Here's what passes for research "supporting circumcision":
"Circumcision made no difference in anything we measured."

The investigators found that sexual activity increased at the same level among both circumcised and uncircumcised men during the study period. However, they also found that condom use increased among both groups, while engagement in risky sexual behaviors - such as having multiple sex partners or having sex in exchange for money - declined.

Sexual activity, condom use, and risky behaviors: Intact or circumcision, no difference.

So why this headline? Circumcised African men 'less likely to engage in risky sexual behavior'

http://www.medicalnewstoday.com/articles/279898.php

A fair reading of "no difference" does not support a surgical intervention.

Perhaps this study argues for the non-surgical intervention that was part of the methodology:

During the study period, all participants were also encouraged to attend clinics for HIV testing and counseling services, where HIV educational videos were shown in waiting areas.

This study find no benefit to circumcision.

That's the take-away message.

It should be the headline.

What Does #i2 Stand For?

Twice I've written on this:

The #i2 twitter campaign for freedom from non-therapeutic circumcision
#i2 is what, exactly?

but people still ask, specifically, what's the "i" and what's the "2"?

As one of a small handful of people who originated the tag, I do not believe there was a single, definitive answer.  We wanted a tag for advocating genital integrity rights (intactivism) on twitter.  We wanted it to be so short there'd be no excuse to exclude it (you can spare 4 characters, right?).  I think it fair to say the "i" is rooted in "intact" or derivatives like "intactivism".

When pressed, my preferred answer (which by no means is authoritative) is "i" for "intact", "2" for "not just one sex" (I won't say "both" sexes since intersex persons have the same genital integrity rights as anyone else).

But the best things about the ambiguity are that this question is frequently asked, and that people come up with innovative answers!

So fire away on twitter!  I'll update this blog post with the best answers!

I'll start with mine and the one which inspired this post:

• @IntactByDefault: "i" for "intact", "2" for "not just one sex"
• @RozeQuartz: Integrity & Intactivism = #i2

Arrests for Billing Unnecessary Services

Well, this is interesting:

Nearly 100 people have been arrested in a series of raids targeting health care fraud on a massive scale. Doctors, nurses, even top hospital administrators in eight cities in seven states were arrested in connection with separate scams totaling $430 million -- nearly a half billion dollars in pilfering. All kinds of fraud are alleged, much of it involving false billing for services that were unnecessary, or never even rendered.

Billing Medicare for medically unnecessary services is a scam warranting prosecution.  Billing Medicaid similarly must be, too.

Where does that leave doctors and hospitals who bill Medicaid for circumcision of newborns who do not need surgery?

AAP Shifts Stance on Male Castration

Following a review of recent medical studies, the American Academy of Pediatrics has issued the following statement:

Evaluation of current evidence indicates that the health benefits of newborn male castration outweigh the risks, and the benefits of newborn male castration justify access to this procedure for those families who choose it.

Research published in the journal Cell Biology has found significantly longer lifespans for males who have undergone the well-established surgical procedure of castration-- as much as 20 years longer.

Activists are upset at what they call a "failure to consider the ethics of non-therapeutic surgery on newborns."  The American Academy of Pediatrics, however, notes that their new policy is not a recommendation of newborn male castration, and that the decision rests with parents:

Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.

This policy is the latest to generate public outrage following the Academy's May 2010 policy supporting a form of Female Genital Cutting and their August 2012 policy on newborn circumcision, which prompted hundreds of activists to "Wash Your Hands Clean of the AAP."  The AAP has since withdrawn its statement on Female Genital Cutting.

So many studies, so few experiments

The African circumcision trials have yielded new data and analysis; Remember those? Foreign researchers attracted African men who wanted to be circumcised and get free health care, counselling, and follow-ups. Circumcision was immediate or in a couple years, at random. Great deal if you want the surgery. Thousands did.

The researchers collected so much data they've been able to mine it over the course of half a decade--and there's no indication they're done--for subsets with which to publish a paper, make news, and give press interviews. Let's face it--The researches want circumcision to work as much as the participants want a free circumcision--or more. They designed the tests and questions, collected the results, and are probing the data for evidence of efficacy.

Sound familiar?

Circumcision helps stop wart virus, study finds

Will the datamining ever end?

Bad methodology is supposed to be moderated by the understanding that you don't rely too heavily on any one experiment. But what if one experiment can be portrayed as dozens of studies, and publicized over a period of many years, giving the impression of many different experiements pointing in the same direction?

If researcher bias and experiment design can shave just a few percent off a measure in an intervention group, then an impressive looking relative reduction can be announced. Why waste that on just one event?

The researchers who so strongly hoped circumcision could be an answer to anything or everything were fortunate to lack the resources to publish all the results of their Ugandan genital cutting experiment expeditiously. That might have influence just one news cycle. Due to slowly dripping out their data, a poorly informed public fed by uncurious journalists will believe they are distinct experiments with independent findings when in fact there was just one experiment.

And all the ways they looked at the data and found the opposite effect, or no effect? They are under no obligation to publish them. Only confirmations of their grand hypothesis, that millions of years of evolution of male genitalia are a dangerous mistake requiring massively funded surgical campaigns, make it out of the desk drawer. Or, perhaps the data which they don't care for will be published, but as a lower priority. They'll get to at in a few decades, after they've circumcised every man in Africa and every newborn child in the United States.

What is really going on with US newborn circumcision rates?

