Talk:Medical analysis of circumcision/Archive 1

Looks ok to me
Even though the article is disputed, having read it in full, I would say that it reflects current medical thinking. Where is the bias? --Dumbo1 14:34, 20 Sep 2004 (UTC)

12.24.47.10
Regarding the smegma/HPV claim inserted by an anonymous user: Cite a source, please.&mdash;Eloquence 11:16, Aug 19, 2003 (UTC)

As announced, I have incorporated what I consider useful edits by User:12.24.47.10, in spite of his strong bias in favor of circumcision and his repeated attempts to remove critical information. On the edits which I have not included in my revision:


 * All vs. many major medical groups -- if you claim that a major medical group still recommends routine infant circumcision, cite it. I have searched and have not found any.
 * Balanitis can occur in both circumcised and uncircumcised men, and according to Van Howe, is actually more common in circumcised men. Preputial adhesions are one of the causes of phimosis but generally harmless. You have your terminology very confused.
 * Studies showing a prevalence of phimosis among uncircumcised boys are hardly relevant since we know already that phimosis is a condition of the foreskin -- by definition, it cannot occur in fully circumcised males.
 * The number of circumcised/uncircumcised men in the dermatological study is irrelevant as long as we do not know the circumcision rate in the control group, which is not listed in the abstract.
 * The US army report is of little interest because the quoted paragraph is only opinion, no hard data. The actual hard data (number of hospital admissions) is not correlated with circumcision.
 * Dr. Dagher's statement is hardly relevant as it contains no hard data but only opinion. This would be interesting if Dagher represented a major medical association, which is not the case.
 * The Danish study on cervical cancer found no statistically significant increased risk because of circumcision: "Other potentially important factors, although not statistically significant, were .."
 * The Ginsburg/McCracken study on UTIs is hardly relevant (nor is Schoen's personal opinion on the matter), as CIRP notes: "Parkland Hospital is a public hospital that serves a large urban population. At the time that this study was carried out, Parkland Hospital had a policy of refusing to do circumcisions even if requested. The hospital's client population of young male infants, therefore, would have been almost completely non-circumcised. Ginsburg and McCracken's observation that only 5 percent of male infants were noncircumcised, therefore, should not be surprising and may not indicate that noncircumcised infants get more urinary tract infections."
 * Some of your text was lifted straight from the medicirc website, such as the following paragraph. This makes me suspicious of all of your additions -- we have a strong policy against copyright infringements, so please do not copy material from other sources.
 * Uncircumcised men were first shown to be more likely to acquire heterosexual HIV infection over a decade ago, in articles in the leading medical journals "Lancet" and "New England Journal of Medicine". Since then over 40 separate studies have shown that uncircumcised men are more likely to become infected with HIV on heterosexual exposure. The ease with which the foreskin tears during intercourse, leaving mini-abrasions through which the virus enters, can lead to the infections. It has recently been shown that certain specialized cells in the foreskin, Langerhans cells, can trap the HIV virus and promote infection.
 * Your long list of studies that show a HIV correlation is of little help -- we could inflate the article with a discussion of dozens of studies. Obviously, you are prone to selection bias and only present those studies which match your preconceived belief that circumcision is useful -- you entirely ignore those studies which found no link or even a higher risk of HIV for circumcised males. We could inflate the article by discussing all the 40+ studies on HIV/circumcision, but it makes more sense to simply give an overview, as the present version does, and present some of the methodological criticisms.
 * Citing HIV/AIDS data for more countries is of no relevance -- circumcision opponents do not claim that the higher AIDS rates in industrialized countries which circumcise disprove the hypothesis, they say that they merely show that behavioral factors are much more important.
 * The "large outcry" argument hardly merits inclusion since there was no "large outcry" against many other questionable medical procedures such as lobotomies or genital surgery to prevent masturbation for many decades. Furthermore, you have not provided the source for the statistical comparison (1 in 4500). That circumcision is a riskier procedure when not done with proper medical equipment is hardly a matter that is open to discussion.

