between uncircumcised men and their female partners having a higher risk of cervical cancer. Just something to think about.

How about letting him decide for himself? It's his body. If he wants to get circumcised for whatever reason, it's no big deal. If he's already circumcised and wants to be intact, he has a problem.

In some countries, many men are repulsed by uncircumcised females (seriously). That doesn't justify circumcising girls though.

Anyway, it's not like it's a big deal. I'm intact, and have never once had a problem, even though two girls I was with had never seen an intact penis before. Now the newborn circ rate is down to 57% (31% on the east coast, and much much lower in other countries), it's not like being intact is going to be unusual.

Cervical cancer? This 2003 paper in the Israeli Medical Association Journal discusses circumcision and cervical cancer at length and says the following:

"Although the dispute over the association of circumcision and cervical cancer in various populations is still ongoing, there seems to be no hard evidence that circumcision prevents its occurrence in Jewish women, and it is no longer considered to play a protective role."

We can also vaccinate against cervical cancer.

 

[DoctwoB]

How about letting him decide for himself? It's his body. If he wants to get circumcised for whatever reason, it's no big deal. If he's already circumcised and wants to be intact, he has a problem.

In some countries, many men are repulsed by uncircumcised females (seriously). That doesn't justify circumcising girls though.

Anyway, it's not like it's a big deal. I'm intact, and have never once had a problem, even though two girls I was with had never seen an intact penis before. Now the newborn circ rate is down to 57% (31% on the east coast, and much much lower in other countries), it's not like being intact is going to be unusual.

Cervical cancer? This 2003 paper in the Israeli Medical Association Journal discusses circumcision and cervical cancer at length and says the following:

"Although the dispute over the association of circumcision and cervical cancer in various populations is still ongoing, there seems to be no hard evidence that circumcision prevents its occurrence in Jewish women, and it is no longer considered to play a protective role."

We can also vaccinate against cervical cancer.

And while we're at it, we should let 5 year olds decide whether or not they should get vaccinated too right? I mean come on, who gets polio anymore /sarcasm.

Medical decisions for infants are made by their parents. No hospital will circumcise an infant against their parents wishes. Got a problem with losing the tip? take it up with the folks, not the hospital.

By your argument, we shouldn't let anyone get non-emergency medical treatment until they're 18 because they have the right to decide for themselves, right?

 

[Llenroc]

The problem is that you're equating circumcision which is a cultural practice (increasingly out of favor in the Western world) with dubious benefits, with something that's extremely low risk/high medical benefit like a polio vaccine. Also a polio vaccine isn't something that physically changes you in a permanent way like circumcision does.

 

[scrubs421]

Wow, passions run high with some people about this.

From your link from the Australia

Benefits: decreased risk of UTI, lowers risk of infecton, lowers risk of penile cancer, lowers risk of AIDS

Cons:complications of surgery, possibly less sensitivity in the tip of the penis, maybe painful procedure for the child.

This is YOUR reference . Didn't think I'd bother to open it?

It seems to me, via a cost benefit analysis its pretty straight forward that there are some benefits to circumcision. However, they are likely NOT huge, so it comes down to cosmetic and tradition.

In terms of letting the baby decide? Um, thats completely unreasonable. Otherwise, children would never want to go undergo procedures that may "hurt them" (dental procedures, vaccinations, the list could go on forever). This is why parents can make the decision for children.....cause they are children.

 

[ml66uk]

Wow, passions run high with some people about this.

From your link from the Australia

Benefits: decreased risk of UTI, lowers risk of infecton, lowers risk of penile cancer, lowers risk of AIDS

Cons:complications of surgery, possibly less sensitivity in the tip of the penis, maybe painful procedure for the child.

This is YOUR reference . Didn't think I'd bother to open it?

It seems to me, via a cost benefit analysis its pretty straight forward that there are some benefits to circumcision. However, they are likely NOT huge, so it comes down to cosmetic and tradition.

In terms of letting the baby decide? Um, thats completely unreasonable. Otherwise, children would never want to go undergo procedures that may "hurt them" (dental procedures, vaccinations, the list could go on forever). This is why parents can make the decision for children.....cause they are children.

Actually, I don't think this discussion has been overly passionate. If we'd been talking about any other procedure, I don't think you'd find the comments so far unusual.

That link does also say in a larger font: "After extensive review of the literature, the Paediatrics & Child Health Division of the Royal Australasian College of Physicians has concluded that there is no medical reason for routine newborn male circumcision."

Here's the full circumcision policy of the RACP.

"Routine" circumcision is now *banned* in public hospitals in Australia in all states except one. It can be done in private hospitals, but generally not straight after birth ("To reduce the risks and the discomfort for the child, the operation is best performed under a general anaesthetic after the age of six months.")

What about the other two references? One specifically recommends not to circumcise, and the other has a discussion of whether or not elective circumcision is even legal. It's worth noting that it's really easy to find circumcised doctors who recommend against circumcision, but almost impossible to find intact male doctors who advocate it.

Why is it unreasonable to let the owner decide for himself? It's an elective procedure, with questionable medical benefits, that involves removing the most sensitive parts of the penis (the foreskin isn't just some random flap of skin, and circumcision normally removes the frenulum too). Hardly anyone chooses circumcision for themselves, so why should it be chosen for them? If my son wants to be circumcised when he's 18 (16 if he knows what he's doing), then I'll pay for it, and help him find a good urologist. Until then, I don't think I or his mother have the right to have part of his penis cut off. Sure, we went ahead with lots of shots, but I don't see much comparison between circumcision and vaccination.

The chair of the RACP's Paediatrics & Child Health Policy & Advocacy Committee wrote the following: "The option of delaying the decision to circumcise is one way of dealing with the ethical and potential legal issues of undertaking an elective procedure on a minor. The procedure is not to be equated with vaccination, either in its delivery or in its effectiveness."
(http://www.6minutes.com.au/articles/z1/view.asp?id=498029)

It would be illegal for us to have the prepuce cut off our daughters, so why isn't our son protected?

