Circumcision

[bluebell]

Just now, Scott Lloyd said:

Have you examined the DOC statement?

Yes, I have.

[pogi]

51 minutes ago, bluebell said:

Have studies done by the World Health Organization and the CDC agreed with the AAP, that the benefit was greater than the risk?  From what I've read, the CDC said (in 2017) that it is measurable and that data shows that the benefit is greater than the risk by 100:1.

They are all looking at the same studies, primarily from Sub-Saharan Africa which pose the same problematic limits that the AAP now concedes are impossible to measure risk vs benefit from. 

Think about this, if the medical benefit was truly greater than the risk by 100:1 why would they concede that the benefit is not strong enough to recommend routine circumcision of all male children.  That message is conflicting to say the least.

Scott is correct in that the draft has not yet been approved, and in fact has been highly criticized by other medical organizations.

Quote

 

During the public commentary following the release, the CDC logged more than 3200 comments on the draft, 97% of them opposed. To date, the draft has not been approved.

https://www.frontiersin.org/articles/10.3389/fped.2015.00018/full

 

 

For other good critiques, see:

Public comment on the CDC male circumcision recommendations of 2014. Doctors Opposing Circumcision website. 2015 January 7.

Earp BD. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Front Pediatr. 2015;3:18.

Van Howe RS. A CDC-requested, evidence-based critique of the Centers for Disease Control and Prevention 2014 draft on male circumcision: how ideology and selective science lead to superficial, culturally-biased recommendations by the CDC. Academia website. January 2015.

Adler P. The draft CDC circumcision recommendations: Medical, ethical, legal, and procedural concerns. Int J Child Rights. 2016. [Forthcoming.]

Frisch M, Earp BD. Circumcision of male infants and children as a public health measure in developed countries: a critical assessment of recent evidence. Glob Public Health. 2016 May 19:1-16. [Epub ahead of print] PMID: 27194404

[Scott Lloyd]

12 minutes ago, pogi said:

They are all looking at the same studies, primarily from Sub-Saharan Africa which pose the same problematic limits that the AAP now concedes are impossible to measure risk vs benefit from. 

Think about this, if the medical benefit was truly greater than the risk by 100:1 why would they concede that the benefit is not strong enough to recommend routine circumcision of all male children.  That message is conflicting to say the least.

Scott is correct in that the draft has not yet been approved, and in fact has been highly criticized by other medical organizations.

 

For other good critiques, see:

Public comment on the CDC male circumcision recommendations of 2014. Doctors Opposing Circumcision website. 2015 January 7.

Earp BD. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Front Pediatr. 2015;3:18.

Van Howe RS. A CDC-requested, evidence-based critique of the Centers for Disease Control and Prevention 2014 draft on male circumcision: how ideology and selective science lead to superficial, culturally-biased recommendations by the CDC. Academia website. January 2015.

Adler P. The draft CDC circumcision recommendations: Medical, ethical, legal, and procedural concerns. Int J Child Rights. 2016. [Forthcoming.]

Frisch M, Earp BD. Circumcision of male infants and children as a public health measure in developed countries: a critical assessment of recent evidence. Glob Public Health. 2016 May 19:1-16. [Epub ahead of print] PMID: 27194404

I just examined the AAP position on routine immunization. They are unequivocal in endorsing it. Not so with circumcision. I find that very telling. 

[bluebell]

17 minutes ago, pogi said:

They are all looking at the same studies, primarily from Sub-Saharan Africa which pose the same problematic limits that the AAP now concedes are impossible to measure risk vs benefit from. 

Think about this, if the medical benefit was truly greater than the risk by 100:1 why would they concede that the benefit is not strong enough to recommend routine circumcision of all male children.  That message is conflicting to say the least.

Scott is correct in that the draft has not yet been approved, and in fact has been highly criticized by other medical organizations.