Your attempts to remove countless studies which do not match your belief system will of course not be tolerated. The present version incorporates those edits of yours which were reasonably neutral, so if you persist in back and forth reverting the article, I will request for the page to be protected.&mdash;Eloquence 01:38, Aug 28, 2003 (UTC)

Oh, Eloquence. You have have strayed so far from NPOV. Yet, I have included much of your additions and replaced much of your deletions. I include citations and you remove them. Why? You place long quotes from your sources yet you think no copyright issue obtains...why do you think a small quote from medicirc constitutes one? Your deletions are more in the nature of someone trying to prove a point. I have deleted some of your assertions that are unsupported by any cite. As for "All" versus "Most", do you have a cite that "ALL" is correct? Isn't is more likely that "Most" is correct because you don't know who all is out there, albeit you'll think they are biased: the Egyptian Urology Association or its Israeli counterpart perhaps?

You claim to be "Eloquence" but in reality you are hide-the-ball. Your cites to circumstitions and cirp sites are inappropriate, because the unadulterated articles are not to be found there...only the anti-circumcision editorialized ones. You should be ashamed....and speaking of copyright where's your righteous indignation, dude? 12.24.47.10


 * You have failed to respond to the points above. If you continue to revert the page to your less neutral revision, I will ask for it to be protected. As for the copyright issue, fair use of quotations is not a problem as long as they are properly labeled as such. If a quotations is presented as your material, it becomes a copyright violation and fair use is no longer applicable. It will be hard to even argue with you as long as you 1) continue to remove facts which you do not like, 2) continue to add silly nonsense like the list of people who are circumcised or a bunch of AIDS studies which you selected (see above).&mdash;Eloquence 01:01, Aug 29, 2003 (UTC)

You are just wrong. Why do you delete the AIDS rates studies that show that in Africa circumcision rates are closely associated with lower AIDS rates?

Why do you want to obscure (or ignore) the fact that there is a large body of scientific literature that demonstrates that circumcision protects against the heterosexual (esp. female to male) transmission of AIDS?

Why do you cite to biased sources written by people without any scientific background?

Why do you insist on using terms like "mutilated" "intact" and the like which are not NPOV?

Why do you totally misunderstand copyright law?

Why do you keep deleting material that you don't agree with?

Why do you want to hide the fact that many of the anti-circumcision forces are led by people advocating the homosexual rights movement? Discrimination on your part? Or shame? 12.24.47.10

1) I have explained why listing individual AIDS studies is pointless above. There are studies which found a positive link, a negative one, or no link at all. It makes no sense to list them all, and you obviously only list the ones which match your bias. We can play this game endlessly, but it makes more sense to list the general methodological criticisms of this research and its current state. As the page notes, the main criticism is that circumcision is not performed randomly -- it is found in cultures with specific rites and hygienic practices, and as such, a link between circumcision and HIV rates is also a link between HIV rates and specific hygienic and sexual practices.

2) Which biased sources written by people without a scientific background are cited?

3) I have never referred to circumcision as "mutilation". Someone else has done so in the main circumcision article, but that was reverted.

4) You are the person who inserted uncredited copyrighted text in violation of US copyright code, not me. Please see fair use and related pages for more information.

5) I do not delete material that "I don't agree with", I delete material that is irrelevant, such as a list of circumcised people. As I have demonstrated, the studies you have cited are actually largely written by people who oppose routine neonatal circumcision.

6) Any alleged links to the homosexual movement are hardly relevant to a medical discussion; they are hardly relevant at all, and require a high standard of evidence which you have not followed. Furthermore, if you want to play that game, I can add links to articles about people who clearly have a sexual fetish for circumcising, about circumcision fans who also advocate female circumcision "for aesthetic reasons" and so on. This is all anecdotal. In any case, do you claim that in European countries, which don't circumcise, there is somehow a higher prevalence of homosexuality? Do you claim that the natural, biologically evolved foreskin is somehow linked to homosexuality? It is much more likely that the cultural practice of circumcision is linked to specific sexual beliefs and patterns rather than that the normal (in 84% of the population) status of the foreskin is linked to any such patterns.