It's worth remembering that no-one except for Jewish people and Muslims would even be having this discussion if it weren't for the fact that 19th century doctors thought that :
a) masturbation caused various physical and mental problems (including epilepsy, convulsions, paralysis, tuberculosis etc), and
b) circumcision stopped masturbation.

Both of those sound ridiculous today I know, but how that's how they thought back then, and that's how non-religious circumcision got started. If you don't believe me, then check out this link:
A Short History of Circumcision in North America In the Physicians' Own Words

Heck, they even passed laws against "self-pollution" as it was called.

 

[Ghost22]

Cosmetic reasons aren't enough? I mean, it's not like it causes any sexual dysfunction in males except for very rare cases.

 

[FutureDoc4]

Actually, I don't think this discussion has been overly passionate. If we'd been talking about any other procedure, I don't think you'd find the comments so far unusual.

That link does also say in a larger font: "After extensive review of the literature, the Paediatrics & Child Health Division of the Royal Australasian College of Physicians has concluded that there is no medical reason for routine newborn male circumcision."

Here's the full circumcision policy of the RACP.

"Routine" circumcision is now *banned* in public hospitals in Australia in all states except one. It can be done in private hospitals, but generally not straight after birth ("To reduce the risks and the discomfort for the child, the operation is best performed under a general anaesthetic after the age of six months.")

What about the other two references? One specifically recommends not to circumcise, and the other has a discussion of whether or not elective circumcision is even legal. It's worth noting that it's really easy to find circumcised doctors who recommend against circumcision, but almost impossible to find intact male doctors who advocate it.

Why is it unreasonable to let the owner decide for himself? It's an elective procedure, with questionable medical benefits, that involves removing the most sensitive parts of the penis (the foreskin isn't just some random flap of skin, and circumcision normally removes the frenulum too). Hardly anyone chooses circumcision for themselves, so why should it be chosen for them? If my son wants to be circumcised when he's 18 (16 if he knows what he's doing), then I'll pay for it, and help him find a good urologist. Until then, I don't think I or his mother have the right to have part of his penis cut off. Sure, we went ahead with lots of shots, but I don't see much comparison between circumcision and vaccination.

The chair of the RACP's Paediatrics & Child Health Policy & Advocacy Committee wrote the following: "The option of delaying the decision to circumcise is one way of dealing with the ethical and potential legal issues of undertaking an elective procedure on a minor. The procedure is not to be equated with vaccination, either in its delivery or in its effectiveness."
(http://www.6minutes.com.au/articles/z1/view.asp?id=498029)

It would be illegal for us to have the prepuce cut off our daughters, so why isn't our son protected?

It's worth remembering that no-one except for Jewish people and Muslims would even be having this discussion if it weren't for the fact that 19th century doctors thought that :
a) masturbation caused various physical and mental problems (including epilepsy, convulsions, paralysis, tuberculosis etc), and
b) circumcision stopped masturbation.

Both of those sound ridiculous today I know, but how that's how they thought back then, and that's how non-religious circumcision got started. If you don't believe me, then check out this link:
A Short History of Circumcision in North America In the Physicians' Own Words

Heck, they even passed laws against "self-pollution" as it was called.

Your right. It's your child's body. So, when they don't want that shot at the doctors or to see the dentist, than I think you should honor their wishes.

You either decide these children are able to make rationale decisions about their body or you don't. (In the US, we realize that they aren't. Hence, the reason that parents make these decisions for their children).

And your argument that waiting until their 16-18 is very specious for one main reason: Going through a circumcision is obviously going to be much more traumatic at an older age than at 6 months (when you won't remember it)..(if you are going to argue against this, than you are just completely irrational)

Everything about your perspective is completely "loaded" you refer to circumcision as "not being whole" or that "part of his penis cut off"......when its just a removal of foreskin (the penis isnt being cut in length). You should let people make this decision for themselves and stop pushing your agenda. Period.

 

[VA Hopeful Dr]

Cosmetic reasons aren't enough? I mean, it's not like it causes any sexual dysfunction in males except for very rare cases.

Exactly. Even were the Hippocratic oath binding (heck, many schools don't even use it anymore), its says do no harm. A circumcision without complications doesn't "harm" a person in the way that the oath means.

 

[Starpower]

And yes, circumcision has been shown to decrease the incidence of HIV in men. Here is ONE (of many) articles showing an explanation for this phenomena:

http://www.ncbi.nlm.nih.gov/pubmed/20395432

Yup, and I read either in William's or Katz that it also decreases transmission of HPV to females.

I'm on my Ob/Gyn rotation (PA student, DO preceptor), and I've done 2 circumcisions so far. The parents are asked and double-asked, just to make sure. I've had no problem doing the circs, but maybe that's because I'm circumcised myself? (I know, tmi, but it's relevant)

I did just find out that circs can be done in adolescent and adult years, but it's probably more painful/more healing time, I'm assuming. Still, why not leave the decision up to the person? It's not like they'd automatically be having sex before they could be presented with the choice.

 

[VA Hopeful Dr]

Yup, and I read either in William's or Katz that it also decreases transmission of HPV to females.

I'm on my Ob/Gyn rotation (PA student, DO preceptor), and I've done 2 circumcisions so far. The parents are asked and double-asked, just to make sure. I've had no problem doing the circs, but maybe that's because I'm circumcised myself? (I know, tmi, but it's relevant)

I did just find out that circs can be done in adolescent and adult years, but it's probably more painful/more healing time, I'm assuming. Still, why not leave the decision up to the person? It's not like they'd automatically be having sex before they could be presented with the choice.

Not probably, definitely.

 

[AegriSomnia]

I think that people have been leaving out an important aspect of this discussion. Sorrells et al. 2007 states that some of the most sensitive areas of the penis are on the foreskin. For obvious reasons there might be some people that would want to keep their foreskin and not have them removed. And remember the ones that make this decision are usually the mothers who may not understand the importance of keeping this piece of skin . If given the choice I think I would have foregone circumcision.

 

[PostLessOne]

The HIV thing is the linchpin of this whole argument. The way I see it, the risks and drawbacks of circumcision are low. However, the benefits have to exceed these drawbacks or the procedure is not medically useful. Penile cancer is so rare it's not worth considering, and UTIs are treatable. That leaves HIV.