 

For other good critiques, see:

Public comment on the CDC male circumcision recommendations of 2014. Doctors Opposing Circumcision website. 2015 January 7.

Earp BD. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Front Pediatr. 2015;3:18.

Van Howe RS. A CDC-requested, evidence-based critique of the Centers for Disease Control and Prevention 2014 draft on male circumcision: how ideology and selective science lead to superficial, culturally-biased recommendations by the CDC. Academia website. January 2015.

Adler P. The draft CDC circumcision recommendations: Medical, ethical, legal, and procedural concerns. Int J Child Rights. 2016. [Forthcoming.]

Frisch M, Earp BD. Circumcision of male infants and children as a public health measure in developed countries: a critical assessment of recent evidence. Glob Public Health. 2016 May 19:1-16. [Epub ahead of print] PMID: 27194404

The article I linked to was from 2017 and I see that most of these critiques are from before.  Are there any good critiques of the 2017 CDC recommendation?  

This is one of the references for the CDC, that discusses where some of the benefits/risk data came from.  Are you saying that the 140 journal articles used to attain the data was from Sub-Saharan Africa?  (Asking to make sure I understand what you are saying).

This is what the CDC article says about the use of Sub-Saharan African data-

The evidence shows the CDC is correct in concluding that findings from sub-Saharan Africa concerning circumcision of adult males for protection against heterosexually-acquired HIV and certain other STIs also apply to men in the United States. The findings also apply to boys when they grow up. Moreover, the cumulative lifetime benefit is greatest if circumcision is performed early in infancy since early infant circumcision is simpler, more convenient, and carries lower risk than when performed later, and circumcision confers immediate protection against urinary tract infections, phimosis, balanitis, and, when older, specific STIs and genital cancers. MC also protects the female partners, as confirmed in randomized controlled trials.

Arguments by MC opponents disputing the validity of the large African RCTs showing that MC provides substantial protection against heterosexually-acquired HIV infection have been exposed as fallacious.60–72Frisch and Earp instead question the CDC for applying the African trial findings to the United States. Although the proportion of HIV infections acquired heterosexually in the United States is far less than in sub-Saharan Africa, in some U.S. localities heterosexually-acquired HIV incidence is high. Furthermore, 2014 CDC figures show 24% of new HIV infections in the United States involved heterosexual contact.73It was estimated that if all boys in the 2011 annual U.S. male birth cohort were circumcised, 5,530 HIV infections would be prevented over their lifetime.74 Lifetime risk of HIV diagnosis in heterosexual males in the United States is currently 1 in 524.75 The increase in HIV infections in African-Americans, in particular, has been faster than in all other groups.76 Modeling by the CDC found MC could reduce heterosexual HIV risk by approximately 21% in African-Americans and by approximately 12% in Hispanics, and costs would be saved in each group.77 Actual MC-related risk reduction in heterosexual African-American men with known HIV exposure was 51%.

Comparison of HIV and MC prevalence in high-income countries also suggest MC has a protective effect, providing further support to the applicability of the African MC trials to the United States and other high-income countries. For example, HIV prevalence in the mostly uncircumcised populations of France and the Netherlands was much higher than in Israel where almost all men are circumcised, despite all other risk factors being comparable.79 In Australia, where MC is less common than in the United States and Israel, the number of HIV infections related to heterosexual contact has increased by 28% over the past decade, representing 25% of new diagnoses in 2013, 29% being in Australian-born patients.80 In Canada, where infant MC prevalence has, like in Australia, declined in recent decades, 9.5% of new HIV infections involve men infected heterosexually.81