Since you refuse to cooperate on developing this page in a neutral fashion, I will now ask a sysop to protect it. &mdash;Eloquence 17:49, Aug 29, 2003 (UTC)

A sysop arrives

 * (to Martin) Could you act as a neutral mediator for the page Medical analysis of circumcision? An anonymous user is trying to turn this page, and circumcision, into a pro-circumcision propaganda page. To this end, he has removed studies and citations which he did not like, source dumped large amounts of material from pro-circumcision websites, added a list of circumcised people to prove that circumcision is associated with intelligence, claimed that circumcision is linked to homosexual beliefs etc. I have explained specifically why I have not integrated certain of his edits on Talk:Medical analysis of circumcision, but he just keeps reverting to his revision instead of discussing his changes. At this point, I think it would make most sense to protect either my last revision (which integrates those edits from him which I consider neutral) or the one before he started editing the page, in order to make him discuss his proposed changes. I would of course refrain from editing the page as long as it is protected, but back and forth reverting the page is pointless.&mdash;Eloquence 18:57, Aug 29, 2003 (UTC)

Hi folks.

Eloquence asked me to intervene in this page as a mediator. To declare my personal biases up front, I was circumcised a few years ago, for medical reasons, I was brought up as a Christian, and am currently a non-militant atheist. I hope, 12.24.47.10, that you will accept me as a suitably impartial third party in this dispute.

I have not read the article yet, and I will now do so and attempt to find a version that can serve as a temporary "protected page" on the subject while we try to resolve this issue.

Thanks for your time, Martin

Proposal
Hi again. I have attempted to understand the nature of this dispute, based on the edits I see in the history, and this talk page, as well as User talk:12.24.47.10.

I see many disputes here, across a wide range of issues. Looking at the diff between the two conflicting versions, I see that the majority of the article is effected in some way or another. Some of these disputes are over facts, others are over relevance, such as the relevance of certain studies. The large number of disputes is itself a problem in such cases, spreading discussion out over many fronts.

I cannot in fairness simply take the version of either Eloquence or 12.24.47.10 and protect that, as that would express a bias towards either the one person or the other, which I cannot do.

Therefore, I propose the following procedure. Where 12.24.47.10 wishes to change some paragraph, I shall leave that paragraph alone. Where 12.24.47.10 wishes to add a paragraph, I shall add that paragraph, but add an explicit disclaimer that the added paragraph is disputed, either on grounds of fact, or on grounds of neutrality, or on grounds of relevance. Additionally, I intend to place a full copy of 12.24.47.10's version at user:12.24.47.10/Medical analysis of circumcision, so that he can work on it independantly if he so chooses. I trust that both parties will be able to accept that as a temporary cease-fire line while the various issues are resolved.

Then, Eloquence and 12.24.47.10, along with other interested parties, can proceed through the changes, one at a time. I suggest that they work from top to bottom and try to find an appropriate solution that they can both agree with. This will take time and patience on both sides, and I beg the patience of all concerned. Martin 21:20, 29 Aug 2003 (UTC)


 * Well, this will result in lots of redundancy (because I have rephrased some of 12.24's sections elsewhere) and a very chaotic article. I would prefer it to discuss the disputed sections individually on the talk page.&mdash;Eloquence 21:42, Aug 29, 2003 (UTC)


 * I propose the following further procedure: I will edit those statements which I think can be integrated without significant changes of meaning. I will move the remaining statements to talk, one by one, and comment on why I think they are redundant/not relevant/wrong. This allows me to whip the article into shape even if 12.24 does not cooperate.&mdash;Eloquence 21:58, Aug 29, 2003 (UTC)


 * That is a good proposal.
 * However, I ask you to remember that 12.24.47.10 does not spend as much time on Wikipedia as yourself, and therefore you may need to proceed slower than you might otherwise. Martin 22:10, 29 Aug 2003 (UTC)


 * He'll have all the time in the world to respond, but since this article is probably a frequent Google-target, I would like to make sure that the public revision is reasonably neutral and redundancy-free ASAP.&mdash;Eloquence 22:19, Aug 29, 2003 (UTC)


 * Understood. Martin


 * A quick note to 12.24.47.10 - please do not reinstate the sections below without replying to Eloquence's detailed comments. Discussion is key to resolving NPOV disputes while avoiding edit wars. Martin 00:04, 30 Aug 2003 (UTC)

Disputed paragraphs and comments
Please indent your comment on the next indentation level respectively using a ":" before the paragraph. The disputed paragraph is always on the first level in italics.