Now is an odd time if you care about newborn circumcision rates, or conversely, genital integrity rates in the United States. Here's why:

Zoler filed a news report from AIDS2010 stating the 2009 newborn circumcision rate is 33%. Zoler correctly states that the review includes "more than 6.5 million U.S. newborn boys during the period," but erroneously reports the same number, 6,571,500, as the total number of circumcisions in 2007, 2008, and 2009. Therefore, Zoler does not report the actual number of circumcisions in those three years. Zoler discusses a "dramatic decline" in rates, but no more specifics.

Sanchez, similarly, gives no details but mentions "a decrease."

Note that there are essentially two distinct studies discussed in the same presentation. One is a study of circumcision rates, the other of complication rates.

Abstract addresses only the complication rates study. There is no data relevant to circumcision rates. Abstract describes its sample of circumcised newborns as "12% of 1.4 million circumcisions annually," thus giving an estimate of the sample size for the study of circumcision complications. It is, however, not an indication of the number of circumcisions per year in any particular year, or the two year period of this study, or of any grouping of the years 2007, 2008, and 2009.

Sanchez and Abstract have no data on circumcision rates from 2007, 2008, and 2009. Zoler has data only for 2009, citing a 33% newborn circumcision rate. Unfortunately due to an error, Zoler does not report the total number newborn circumcisions in one or more of the years 2007, 2008, and 2009.

Thus far, the only data we have is "33% in 2009" from Zoler.

A photograph of a slide from the presentation on which Zoler and Sanchez reported and which included the study in Abstract provides more data.

The slide corroborates Zoler by depicting a "32.5% in 2009" on its graph. The slide also corroborates the total number of newborn boys in 2007, 2008, and 2009 (6,571,500). The slide reports the total number of circumcisions in 2007, 2008, and 2009 to be 2,834,849. The slide calculates and reports that the average newborn circumcision rate in 2007, 2009 2008, and 2009 was 43.13% (by dividing two previously reported numbers). The slide depicts but does not state the circumcision rates in 2007 and 2008. They appear approximately equal and just below 50%. The average rate in 2007 and 2008 is therefore 48.45% (which is consistent with the graph) as calculated by applying the 2009 rate (32.5%) and the overall rate 2007-2009 (43.13%).

All together, the picture is clear. On a year-over-year basis, newborn circumcision was down 13.8% in 2007 (56.2% to 48.45%), flat in 2008, then down another 33% in 2009 (48.45% to 32.5%). The latest rate is 32.5% in 2009.

Which brings us back to why this is such an odd time. This is a dramatic change with major social implications that is highly newsworthy, but no mainstream news media have reported it. This cannot be due to the significance of the new circumcision rates and is probably due to the narrow and indirect sourcing of this information. Although CDC researchers gave the presentation, CDC has not released this data directly to the public, and has made no public comment on it.

But thanks to Zoler and to the slide photograph, the cat is out of the bag. CDC needs to publicly comment on this information so that the public will be informed. For those of us who care about America's rate of genital integrity, or conversely circumcision, this is a very important statistic as it is for anyone who places importance upon "the norm" when contemplating circumcision. Silence by the CDC on this matter is a disservice to the public.

A CALL TO ACTION: Lobby the CDC to release the numbers on neonatal circumcision

Soreness, Injuries, Perspective, and Circumcision

The African circumcision trials have yielded new data and analysis; Remember those? Foreign researchers attracted African men who wanted to be circumcised and get free health care, counselling, and follow-ups. Circumcision was immediate or in a couple years, at random. Great deal if you want the surgery. Thousands did.

The researchers collected so much data they've been able to mine it over the course of half a decade--and there's no indication they're done--for subsets with which to publish a paper, make news, and give press interviews. Let's face it--The researches want circumcision to work as much as the participants want a free circumcision--or more. They designed the tests and questions, collected the results, and are probing the data for evidence of efficacy.

"Are you sore after sex?"

That's what they asked the African men. That's what they're publishing. This is not a joke. Self reported "general soreness" from sex--which probably happens from time to time to everybody who has much of it--is the subject of this study.

The men didn't need to have a sore penis to make the "penile coital injuries" group which netted 1775 of 2784 men initially. They could have reported any cut, abrasion, any scratch or bleeding or soreness of the penis in the past 6 months. 64% did.

Then, some of the men underwent circumcision.

Those who did not get circumcised later reported "penile coital injuries" at a rate of 42%. That's a big improvement over 64% and reflects aspects of participation unrelated to surgery. Men circumcised later reported a rate of 31%. That's an even bigger improvement over 64%.

Let's reflect a moment on self reporting, particularly of feelings like soreness. Person A's soreness may be Person B's great day may be Person C's awful pain. Worse, Person A's soreness now may be his own great day later. A person's standards change based on their experiences. We may not expect to feel as good as we age, so we report equal or less soreness even though more careful questions tell a different story. Aging isn't the only experience that can change perspective--so can surgery--like circumcision.

Experiencing an adult circumcision might make a man laugh off what he previously thought was "penile soreness"--or "cuts" for that matter--and use a more relaxed standard.

"Are you sore after sex? I used to think so, but boy was I wrong! I had no idea what sore was!" If you later re-questioned the men about soreness experienced prior to study enrollment, the circumcised ones might recall it in a rosier fashion than they did initially.

That's my hypothesis, but did these researchers take the initiative to collected such data? And if they did, will they bother to publish a paper about it? How much data did they collect which doesn't support their various pro-circumcision hypotheses?

Will we ever know?

Circumcision and Reduced Risk of Self-Reported Penile Coital Injuries: Results From a Randomized Controlled Trial in Kisumu, Kenya. (Abstract)

Circumcision may prevent sex-related penis injuries (REUTERS)