As well as substantial protection against HIV, data from the African RCTs reinforced the ability of MC to protect against several other STIs in heterosexual males,10,11,13,16,71,82–90 as well as their female sex partners10,91–95 and among MSM who are insertive-only.96–100 With regard to MSM in particular, a Cochrane analysis of MC and HIV prevalence among MSM found results were statistically significant among 3,465 men in 7 studies reporting an insertive role (odds ratio, 0.27; 95% confidence interval, 0.17 to 0.44; I2=0%), but were not significant among 1,792 men in 3 studies reporting a receptive role (odds ratio, 1.20; 95% confidence interval, 0.63 to 2.29; I2 = 0%).”1,80 MC also reduces the risk of potentially fatal penile, prostate, and cervical cancer.10,16–18,101–104 Partial protection against prostate cancer incidence was seen in U.S.101 and Canadian103 studies and in a meta-analysis of all studies,104 the protective effect being strongest (36%101 and 60%103) in North American men of African heritage.

Edited January 17, 2019 by bluebell

[Hamba Tuhan]

40 minutes ago, pogi said:

They are all looking at the same studies, primarily from Sub-Saharan Africa which pose the same problematic limits that the AAP now concedes are impossible to measure risk vs benefit from. 

On this topic, have you already read Gregory J. Boyle and George Hill, 'Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: methodological, ethical and legal concerns', Journal of Law and Medicine 19:2 (Dec. 2011), pp. 316--34?

Here's the abstract:

Quote

In 2007, WHO/UNAIDS recommended male circumcision as an HIV-preventive measure based on three sub-Saharan African randomised clinical trials (RCTs) into female-to-male sexual transmission. A related RCT investigated male-to-female transmission. However, the trials were compromised by inadequate equipoise; selection bias; inadequate blinding; problematic randomisation; trials stopped early with exaggerated treatment effects; and not investigating non-sexual transmission. Several questions remain unanswered. Why were the trials carried out in countries where more intact men were HIV-positive than in those where more circumcised men were HIV-positive? Why were men sampled from specific ethnic subgroups? Why were so many participants lost to follow-up? Why did men in the male circumcision groups receive additional counselling on safe sex practices? While the absolute reduction in HIV transmission associated with male circumcision across the three female-to-male trials was only about 1.3%, relative reduction was reported as 60%, but, after correction for lead-time bias, averaged 49%. In the Kenyan trial, male circumcision appears to have been associated with four new incident infections. In the Ugandan male-to- female trial, there appears to have been a 61% relative increase in HIV infection among female partners of HIV-positive circumcised men. Since male circumcision diverts resources from known preventive measures and increases risk-taking behaviours, any long-term benefit in reducing HIV transmission remains uncertain.

I think what is perhaps most troubling in the research is the acknowledged fact that circumcision significantly increased the incidence of HIV transmission from males to females. So even if the already suspect medical benefits to men could be proven -- which they have not been, as this piece and the list of studies in its appendix make clear -- the victims, once again, would be the women.

Edited January 17, 2019 by Hamba Tuhan

[Hamba Tuhan]

1 hour ago, bluebell said:

One of the reasons that I circumcised my boys was because of my mother's experience (as a nurse) caring for older males who had to be circumcised due to health problems and how horrible the process and recovery was for them.

Just want to add once again that I live in a nation that doesn't use circumcision as a medical treatment for any age group of males.

Literally every single 'health problem' that might result in a circumcision in the US has a non-surgical fix that is used in other places.

[pogi]

1 hour ago, bluebell said:

Not at all.  One of the reasons that I circumcised my boys was because of my mother's experience (as a nurse) caring for older males who had to be circumcised due to health problems and how horrible the process and recovery was for them.  That, coupled with the medical information that I had back then and have recently read, cause me to feel good about my decision.  