Recent studies from Europe demonstrate the prevalence of balanitis and phimosis due to the low rate of circumcision.


 * This phrasing is not neutral. First, it generalizes studies with conflicting data. Second, as I have already explained, phimosis is a condition of the foreskin -- it is obvious that it will all but disappear with routine neonatal circumcision.&mdash;Eloquence

''Doctors at Royal Liverpool Children&#8217;s Hospital diagnosed over 100 cases (a 4% rate) of balanitis in a 3 ½ year survey of English boys. (Source: Escala JM, Rickwood AMK. Balanitis. Brit J Urol 1989;63:196-197).''


 * This is now summarized under the heading "Balanitis".&mdash;Eloquence

''Doctors from the Children&#8217;s Hospital, Sheffield found a prevlance of phimosis among uncircumcised English boys. (Source: Rickwood AMK, Hemalatha V, Batcup G, Spitz L. Phimosis in Boys. Brit J Urol 1980;52:147-150).''


 * Not only is this duplicated, it is also wrong. The study, which can be found here, examines 23 boys suffering from phimosis to determine the actual pathology of the condition. It makes no claims of frequency whatsoever. Instead it states that, "The findings of a previous survey (Rickwood, 1977) confirm that phimosis in the pathological sense is rarely seen in pre-school boys. Its aetiology remains obscure." Rickwood at al. have repeatedly criticized routine circumcision, including in their 1980 paper, as a method to prevent phimosis. But this study is of no relevance at all to the circumcision question -- it is only relevant to the aetiology of phimosis.&mdash;Eloquence

From the quoted study abstract:

''All patients with Zoon balanitis, bowenoid papulosis, and nonspecific balanoposthitis were uncircumcised. Lichen sclerosus was diagnosed in only 1 circumcised patient. Most patients with psoriasis, lichenplanus, and seborrheic eczema (72%, 69%, and 72%, respectively) were uncircumcised at presentation. The majority of men with penile infections (84%) were uncircumcised.''


 * While this is interesting data, it is only relevant when related to the sociodemographic data of the community. What is the circumcision rate in the area of referral? We know that the majority of men in the UK are uncircumcised by now, so it should not be surprising that the majority of men with penile infections are uncircumcised. The study works with a control group to obtain its odds ratio, but the data above does not work with the control group. Only the actual odds ratio is statistically relevant, and the abstract does not show if they examined confounding variables like genital washing habits, sociodemographic status, sexual behavior etc. -- which is all different depending on circumcision status. I'll say this many times so you remember it: Circumcision is not performed randomly. If you examine circumcision status, you always have to examine for tons of confounding variables. I can't really judge the scientific value of the study without looking at it, but they want 12 dollars for the DRM protected full text. If you have a copy of the full text, let me know.&mdash;Eloquence

''A study conducted in Denmark examined 9,545 Danish boys between 6 and 17 years of age, and found that 4% had phimosis, (incidence of 8% among 6 year olds), 33% had preputal adhesions (63% among 6 year olds), and 5% had smegma. (Source: Øster J. Further fate of the foreskin. Arch Dis Child 1968; 43:200-203.)''


 * I have already accurately summarized this study. It does not claim that these are actual medical conditions. Both preputial adhesion and smegma are part of the natural development of the foreskin, and as Øster himself states, these problems disappear at a later age. You are distorting Øster's conclusions by not reporting this.&mdash;Eloquence

''In "Medical Department, United States Army, Surgery in World War II, Urology", links observed by clinicians in the field were surveyed and compiled. In it, the author notes that &#8220;hospital admissions for paraphimosis, phimosis, balanitis, and condyloma acuminata during 1942-1945 totaled 146,793.&;#8221; (Source: JF Patton, Medical Department, United States Army, Surgery in World War II, Urology, p. 145).''