If those numbers above from Africa are correct, then the protective benefits of circumcision against HIV are not supported by evidence, and a ban should be instated against it. It is against the Hippocratic Oath to perform a procedure that has no medical benefits but does involve harm.

On the other hand, some studies show that circumcision cuts the risk of HIV infection in half, or something like that. That is a significant benefit, and worth the risks of performing the operation.

 

[Fellow Traveler]

The HIV thing is the linchpin of this whole argument. The way I see it, the risks and drawbacks of circumcision are low. However, the benefits have to exceed these drawbacks or the procedure is not medically useful. Penile cancer is so rare it's not worth considering, and UTIs are treatable. That leaves HIV.

If those numbers above from Africa are correct, then the protective benefits of circumcision against HIV are not supported by evidence, and a ban should be instated against it. It is against the Hippocratic Oath to perform a procedure that has no medical benefits but does involve harm.

On the other hand, some studies show that circumcision cuts the risk of HIV infection in half, or something like that. That is a significant benefit, and worth the risks of performing the operation.

PostLessOne I agree up to this point because this statement has to be qualified with the context of the situation. While some studies do show what you suggest, we have to consider not necessarily the relative risk reduction but the actual risk reduction in specific contexts. That is to say with regard to HIV there will be little (if any) benefit to anyone who is born and grows up in a country where prevalence is low and/or where the epidemic relates to specific populations. In most Western, first world, (and actually most places not in Africa) such as the US, the epidemic is largely driven by MSM, bi-sexual, and IV drug users. Heterosexual cases (while they do occur) occur mainly in high-risk heterosexual populations such as: men/women who've arrived from a high-risk area (immigration), longterm sero-discordant relationship, and sex with high risk individuals (IV-drug users or those who've recently arrived from a high prevalence country). So the practical impact of circumcision in the US would almost certainly be negligible. It's a situation similar to not providing vaccines for certain diseases because, even though there is a very effective vaccine, it's simply not necessary to receive it except under certain circumstances, exotic travel for instance.

Having said that circumcision unquestionably is in violation of the Hippocratic Oath. In discussing consent by proxy, the AAP noted in part that:

Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses.

and that the pediatrician's responsibilities were independent of the parent's desires.

Given that the majority of infants and children don't require a circumcision and the benefits it's supposed to provide are either very small or can be realized in less invasive (often more effective) ways, it's difficult to see how one can square circumcision with either the Hippocratic Oath, the AAP's statement on Informed/Proxy consent, or the ethical practice of medicine. The routine child/infant kind not adults who can do as they wish.

 

[PostLessOne]

Fellow Traveler, I'm inclined to agree with you. However, the 'right' way to come to this decision would be to assign actual numerical values to the risks of circumcision versus the benefits and to determine if the procedure is actually useful from there. I don't really like even the concept of circumcision either, but sometimes unpleasant things have to be done, and we should reach a conclusion based upon objective criteria.

Most posters on this thread seem to be all one side or the other, and are trying to twist the evidence to support their own viewpoints. The pro-circumcision people are making social arguments : you gotta chop the foreskins off infants so they can 'fit in' and get laid as adults. The antis are saying that cutting off a piece of skin reduces sexual pleasure so much it might as well be torture, and it's a barbaric practice that is based upon religion.

Evidence based medicine means that we need to objectively look at the best available evidence, and make a decision. If it turns out that circumcisions have no detectable benefit, but do carry risks, then the procedure should be banned and any doctor who does one should be sanctioned by a medical board. Period. And if the OTHER argument turns out to be true, then every doctor should offer new parents of a male baby the opportunity to have their child circumcised, or face similar sanctions.

 

[Fellow Traveler]

Fellow Traveler, I'm inclined to agree with you. However, the 'right' way to come to this decision would be to assign actual numerical values to the risks of circumcision versus the benefits and to determine if the procedure is actually useful from there. I don't really like even the concept of circumcision either, but sometimes unpleasant things have to be done, and we should reach a conclusion based upon objective criteria.

I agree with you that this is the right way to come to such a decision. And along with that type of evaluation we have to include considerations such as less invasive ways of achieving the same result and/or ways to otherwise treat. You did this for UTIs and Penile cancer. I just wanted to add that in the case of HIV we have to similarly consider context; it's not sufficient to say F->M acquisition was reduced by X% to understand the practical impact. I think at this point, the most favorable thing that could be said about circumcision is that it's a wash particularly in first world countries. It is therefore no surprise that circumcision (secular circumcision) is rarely practiced outside the US.

Most posters on this thread seem to be all one side or the other, and are trying to twist the evidence to support their own viewpoints. The pro-circumcision people are making social arguments : you gotta chop the foreskins off infants so they can 'fit in' and get laid as adults. The antis are saying that cutting off a piece of skin reduces sexual pleasure so much it might as well be torture, and it's a barbaric practice that is based upon religion.

I agree, I see that a lot and for purposes of disclosure, I fall in the against camp. I might add though what is more interesting is the rift in the medical establishment, most especially between those (mostly) in the US and those (mostly) outside the US. In the US benefits tend to be greatly up sold, in the UK, Australia, Europe, and other places they are far more skeptical. So much so that I suspect, were it not for circumcision's association with religion, I would not be surprised if it would have been banned in some of those countries by now.

Evidence based medicine means that we need to objectively look at the best available evidence, and make a decision. If it turns out that circumcisions have no detectable benefit, but do carry risks, then the procedure should be banned and any doctor who does one should be sanctioned by a medical board. Period. And if the OTHER argument turns out to be true, then every doctor should offer new parents of a male baby the opportunity to have their child circumcised, or face similar sanctions.

I don't think the situation is quite as objective as we would like to think. The benefits (as they are now) I think are largely subjective. For instance, there may in fact be a detectable reduction in UTIs but as you said they are rare and can easily be treated. On the other hand, if an individual child is predisposed to UTIs because of (for example) some congenital anomaly of the urinary tract, then circumcision might be an option in that case. Similarly, there may be a reduction in incidence of HIV, and therefore an individual in a low incidence country like the US might only find that beneficial or desirable if they are in a sero-discordant longterm relationship.