I worked as a CNA in a long-term care facility and also as a home health and hospice nurse - so I have a lot of first hand geriatric experience.  In all the years that I have worked in geriatrics, I have never ever, ever seen or heard of a geriatric patient requiring circumcision due to health problems.   Surgery of any kind on geriatric patients is avoided at all costs due to their delayed and often poor recovery, but especially on an infected penis.   The only time it ever became an issue is when 1) the patient is incapacitated to care for himself, mentally or physically, AND 2) the CNA did not use proper hygiene techniques.  The only time circumcision would be indicated is if the patient was in decent health (that's questionable if he can't care for himself) and had repeated infections due to neglect by care staff.  That scenario would be extremely rare.  To be honest, I saw similar hygiene complications with other skin folds - under the breasts and belly folds, etc. Not a big enough deal to cut of their breasts as a prophylactic measure though.  The fact is, the vast majority of the population never require supportive hygiene care in long term care facilities and most often can care for themselves. The rare exceptions certainly do not justify routine circumcision as a preventive measure. Even the AAP statement clearly does NOT support or attempt to justify routine circumcision for the medical reasons you mentioned.  In fact, they don't justify or recommend routine circumcision for ANY medical reason.  

Furthermore, they admit that the risk vs bennefit is unmeasurable, so how can you rationalize any decision to circumcise on medical grounds?  Their statement is intended to act as an ethical buffer to allow parents to make decisions based purely on social/cultural reasons (highly questionably) rather than being an attempt to justify the practice on purely medical grounds.

1 hour ago, bluebell said:

But to answer your question on culture and ethics, I think you would have to prove that it's unethical for a parent to make medical decisions for their children based on culture.  I don't necessarily disagree with that, but neither do I believe it's a given like you do.

Clearly there are cultural medical practices that are unethical, so I don't understand the need to establish that any further.

1 hour ago, bluebell said:

Did DAC have something to say about the 2017 CDC report.  I think that would be interesting to read.

It is in the same criticism of the AAP, towards the bottom.  Highly recommend reading the other linked reviews from that link:

https://www.doctorsopposingcircumcision.org/for-professionals/medical-organization-statements/#anchor-04

Edited to note that you are referencing a different CDC report.  Let me read it first before I comment. 

Edited January 18, 2019 by pogi

[bluebell]

19 minutes ago, pogi said:

I worked as a CNA in a long-term care facility and also as a home health and hospice nurse - so I have a lot of first hand geriatric experience.  In all the years that I have worked in geriatrics, I have never ever, ever seen or heard of a geriatric patient requiring circumcision due to health problems.   Surgery of any kind on geriatric patients is avoided at all costs due to their delayed and often poor recovery, but especially on an infected penis.   The only time it ever became an issue is when 1) the patient is incapacitated to care for himself, mentally or physically, AND 2) the CNA did not use proper hygiene techniques.  The only time circumcision would be indicated is if the patient was in decent health (that's questionable if he can't care for himself) and had repeated infections due to neglect by care staff.  That scenario would be extremely rare.  To be honest, I saw similar hygiene complications with other skin folds - under the breasts and belly folds, etc. Not a big enough deal to cut of their breasts as a prophylactic measure though.  The fact is, the vast majority of the population never require supportive hygiene care in long term care facilities and most often can care for themselves.

I'm not sure what you want me to say?  That my mother (and her patients, which I knew personally) were lying?  That the doctors who ordered the procedures were incompetent?  Not being snarky, I just really don't know how you are expecting your experience to invalidate mine?  I understand that my experience doesn't match your's but my mother has been a nurse for 30 years, has worked in med surge, home health/hospice/nursing home, the ER, ICU for head injuries (I don't remember what that label was), urgent care, and now triages for a doctor.  The two patients I am speaking specifically about were a home health patients.  They became good friends with my mother and she had them over for dinner with the family and and other events.  

Quote

Furthermore, they admit that the risk vs bennefit is unmeasurable, so how can you rationalize any decision to circumcise on medical grounds? 

Based on the CDC recommendations.

Quote

Clearly there are cultural medical practices that are unethical, so I don't understand the need to establish that any further.

Yes, but you haven't established that all cultural medical practices are unethical, so the existence of some does not establish anything in regards to a specific practice.

[Hamba Tuhan]

8 minutes ago, bluebell said:

That the doctors who ordered the procedures were incompetent?