 * The numbers themselves are uninteresting unless they are correlated with circumcision status and checked for confounding variables. Patton's assessment itself is not entirely irrelevant, but mostly outdated (chancroid is of little relevance today, and the beliefs about phimosis as well as treatment methods have been largely superceded by modern knowledge). I have summarized it in the article.&mdash;Eloquence 02:05, Aug 30, 2003 (UTC)

Statement by Dagher

Despite overwhelming evidence from urological surgeons that neoplasm of the penis is a lethal disease that can be prevented by removal of the foreskin, some physicians continue to argue against routine neonatal circumcision in a highly emotional and aggressive fashion.


 * This is pure opinion. Irrelevant.&mdash;Eloquence

'Schoen's claim on penile cancer

''The evidence that circumcision protects against penile cancer is overwhelming. In the US, incidence of penile cancer in circumcised men is essentially zero (about one reported case every five years)''


 * This is so misleading as to make Schoen completely unreliable. Hitchcock only mentions this briefly in her response but at least on the talk page it deserves greater emphasis. He claims that penile cancer in circumcised men is essentially zero based on the number of published case reports! This is of course nonsensical and fraudulent. Cases will only be reported by doctors who find them interesting and unusual -- most of the time it simply does not matter whether the person in question is circumcised or not, the cancer is treated and the patient either dies or is released. Regardless, I have always included Schoen's claim in my revisions, including the response from Hitchcock.&mdash;Eloquence

Circumcision as an indication of elite status

Circumcision is fast becoming a mark of the elite &#8211; a status it enjoyed prior to the 19th Century.


 * Followed by a list of "famous circumcised men". This is not only completely unrelated to the medical analysis of circumcision, it is also extremely silly. Of course you can list many famous and important Americans and Jews here because circumcision is so prevalent in the United States and a Jewish ritual. Anti-circ advocates can list countless famous Europeans, and Americans who were born before circumcision became popular in the US. Indeed, it should not come as a surprise that a nine-page "gallery of famous intact men" can be found on one of the genital integrity websites. Many of these are/were of course part of the elite of their time, refuting the allegation that circumcision is a defining feature of elite status (although it is true that in certain regions, at certain times, it is or was such a feature). As such, this list is completely pointless, here or elsewhere, as it proves nothing and will only lead to similar lists from the other side.&mdash;Eloquence 02:13, Aug 30, 2003 (UTC)

Schoen's claims about UTI

On his website, Dr. Schoen, a circumcision advocate, states:

''Uncircumcised boys are about 10 times as likely to get serious kidney infections in the first year of life as are circumcised infants; uncircumcised older boys and men are more likely to get UTIs as well. These kidney infections are most dangerous in the first 3 months, during which time they often lead to hospitalization and can result in overwhelming blood infection and other serious infections. Kidney scarring has been shown to occur later. There is concern that future kidney failure and high blood pressure may follow infantile UTIs. Abnormal kidney function and hormonal secretion can occur with infant UTIs. Fecal contamination of the moist inner foreskin layer with bacterial attachment leads to these kidney infections.''


 * These claims are Schoen's interpretation of the present research. Schoen is of course highly biased and unreliable, as we have seen above, and he picks the highest estimates for UTI incidence in intact males instead of the one with the best methodology. Because this is a summarizing statement that does not come from a medical group nor from a methodologically impeccable meta-analysis, it is of no relevance to the article. The cohort study by To et al. is the best designed one I have found so far.&mdash;Eloquence 07:33, Sep 8, 2003 (UTC)

''Twentieth century doctors once believed that circumcision has no effect on sexual intercourse. That belief, however, is weakening as new evidence of sexual effects accumulates. Medical historians have shown that nineteenth century doctors introduced male circumcision as an intentional sexual injury with the intent of making masturbation impossible. The medical evidence on the effects of circumcision on sexuality are somewhat contradictory. Nevertheless, a pattern is beginning to emerge as more research becomes available.''