I would say that it should be offered (as you present it) only if there is a significant benefit that clearly outweighs the risk, there are no other reasonable alternatives, and/or it is necessary to the welfare of the child. Most vaccines fall within this criteria I don't see circumcision close to it.

 

[badasshairday]

Always an interesting debate guys/gals.

 

[Starpower]

In most Western, first world, (and actually most places not in Africa) such as the US, the epidemic is largely driven by MSM, bi-sexual, and IV drug users. Heterosexual cases (while they do occur) occur mainly in high-risk heterosexual populations such as: men/women who've arrived from a high-risk area (immigration), longterm sero-discordant relationship, and sex with high risk individuals (IV-drug users or those who've recently arrived from a high prevalence country).

Would you mind if I asked you for some references on this?

I don't know if I'd use the word, "negligible":
http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm
http://www.cdc.gov/hiv/resources/factsheets/us.htm

 

[Fellow Traveler]

Would you mind if I asked you for some references on this?

I don't know if I'd use the word, "negligible":
http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm
http://www.cdc.gov/hiv/resources/factsheets/us.htm

Well, I think you've posted the references yourself. The diagram provided for men shows that 85% of new infections are among MSM and IV drug use. While only about 14% are among high-risk heterosexual men. High-risk in this references is defined as: "sexual contact with persons known to have HIV infection or have a higher risk of contracting HIV infection."

So high risk would mean: men in a longterm sero-discordant relationship with a known HIV positive woman, having sex with an IV drug user, or some long term relationship with a person (of unknown status) from a high prevalence country. I think I noted this in my previous post:

In most Western, first world, (and actually most places not in Africa) such as the US, the epidemic is largely driven by MSM, bi-sexual, and IV drug users. Heterosexual cases (while they do occur) occur mainly in high-risk heterosexual populations such as: men/women who've arrived from a high-risk area (immigration), longterm sero-discordant relationship, and sex with high risk individuals (IV-drug users or those who've recently arrived from a high prevalence country).

Most men are not in these high risk groups so circumcision would change the lifetime risk of HIV infection for the average man in the US very little. As I also pointed out, if a man is in such a position, circumcision might be a consideration for him. But as a general strategy, in the US (and other first world/western countries), it's a poor approach to the problem.

 

[cpants]

I just would like to point out for the sake of argument that it is impossible to know if a baby will be a man who has sex with men. About 10% are. Heterosexual transmission to women is also very common. I believe it's the most rapidly expanding group of HIV positive patients in the US. Circumcision reduces transmission to women also.

 

[Fellow Traveler]

I just would like to point out for the sake of argument that it is impossible to know if a baby will be a man who has sex with men. About 10% are. Heterosexual transmission to women is also very common. I believe it's the most rapidly expanding group of HIV positive patients in the US. Circumcision reduces transmission to women also.

It might be the most rapidly expanding group (I am not sure of that) but circumcision doesn't appear to reduce transmission to women. There was a study on that published last summer that was done in parallel with those F->M studies in Africa. See:

Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229–37.

If there is an effect, it is very small.

 

[Orbo]

FWIW, I was circumsized at age 14ish and while it kinda sucked (in terms of inconvenience of bathing, peeing, and bloody discharges [yes, TMI, but deal with it you pansies]), it wasn't anything worse than staying home for the weekend and walking a little awkward for a week or 2.

For that reason, I'm personally against routine circumcision. Let the guy decide later on in life if he wants himself snipped or not. But I'm not going to cry foul if parents do decide to circumsize their child after evaluating the pros and cons.

Just as an aside, I was put under general anaethesia for the operation. Not sure if that's standard or not but it wasn't a "traumatic" experience that is often said here.

Oh, and another aside: the glans is definitely less sensitive after being cut. Also TMI but you know you wanted to know so quit wincing ya pansy.

 

[ml66uk]

Your right. It's your child's body. So, when they don't want that shot at the doctors or to see the dentist, than I think you should honor their wishes.

You either decide these children are able to make rationale decisions about their body or you don't. (In the US, we realize that they aren't. Hence, the reason that parents make these decisions for their children).

There's a big difference between vaccination, visits to the dentist, and genital surgery of dubious medical benefit.

We don't let parents decide to make the decision to have their baby girl's prepuce cut off, so why is it allowed for baby boys?

And your argument that waiting until their 16-18 is very specious for one main reason: Going through a circumcision is obviously going to be much more traumatic at an older age than at 6 months (when you won't remember it)..(if you are going to argue against this, than you are just completely irrational)

Circumcision later in life is actually safer and less painful than infant circumcision, there's almost never a revision (a second operation), and the results are cometically better. Most males left intact never get circumcised though, so there's no "trauma" whatsoever. If they do want to get circumcised, they can choose what kind of circumcision they want, rather than having someone else choose for them.

Everything about your perspective is completely "loaded" you refer to circumcision as "not being whole" or that "part of his penis cut off"......when its just a removal of foreskin (the penis isnt being cut in length). You should let people make this decision for themselves and stop pushing your agenda. Period.

The foreskin is part of the penis, and an important part at that. Just ask any intact man.

I'm all in favor of people making the decision for themselves. Not for other people though, even their children. Whose body is it?

 

[Integrity]

Who cares. I don't think the hippo-oath is a great algorithm, anyway.

 

[ml66uk]

The HIV thing is the linchpin of this whole argument. The way I see it, the risks and drawbacks of circumcision are low. However, the benefits have to exceed these drawbacks or the procedure is not medically useful. Penile cancer is so rare it's not worth considering, and UTIs are treatable. That leaves HIV.

If those numbers above from Africa are correct, then the protective benefits of circumcision against HIV are not supported by evidence, and a ban should be instated against it. It is against the Hippocratic Oath to perform a procedure that has no medical benefits but does involve harm.

On the other hand, some studies show that circumcision cuts the risk of HIV infection in half, or something like that. That is a significant benefit, and worth the risks of performing the operation.