I think culturally bound would be a better descriptor than incompetent.

[bluebell]

1 minute ago, Hamba Tuhan said:

I think culturally bound would be a better descriptor than incompetent.

What culture binds doctors to perform circumcision on geriatric patients who are dealing with severe complications concerning their foreskins?  As far as I know, America doesn't have a culture of adult circumcision.

[bluebell]

45 minutes ago, Hamba Tuhan said:

Just want to add once again that I live in a nation that doesn't use circumcision as a medical treatment for any age group of males.

Literally every single 'health problem' that might result in a circumcision in the US has a non-surgical fix that is used in other places.

Ok.

[pogi]

57 minutes ago, bluebell said:

I'm not sure what you want me to say?  That my mother (and her patients, which I knew personally) were lying?  That the doctors who ordered the procedures were incompetent?  Not being snarky, I just really don't know how you are expecting your experience to invalidate mine?  I understand that my experience doesn't match your's but my mother has been a nurse for 30 years, has worked in med surge, home health/hospice/nursing home, the ER, ICU for head injuries (I don't remember what that label was), urgent care, and now triages for a doctor.  The two patients I am speaking specifically about were a home health patients.  They became good friends with my mother and she had them over for dinner with the family and and other events. 

I apologize if I made it sound like your mother was lying.  That was not my intent.  I don't doubt that she saw it, and I am not saying that it would never be indicated, but am simply emphasizing that the incidence is very low for reasons I mentioned.  I understand why hearing her stories would have had a tremendous impact on your decision, but you have to understand that her stories are anecdotal and do not consider the BIG picture of all geriatric experience.  Most elderly uncircumcised men simply don't have any issues like that.  They are able to care for themselves, and when they are not, they are usually not neglected.  In almost every case negligence would have to be a factor.  Sure, I saw some nasty stuff sometimes with uncircumcised geriatric men, but again, it was always treatable, and more importantly easily preventable without requirement of invasive measures.  Again, I saw even nastier things under breasts (of both men and women)- that should not be an indication to amputate all breasts preventively.  Again, the risk of geriatric circumcision due to complications is so low, that it was not even considered as a potential benefit of child circumcision by the AAP or the CDC that I can see. 

57 minutes ago, bluebell said:

Based on the CDC recommendations.

I'll have to look at the 2017 ones before responding on this.  But if all other reports are indications of what it says, it will be more about STI's and not hygiene.  I have a huge problem with cutting up the penis instead of recommending more effective and less invasive practice of condoms.  Should we routinely assume that all male children are going to be irresponsible and therefore recommend cutting all of the genitals?  Is it ethical to recommend the cutting of all male genitals so that irresponsible ones will have a little more protection.  Should all responsible people be expected to suffer because of irresponsible ones? Shouldn't they have a choice and voice in the matter whether or not they want to be responsible and thus avoid going under the knife?  Even if circumcision slightly reduces the risk of UTI's, the odds are still exceptionally high that they will likely become infected anyway if they are not using a condom.  So, the argument is bankrupt. 

Edited January 18, 2019 by pogi

[Amulek]

9 hours ago, pogi said:

Just curious, if it is true that there is no net medical benefit to the practice of circumcision (as the AAP has now admitted in a follow up editorial published in 2016), [...]

I've pretty much disengaged with this thread, but I don't think it's accurate to say that the "AAP has now admitted" that there is no net benefit. 

To begin with, the editorial doesn't actually say that anywhere. And, more importantly, it's just an opinion piece - not an actual policy statement for the AAP.

Scroll down to read the following footnote:

"Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees."

 

[Hamba Tuhan]

1 hour ago, bluebell said:

What culture binds doctors to perform circumcision on geriatric patients who are dealing with severe complications concerning their foreskins?  