 * Can we substantiate any of this? If not, this comes across as POV &mdash; the nineteenth-century doctors were maliciously chopping off foreskins, and that only recently has medicine seen the light.  Also, this phrasing implies that ALL DOCTORS EVERYWHERE believed whichever; this is  a rather absurd generalization that needs some clarification.  Finally, the last two sentences are duplicated; we'll need to either remove them from this paragraph or remove the intro paragraph from the "Sexual Effects" section. - jredmond 00:23, 18 Sep 2004 (UTC)


 * I believe that much of the quoted passage above can be substantiated. However, it would need to be phrased in more neutral language and recast in chronological order. I would start off by referring to the Nineteenth Century doctors who introduced circumcision as a way of curbing masturbation. Then, when circumcision became established doctors began to claim that it had no effect on sexual performance, e.g., as in the Masters and Johnson study. Lately, however, new evidence has been accumulating that suggests that circumcision does have an impact on coitus for both the male and the female. At this point, to give it credibility, every example of impact should be substantiated with a link to further information or studies. Such information should be expressed in neutral language. Now where this could or should be done is a question that I would leave to others. Michael Glass 03:32, 19 Sep 2004 (UTC)

AIDS in Africa
It is quite curious how massively the "circumcision prevents HIV/AIDS" fallacy is promoted, particularly by Halperin and Bailey. Here is a map of HIV adult prevalence in Africa:



As you can see, AIDS is clearly most widespread in sub-Saharan Africa. Curiously enough, circumcision rates are higher in the northern countries -- but more importantly, if AIDS had a single epidemiological source in southern Africa, then it would be expected that the disease is most concentrated in the south. It has nothing to do with circumcision -- and it probably has little to do with sex at all. Recent research indicates that heterosexual transmission only accounts for 25-35% of HIV infections -- the majority is from unsafe medical care. Circumcision obviously has nothing to do with it. But that does not prevent charlatans from making outrageous claims about circumcision -- whenever there's a new disease, there's a new disease that circumcision can cure. I will update the article to reflect the flaws in the research.&mdash;Eloquence 03:15, Sep 4, 2003 (UTC)


 * Hmm, that might make a good map for an AIDS-related article. Shame it's only fair use.


 * Doesn't look like 12.24.47.10 is coming back. Martin 09:02, 4 Sep 2003 (UTC)

Paraphimosis
I would question some of the information in this passage:


 * Circumcision formerly was the recommended remedy for this condition, which typically arises in teenagers experimenting with sex, but medical treatment with topical steroid ointment has replaced circumcision as the preferred treatment modality. In the NHS of the U.K. it is recommended to patients who wish to retain their foreskin for religious or sexual reasons. A newer, proven, procedure is minor surgery to make a small slit in the foreskin without removing any tissue.

Where is the evidence for this?
 * which typically arises in teenagers experimenting with sex


 * my doctor, by mouth, from some NHS database.

or this?
 * In the NHS of the U.K. it is recommended to patients who wish to retain their foreskin for religious or sexual reasons.


 * ditto. Martin 13:00, 26 Sep 2003 (UTC)

I believe that this passage would be more accurate if it read:
 * Circumcision formerly was recommended for this condition but treatment with topical steroid ointment has replaced circumcision as the preferred treatment method in the NHS of the U.K. A newer, proven, procedure is minor surgery to make a small slit in the foreskin without removing any tissue.

Others might be able to suggest further changes to more accurately reflect the relative popularity of these methods of treatment in different countries.

Length of the article
As this article is so long, perhaps it would be the time to consider dealing with matters such as phimosis, paraphimosis, penile cancer. AIDS and circumcision in their own articles and reducing this article to a summary of findings with links to the other articles.

What do other contributors think? Michael Glass 16:34, 4 Sep 2004 (UTC)