You're suggesting that it might be ok to circumcise children based on the assumption that they're going to have unsafe sex with an HIV+ partner. Not only is that an unreasonable assumption, but it's questionable that circumcision actually protects against HIV anyway.

In Europe, almost no-one circumcises unless they're Muslim or Jewish, and they have significantly lower rates of almost all STI's including HIV.

Even in Africa, there are six countries where men are *more* likely to be HIV+ if they've been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms. . 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".

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, and this 1993 study found that "partner circumcision" was "strongly associated with HIV-1 infection [in women] even when simultaneously controlling for other covariates."

ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost lives, not save them.

Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia, and then start promoting that.

 

[VA Hopeful Dr]

Who cares. I don't think the hippo-oath is a great algorithm, anyway.

Agreed, that's why lots of places don't really even use it anymore.

 

[tibor75]

Preventative mastectomies aren't performed without the patient's consent.

Children cannot give consent. Their parents give consent for them. A parent giving consent for a child is THE SAME THING as an adult giving consent for himself.

The argument about it being cosmetic has no bearing on the consent issue. Based on that logic, a parent should never be allowed to give consent for a purely cosmetic surgery on their child, whether to "fix" a birth defect or due to some accident.

 

[Sol Rosenberg]

Children cannot give consent. Their parents give consent for them. A parent giving consent for a child is THE SAME THING as an adult giving consent for himself.

The argument about it being cosmetic has no bearing on the consent issue. Based on that logic, a parent should never be allowed to give consent for a purely cosmetic surgery on their child, whether to "fix" a birth defect or due to some accident.

Your point would be a valid one if we didn't already place limits on what cosmetic procedures that parents could have done on their children. The most relevant one here is female circumcision, which is a purely cosmetic procedure (like male circumcision) that is not performed because of (until recently) guidelines set forth by professional organizations and, I believe, by law. Therefore, it is not unequivocally true that parents are able to give consent for their minor children as you say....unless you believe that these laws/guidelines are misguided and that parents should be able to circumcise their daughters.

 

[Eta Carinae]

Is this procedure a justified one according to the regulatory powers here in the US?

In answer to the question posed by the OP, " Is circumcision in line with the Hippocratic Oath?", I venture, no.

Neither is any form of open surgery by the way.

 

[ml66uk]

The Dutch Medical Association (the KNMG) has released a new position statement on "Non-therapeutic circumcision of male minors". It's quite long, but this is the summary:

There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene. Partly in the light of the complications which can arise during or after circumcision, circumcision is not justifiable except on medical/therapeutic grounds. Insofar as there are medical benefits, such as a possibly reduced risk of HIV infection, it is reasonable to put off circumcision until the age at which such a risk is relevant and the boy himself can decide about the intervention, or can opt for any available alternatives.

Contrary to what is often thought, circumcision entails the risk of medical and psychological complications. The most common complications are bleeding, infections, meatus stenosis (narrowing of the urethra) and panic attacks. Partial or complete penis amputations as a result of complications following circumcisions have also been reported, as have psychological problems as a result of the circumcision.

Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations.

Non-therapeutic circumcision of male minors conflicts with the child’s right to autonomy and physical integrity.

The KNMG calls on (referring) doctors to explicitly inform parents/carers who are considering non-therapeutic circumcision for male minors of the risk of complications and the lack of convincing medical benefits. The fact that this is a medically non-essential intervention with a real risk of complications makes the quality of this advice particularly important. The doctor must then record the informed consent in the medical file.

The KNMG respects the deep religious, symbolic and cultural feelings that surround the practice of nontherapeutic circumcision. The KNMG calls for a dialogue between doctors’ organisations, experts and the religious groups concerned in order to put the issue of non-therapeutic circumcision of male minors on the agenda and ultimately restrict it as much as possible.

There are good reasons for a legal prohibition of non-therapeutic circumcision of male minors, as exists for female genital mutilation. However, the KNMG fears that a legal prohibition would result in the intervention being performed by non-medically qualified individuals in circumstances in which the quality of the intervention could not be sufficiently guaranteed. This could lead to more serious complications than is currently the case.

This viewpoint by the KNMG is jointly endorsed by the following scientific associations:
The Netherlands Society of General Practitioners
The Netherlands Society of Youth Healthcare Physicians
The Netherlands Association of Paediatric Surgeons
The Netherlands Association of Plastic Surgeons
The Netherlands Association for Paediatric Medicine
The Netherlands Urology Association
The Netherlands Surgeons’ Association

 

[morning]

The HIV thing is the linchpin of this whole argument. The way I see it, the risks and drawbacks of circumcision are low. However, the benefits have to exceed these drawbacks or the procedure is not medically useful. Penile cancer is so rare it's not worth considering, and UTIs are treatable. That leaves HIV.

If those numbers above from Africa are correct, then the protective benefits of circumcision against HIV are not supported by evidence, and a ban should be instated against it. It is against the Hippocratic Oath to perform a procedure that has no medical benefits but does involve harm.

On the other hand, some studies show that circumcision cuts the risk of HIV infection in half, or something like that. That is a significant benefit, and worth the risks of performing the operation.

The problem with the HIV protection/circumcision link in Africa is that those guys are given extensive sex ed and told that having sex after the circumcision is extremely risky due to the newly sensitive area and that they MUST use a condom to prevent infection via the penis. I'm pretty sure if you went around counseling every guy in a region about safe sex, provide free condoms and show them how to use them, HIV rates will drop without circumcision.

I'm very, very anti-circumcision, whether male or female, and I don't believe that even a reduced risk of HIV warrants it. There's a lot of things we could remove to prevent future disease, and the foreskin should not be singled out as the acceptable one. I mean, removing your daughter's breasts will probably prevent breast cancer and won't result in loss of sexual feeling, but we don't advocate that for little girls.

Children cannot give consent. Their parents give consent for them. A parent giving consent for a child is THE SAME THING as an adult giving consent for himself.

The argument about it being cosmetic has no bearing on the consent issue. Based on that logic, a parent should never be allowed to give consent for a purely cosmetic surgery on their child, whether to "fix" a birth defect or due to some accident.