Being 'culturally bound' doesn't mean one is bound to do something; rather, it's about operating without the boundaries of a culture. Inside those boundaries, there are are shared experiences and shared expectations, and that means that things that make sense in one culture may not make sense or even translate into another.  That medicine is culturally bound is not a controversial point, that I'm aware of.

Quote

As far as I know, America doesn't have a culture of adult circumcision.

Probably not, but cultures that include routine genital cutting of infants for presumed health reasons inevitably see circumcision as a fix for medical problems. Then when an elderly patient shows up in need of, for example, an antibiotic cream, the doctor might see a foreskin, think, 'Good heavens! Why didn't someone cut that off in the first place?', and order a circumcision instead of the cream. This makes perfect sense within the boundaries of that culture, where complete male genitals have been routinely pathologised in both medical and non-specialist discourse and practice.

In non-cutting cultures, this response appears ill-informed and extreme -- because it lies outside the boundaries of cultural expectations. Here the patient will just get the cream.

Interestingly, the following is one prominent online definition:

Quote

Restricted in character or outlook by belonging or referring to a particular culture.

‘what evidence there is may be culture-bound, since most of it comes from the USA’

Globally, we are at the beginning of what appears to be a potentially radical shift in the social sciences, where virtually all research emanates from the West, and the vast majority of that from the US in particular. Increasingly, non-American researchers are arguing that what appear to be universal descriptions are really culturally bound descriptions of Americans and their reality.

Edited January 18, 2019 by Hamba Tuhan

[Scott Lloyd]

11 hours ago, bluebell said:

But the CDC article rebuts Frisch and Earp's claims and findings.  Where can I see their rebut of the rebuttal?

To be clear and accurate, the 2017 “CDC article” you refer to here is not actually from the CDC. It is an article from a publication called Global Health: Science and Practice Journal. While the article might be looked upon as an apologetic for the CDC draft statement (which has yet to be formalized), it is not a statement from the CDC itself. It is, as such, an opinion piece, just as are the commentaries taking issue with the AAP position and the CDC draft statement on this matter. 

Since the AAP has a pattern of shifting its position on circumcision every decade or so,  I wonder if there will be yet another AAP revision before the CDC gets around to formalizing its draft statement. Then, since the CDC seems to allow its own position to be driven by what the AAP has to say on the matter, the CDC will have to scrap its draft and start the process all over again  

Edited to add: 

FYI, here is a description of the GHSP journal from the journal’s own website:

“Global Health: Science and Practice (GHSP) is a no-fee, open-access, peer-reviewed, online journal aimed to improve health practice, especially in low- and middle-income countries. Our goal is to reach those who design, implement, manage, evaluate, and otherwise support health programs. We are especially interested in advancing knowledge on practical program implementation issues, with information on what programs entail and how they are implemented. GHSP is currently indexed in PubMed, PubMed Central, POPLINE, and the Development Experience Clearinghouse (DEC)”

Not to disparage the journal, but like most all publications it does seem to have a certain editorial bent, as it is aimed at influencing “health practice, especially in low- and middle-income countries.” Little wonder, given that bent, it would look favorably on circumcision research done in Africa without giving much regard to how applicable those studies are in the more developed nations and environments of the United States, the UK, Australia and the nations of Europe. 

Edited January 18, 2019 by Scott Lloyd

[pogi]

13 hours ago, Amulek said:

I've pretty much disengaged with this thread, but I don't think it's accurate to say that the "AAP has now admitted" that there is no net benefit. 

To begin with, the editorial doesn't actually say that anywhere. And, more importantly, it's just an opinion piece - not an actual policy statement for the AAP.

Scroll down to read the following footnote:

"Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees."

You are right, it was not accurate of me to say the AAP has now admitted... It was one of the committee members who helped draft the 2012 statement.  He did not specifically state that there was no net benefit, but he clearly did state that measuring such benefit against risk was impossible - which means their statement was misleading and inaccurate. 

Edited January 18, 2019 by pogi