Parents are NOT given universal free reign to do whatever they want with their child's bodies.

Google "pillow angel"

 

[deleted50478]

How about- I don't care what the disease transmission difference is or if some people make a big deal out of a nothing-procedure.
Foreskin is nasty and my son is going to get cut. He and his future girlfriends/wife will appreciate it.
We'll also remove or trim any other sick growths- skin tags, excessive finger nails, warts, etc. Appearance is important and if you act like it isn't you are kidding yourself.

 

[ml66uk]

How about- I don't care what the disease transmission difference is or if some people make a big deal out of a nothing-procedure.
Foreskin is nasty and my son is going to get cut. He and his future girlfriends/wife will appreciate it.
We'll also remove or trim any other sick growths- skin tags, excessive finger nails, warts, etc. Appearance is important and if you act like it isn't you are kidding yourself.

So you're prepared to have cosmetic surgery to remove parts of your son's genitals. How about any daughters? There are plenty of people in the world who find intact female genitalia unpleasant. Should they have the right to have their daughters' labia minora, prepuce or external clitoris removed if they consider them to be "sick growths".

And how do you know what his future girlfriends/wife will prefer? I can put you in touch with several women who resent their parents-in law for having had their husbands circumcised.

How about letting your son decide? It's his body.

 

[cpants]

You're suggesting that it might be ok to circumcise children based on the assumption that they're going to have unsafe sex with an HIV+ partner. Not only is that an unreasonable assumption, but it's questionable that circumcision actually protects against HIV anyway.

No it's not questionable. It's fact. At least three large randomized controlled trials have shown that HIV transmission is decreased in circumcised males (by around 60%). It is based upon these studies that the WHO recommends routine circumcision as part of HIV prevention strategy in endemic areas.

 

[ml66uk]

You're suggesting that it might be ok to circumcise children based on the assumption that they're going to have unsafe sex with an HIV+ partner. Not only is that an unreasonable assumption, but it's questionable that circumcision actually protects against HIV anyway.

No it's not questionable. It's fact. At least three large randomized controlled trials have shown that HIV transmission is decreased in circumcised males (by around 60%). It is based upon these studies that the WHO recommends routine circumcision as part of HIV prevention strategy in endemic areas.

I went on to say the following:

In Europe, almost no-one circumcises unless they're Muslim or Jewish, and they have significantly lower rates of almost all STI's including HIV.

Even in Africa, there are six countries where men are *more* likely to be HIV+ if they've been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms. . 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".

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, and this 1993 study found that "partner circumcision" was "strongly associated with HIV-1 infection [in women] even when simultaneously controlling for other covariates."

ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost lives, not save them.

Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia, and then start promoting that.

See also morning's comments from yesterday.

 

[morning]

How about- I don't care what the disease transmission difference is or if some people make a big deal out of a nothing-procedure.
Foreskin is nasty and my son is going to get cut. He and his future girlfriends/wife will appreciate it.
We'll also remove or trim any other sick growths- skin tags, excessive finger nails, warts, etc. Appearance is important and if you act like it isn't you are kidding yourself.

If his future wife/girlfriend (what are you going to do if your son is gay??) prefers a circumcised man, can't your son make the decision then?

 

[cpants]

I went on to say the following:



See also morning's comments from yesterday.

I didn't go on to quote the rest of your post because it was largely irrelevant. A comparison of the rate of circumcision and the HIV prevalence in Europe and Africa tells you nothing. I could make a similar comparison and state that white skin is protective against HIV.

As far as the African studies go, there are also many cross-sectional studies which have suggested a protective effect of circumcision. However, a cross sectional study is a poor indicator of the protective effects of circumcision, since it only provides a snapshot in time and cannot tell you whether or not the men contracted HIV before or after circumcision. In fact, men may have been infected with HIV in the course of their circumcision due to nonsterile instruments. Your prevalence statistics are especially irrelevant when you are comparing them to several large, well-designed, well-controlled, blinded, randomized studies which show circumcision to be effective at preventing transmission.

Here are the three studies to which I'm referring:

Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. (2005) Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLoS Med 2(11): e298. doi:10.1371/journal.pmed.0020298 (Link)

Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; 369: 643-656. (Link)

Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007; 369: 657-666. (Link)

All of these studies have been extensively peer-reviewed, including a Cochrane review which analyzed their data and agreed with their conclusions. The jury really isn't still out on this. Circumcision prevents transmission of HIV to heterosexual men. Based on this data the WHO recommends circumcision as part of their HIV prevention strategy. This is in combination with massive education efforts and condom/abstinence/monogamy promotion.

The problem with the HIV protection/circumcision link in Africa is that those guys are given extensive sex ed and told that having sex after the circumcision is extremely risky due to the newly sensitive area and that they MUST use a condom to prevent infection via the penis. I'm pretty sure if you went around counseling every guy in a region about safe sex, provide free condoms and show them how to use them, HIV rates will drop without circumcision.

First of all, in these studies, both the control and intervention populations were given regular and extensive sex ed and free condoms and were followed regularly with medical care and treatment for STD's. Education was provided by blinded professionals who didn't know which group the men were in. So essentially they received the same education and access to condoms and medical care, except that the circ-ed men were told about the added risk of having unprotected sex within 30 days of circumcision. Yet the circumcision group saw 60% less seroconversion over 2 years compared to the control group. You attribute that risk reduction to the added postoperative education that the circumcised men received?

I find that extremely unlikely, but even if we assume it's true, so what? All that would mean is that circumcision with appropriate postop education is 60% effective.

By the way, these same populations were studied regarding complications and various measures of sexual satisfaction. There were very few complications and no significant differences between control and intervention populations regarding satisfaction two years out.

 

[ml66uk]

I didn't go on to quote the rest of your post because it was largely irrelevant.

...

Your prevalence statistics are especially irrelevant when you are comparing them to several large, well-designed, well-controlled, blinded, randomized studies which show circumcision to be effective at preventing transmission.

Your RCT's are especially irrelevant when you are comparing them to the real world, where there are six African countries where men are more likely to be HIV+ if they are circumcised? What about the RCT into male-to-female transmission, which showed a 54% higher rate in the circumcised group, or the other study which found that "partner circumcision" was "strongly associated with HIV-1 infection [in women] even when simultaneously controlling for other covariates."

How can you deem this "irrelevant"?

You're right that some men are infected by the operation itself, but if circumcision really provided significant protection against HIV, then there shouldn't be any countries where men are more likely to be HIV+ if they've been circumcised. Remember that medicalized circumcision isn't going to replace traditional tribal circumcision btw. The people that practise that are almost all going to get circumcised their way anyway, and some of them will assume they are immune from AIDS.

Men that are circumcised for religious reasons are likely to have fewer sexual partners btw, so you'd actually expect circumcised men to have lower rates of HIV for behavioural reasons, rather than anything to do with the circumcision itself.

See also http://www.iasociety.org/Default.aspx?pageId=11&abstractId=2197431
"Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs."

http://apha.confex.com/apha/134am/techprogram/paper_136814.htm
"Results: … No consistent relationship between male circumcision and HIV risk was observed in most countries."

I'm well aware of the studies you're referring to (and they're not blinded btw, as that's sadly not possible). There are good summaries of criticism of them here: http://www.annfammed.org/cgi/eletters/8/1/64#11574
and here: http://www.circumcisionandhiv.com/files/mcnotavaccine.pdf
"Rather than complementing ABC programs, promoting circumcision will undermine the ABC approach by diverting funds and encouraging risk compensation behavior, ultimately leading to an increase in HIV infections"


There are some very influential people in the USA looking for any way of fighting AIDS which isn't condoms, and I think they care more about promoting their religious agenda than they do about fighting AIDS. I know there are religious groups on the ground (Catholics included) who are actively promoting condom use, but there are people high up who are totally against this. Until recently, a third of the entire PEPFAR budget had to be spent on abstinence programmes, probably the least effective way of countering AIDS. Male circumcision appeals to Americans anyway, as most American men are circumcised themselves (circumcision used to be common in Canada, the UK, Australia, and New Zealand, but is now quite rare - in mainland Europe, it's almost exclusively a Muslim and Jewish practice).

I'm not the only person questioning the promotion of circumcision btw. The French AIDS council and the South African Medical Association have also spoken out against it.

Consider this, and let me know how it can make any sense:
Rwanda has one doctor for every 50,000 people, and one nurse for every 3,900 people.
The HIV rate in circumcised Rwandan men is 3.5%, but 2.1% in intact men.
Rwanda started a mass circumcision programme last year.

Believe me, if I thought circumcision really worked against AIDS in areas with high rates of HIV (or condoms didn't exist) I'd support it, but the evidence doesn't even come close to suggesting that. The evidence strongly suggests that mass circumcision programmes will make things worse. Remember that 15% of South African adults believe that circumcised men can't get HIV, which suggests the likelihood of massive risk compensation.

ABC works against HIV. Circumcision appears not to. Remember that circumcision won't make any difference unless someone is having unsafe sex with an HIV+ partner. Condoms are vastly more effective against HIV transmission than anything that has ever been claimed for male circumcision.

Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia, and then start promoting that.

 

[FutureDoc4]

Your RCT's are especially irrelevant when you are comparing them to the real world, where there are six African countries where men are more likely to be HIV+ if they are circumcised? What about the RCT into male-to-female transmission, which showed a 54% higher rate in the circumcised group, or the other study which found that "partner circumcision" was "strongly associated with HIV-1 infection [in women] even when simultaneously controlling for other covariates."

How can you deem this "irrelevant"?

You're right that some men are infected by the operation itself, but if circumcision really provided significant protection against HIV, then there shouldn't be any countries where men are more likely to be HIV+ if they've been circumcised. Remember that medicalized circumcision isn't going to replace traditional tribal circumcision btw. The people that practise that are almost all going to get circumcised their way anyway, and some of them will assume they are immune from AIDS.

Men that are circumcised for religious reasons are likely to have fewer sexual partners btw, so you'd actually expect circumcised men to have lower rates of HIV for behavioural reasons, rather than anything to do with the circumcision itself.

See also http://www.iasociety.org/Default.aspx?pageId=11&abstractId=2197431
"Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs."

http://apha.confex.com/apha/134am/techprogram/paper_136814.htm
"Results: … No consistent relationship between male circumcision and HIV risk was observed in most countries."

I'm well aware of the studies you're referring to (and they're not blinded btw, as that's sadly not possible). There are good summaries of criticism of them here: http://www.annfammed.org/cgi/eletters/8/1/64#11574
and here: http://www.circumcisionandhiv.com/files/mcnotavaccine.pdf
"Rather than complementing ABC programs, promoting circumcision will undermine the ABC approach by diverting funds and encouraging risk compensation behavior, ultimately leading to an increase in HIV infections"


There are some very influential people in the USA looking for any way of fighting AIDS which isn't condoms, and I think they care more about promoting their religious agenda than they do about fighting AIDS. I know there are religious groups on the ground (Catholics included) who are actively promoting condom use, but there are people high up who are totally against this. Until recently, a third of the entire PEPFAR budget had to be spent on abstinence programmes, probably the least effective way of countering AIDS. Male circumcision appeals to Americans anyway, as most American men are circumcised themselves (circumcision used to be common in Canada, the UK, Australia, and New Zealand, but is now quite rare - in mainland Europe, it's almost exclusively a Muslim and Jewish practice).

I'm not the only person questioning the promotion of circumcision btw. The French AIDS council and the South African Medical Association have also spoken out against it.

Consider this, and let me know how it can make any sense:
Rwanda has one doctor for every 50,000 people, and one nurse for every 3,900 people.
The HIV rate in circumcised Rwandan men is 3.5%, but 2.1% in intact men.
Rwanda started a mass circumcision programme last year.

Believe me, if I thought circumcision really worked against AIDS in areas with high rates of HIV (or condoms didn't exist) I'd support it, but the evidence doesn't even come close to suggesting that. The evidence strongly suggests that mass circumcision programmes will make things worse. Remember that 15% of South African adults believe that circumcised men can't get HIV, which suggests the likelihood of massive risk compensation.

ABC works against HIV. Circumcision appears not to. Remember that circumcision won't make any difference unless someone is having unsafe sex with an HIV+ partner. Condoms are vastly more effective against HIV transmission than anything that has ever been claimed for male circumcision.

Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia, and then start promoting that.

Cpants really put you in your place. So, I so no reason to further argue the point. No one here is suggestion circumcision can replace the use ofa condom (though that's what you seem to imply with anyone who supports circumcision)--many here would advocate that circumcision in conjunction with condom use and education would be the most effective.

You linked studies are just retrospective or cross sectional "BS" that does not really back up your claims so I won't address them,

Finally, you are absolutely allowed to have your own believes but the fact that you have the "balls" to constantly compare female mutilation or the premeptive removal of breast tissue to male circumsion is terrible. These are extremely traumatic events for women to go through with life long changes that I'm sure you cannot begin to understand. It in no way can compare to a male circumcision. Grow up.

 

[ml66uk]

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Cpants really put you in your place. So, I so no reason to further argue the point. No one here is suggestion circumcision can replace the use ofa condom (though that's what you seem to imply with anyone who supports circumcision)--many here would advocate that circumcision in conjunction with condom use and education would be the most effective.

You linked studies are just retrospective or cross sectional "BS" that does not really back up your claims so I won't address them,

Finally, you are absolutely allowed to have your own believes but the fact that you have the "balls" to constantly compare female mutilation or the premeptive removal of breast tissue to male circumsion is terrible. These are extremely traumatic events for women to go through with life long changes that I'm sure you cannot begin to understand. It in no way can compare to a male circumcision. Grow up.

Yeah, he really put the South African Medical Association and the French Aids Council in their place too. I'm guessing you're circumcised yourself, or else you might think I'd put cpants in his place.

Remember that no fewer than 15% of South Africans think that circumcision makes them immune from HIV, so what are the chances of them continuing with the same rate of condom use?

As the French AIDS Council put it:
"Even though the WHO insists on the idea that, beyond male circumcision, the use of other forms of prevention remains essential, it is very likely that people who mistakenly believe themselves to be adequately protected will no longer use condoms."

and as that South African paper put it:
"Those promoting circumcision argue that circumcision is an additional tool that will ultimately reduce infections more than just relying on condoms, monogamy and abstinence. However, African males are already lining up to be circumcised, thinking they will no longer need to use condoms. Rather than complementing ABC programs, promoting circumcision will undermine the ABC approach by diverting funds and encouraging risk compensation behavior, ultimately leading to an increase in HIV infections."

It's only a cultural thing that you think there is something fundamentally different between cutting parts off female genitals and cutting parts off female genitals. The people that cut girls certainly don't see a difference. It's generally not men, but circumcised women who are the most vociferous proponents of female circumcision. There are intelligent, educated, articulate women who will passionately defend it, and as well as using the exact same reasons that are used to defend male circumcision in the US, they will also point to male circumcision itself, as well as labiaplasty and breast operations, as evidence of western hypocrisy regarding female circumcision.

Are you aware that the USA also used to practise female circumcision? Fortunately, it never caught on the same way as male circumcision, but there are middle-aged white US American women walking round today with no external clitoris because it was removed. Some of them don't even realise what has been done to them. There are frequent references to the practice in medical literature up until at least 1959. Most of them point out the similarity with male circumcision, and suggest that it should be performed for the same reasons. Blue Cross/Blue Shield had a code for clitoridectomy till 1977.

Female Circumcision, Indications and a New Technique
W. G. Rathmann, MD, Inglewood, California, September, 1959
"The value of this procedure [female circumcision] in improving function has been recognized by various cultures for the past 3,500 years."

Circumcision of the Female
C. F. McDonald, MD, Milwaukee, Wisconsin, September, 1958
"If the male needs circumcision for cleanliness and hygiene, why not the female?"

I don't think you'd argue that the minor forms of female circ do less damage than regular male circ. The example I quoted was this:
"Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia, and then start promoting that."
If someone put a gun to my head, and said I had to choose between my son being circumcised, or one of my daughters having her inner labia removed, then it would be my daughter that got circumcised, as that is less damage.

Some forms of female "circumcision" are the tiniest of nicks or incisions. In this Malaysian blog , a woman is proudly talking about how her daughter had been circumcised, and there is a picture of the tiniest spec of clitoris that has been removed (5th and 6th pictures down).

Just six weeks ago, the AAP released a statement (since retracted) which appears to condone lesser versions of female circumcision/FGM/FGC:

"Most forms of FGC are decidedly harmful, and pediatricians should decline to perform them, even in the absence of any legal constraints. However, the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting. There is reason to believe that offering such a compromise may build trust between hospitals and immigrant communities, save some girls from undergoing disfiguring and lifethreatening procedures in their native countries, and play a role in the eventual eradication of FGC. It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm."

They were heavily criticised and retracted that statement, even though the form of FGC they were talking about does demonstrably less harm than the usual form of male circumcision.

Do you know any women that have been circumcised btw? All the ones I know personally are against male circumcision as well as female circumcision.

 

[cpants]

To respond to your claims regarding the French Aids Council and the South African Medical Association, neither group claims that circumcision is not protective against HIV. The French group accepts the data, but believes that promoting circumcision to prevent HIV is not a good prevention strategy, which is a different thing. I was unable to find a statement from the SAMA criticizing circumcision. Please link if you have it. In fact, it is the policy of South Africa, the nation, to promote medical circumcision as a prevention strategy.

You are the one who claimed that circumcision does not prevent HIV transmission. This claim has been shown to be false by peer-reviewed RCT's as outlined above. If you are against circumcision for prevention due to philosophical reasons or fears of abandonment of more effective prevention strategies, I can respect that. Certainly reliable condom use or abstinence are the gold standards for prevention. In the real world, many do not use condoms, even knowing the risks and benefits. Widespread circumcision could help to reduce transmission in the face of unreliable condom use.

Your claims based on cross sectional studies that circumcision is not protective are false, and no legitimate medical society that I know of agrees with them.