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)

New AAP policy must discourage male circumcision

Times have changed, and American Academy of Pediatrics need to get with them. Originating before children were believed to feel pain or have rights, male circumcision became a social custom in the United States. Since then medical justifications were invented with fervor and at great expense, but they always fall under scrutiny. The latest group of physicians to put this in writing are Royal Dutch Medical Association (KNMG), dating to 1849.

Speculation that AAP might take the unprecedented action of recommending newborn circumcision rests on studies conducted in Africa on HIV transmission. But KNMG--and several other physicians organizations--have issued statements since publication of those studies and found the data not compelling.

"In recent decades, evidence has been published which apparently shows that circumcision reduces the risk of HIV/AIDS, but this evidence is contradicted by other studies.

Moreover, the studies into HIV prevention were carried out in sub-Saharan Africa, where transmission mainly takes place through heterosexual contact. In the western world, HIV transmission is much more frequently the result of homosexual contact and the use of contaminated needles. That the relationship between circumcision and transmission of HIV is at the very least unclear is illustrated by the fact that the US combines a high prevalence of STDs and HIV infections with a high percentage of routine circumcisions. The Dutch situation is precisely the reverse: a low prevalence of HIV/AIDS combined with a relatively low number of circumcisions. As such, behavioural factors appear to play a far more important role than whether or not one has a foreskin."

Uncertain for adults, not relevant for newborns:

"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."

Babies don't have sex.

But they do have rights, which AAP learned the hard way after issuing a statement suggesting a "nick" to the genitals of young girls if it may avoid more severe cutting. People were outraged. Girls have rights--their bodies, certainly their genitals, are not to be modified, however slightly. AAP buckled under intense pressure from Intact America and others. After a very short career they "retired" the controversial policy statement. This is the 21st century: Children have rights.

KNMG had never before issued a policy on male circumcision. Why did they do so now? They explain,

"The reason for our adoption of an official viewpoint regarding this matter is the increasing emphasis on children’s rights. It is particularly relevant for doctors that children must not be subjected to medical proceedings that have no therapeutic or preventative value. In addition to this, there is growing concern regarding complications, both minor and serious, which can occur as a result of circumcising a child. A third reason for this viewpoint is the growing sentiment that there is a discrepancy between the KNMG’s firm stance with regard to female genital mutilation and the lack of a stance with regard to the non-therapeutic circumcision of male minors, as the two have a number of similarities."

American Academy of Pediatrics exhibits discrepancy of a more serious nature. They have policies pertaining to both males and females, but--if we believe all children have the same rights--they are in conflict. As KNMG state:

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

AAP now have an opportunity to narrow the discrepancy by taking a stance discouraging non-therapeutic circumcision of boys. The right trajectory for children's rights is more. When AAP issue a new policy, it must be aimed squarely in that direction. Recognizing boys' rights to freedom from non-therapeutic circumcision--even if like KNMG they don't recommend it's abolition--will align AAP, medically and ethically, with their physician colleagues worldwide.

AAP should be keen to avoid repeating their recent mistake of shifting policy in the wrong direction--the direction of less autonomy, less physical integrity for their young patients. It's time they close the policy gap with their peers. It's time American Academy of Pediatrics discourage newborn male circumcision.

KNMG Viewpoint Non-therapeutic circumcision of male minors

Circumcision may increase HIV spread among gay men

We need data, not headline.

It's unconscionable that since early today, this story has been all the public knows about the referenced study.

Here is what little we are told:

"The findings are based on data from 4,889 men who took part in an HIV vaccine trial begun in 1998; 86 percent had been circumcised. During the three-year study, 7 percent of the men became HIV-positive.

When the researchers accounted for other factors -- including demographics, and HIV risk factors like drug use and having unprotected sex -- circumcision showed no effect on the odds of HIV transmission.

Still, Gust and her colleagues point to some limitations of their study, including the relatively small number of uncircumcised men overall and the small number of uncircumcised men who became HIV-positive during the study -- 43"

So, what can the public think with so little to go on?

4,889 men

86% circumcised

7% HIV infection rate

43 intact men became HIV infected

So that means:

4205 circumcised men (4,889 * .86) = 4,205

684 intact men (4,889 - 4,205) = 684

342 men infected (4,889 * .07) = 342

43 intact men infected

299 circumcised men infected (342 - 43) = 299

7.11% circumcised men infection rate (299 / 4205) = .0711

6.29% intact men infection rate (43 / 684) = .0629

Well, isn't that curious. If you stop and puzzle it out, assuming what little data we're given is at least accurate, you find circumcised men had a 13% increase in HIV infection.

13% increased infection rate of circumcised group (.0711 - .0629) / .0629 = .1304

But it's time-consuming and inconvenient to see this fact. In other words, it was spun to favor the hypothesis of the researchers. The same hypothesis which this data resoundingly fails to confirm.

Since the reporters chose a headline expressed as "circumcision (or not) may (or may not) cut (or not cut, or increase) HIV spread among gay men," it would be more in agreement with the study if the headline were "Circumcision may increase HIV spread among gay men."

If that sounds like an overly strong and misleading title, consider that the actual title ("Circumcision may not cut HIV among gay men") must then be more overly strong and misleading, since it is less true to the data.

The first paragraph of the article establishes relative risk reduction as the standard for this sort of study:

"A number of studies in African nations have found that circumcised heterosexual men were up to 60 percent less likely than uncircumcised men to contract HIV during the study periods."

Given the researcher bias in favor of the hypothesis, and the use of relative risk reduction figures for past studies, does anyone think this wouldn't have been expressed as a 13% reduction in HIV, though statistically insignificant, if it had been in favor of the circumcised group?

We are being spun by the researchers (*) while the data is withheld from the public.

(*) The reporters are not making things better.

No evidence circumcision works = It may work?

It's natural to seize any possible hope for slowing or stopping the spread of HIV. Some researchers have spent careers investigating the hypothesis that less penis will lead to less HIV. But even when evidence emerges that this hypothesis is wrong, it is spun as hope that it may still be right.

Today it is reported that in the latest study of 4,889 homosexual men, about 7% became infected with HIV over three years, regardless of whether they were missing part of their penis.

circumcised and uncircumcised men showed no difference in the risk of HIV infection over three years.

while having unprotected sex with an HIV-positive partner increased a man's risk of infection, there was no evidence that circumcision altered that risk.

The report also makes clear that no previous studies have found circumcision helpful in preventing HIV in gay men, either:

There has so far been no good evidence that circumcision lowers HIV risk among these men.

Despite all the speculation, hope, and expense aimed at discovering that it does, there is no evidence that reducing the penis also reduces HIV infection. There is, however, good evidence that it does not.

But those looking for such a link still have hope. If only they could receive more funding, and perform larger studies, perhaps they may find that if gay men only had their foreskins removed, they might get less HIV.

This hope can be seen in the language in the story, which reflects the views of the researchers who would like more funding to perform more studies. Let's compare what is actually known with what is stated:

evidence that circumcision does nothing --> "may not do much"

evidence that circumcision clearly did not help --> "unclear"

circumcision made no difference --> "may not make much difference"

Is this simply the sort of sensible caution which should always be applied to medical study results? If so, we would expect the same caution to be applied to the evidence which found reduced HIV transmission to heterosexual adult men in Africa. Those findings should be similarly stated with prudent scientific uncertainty. Let's see what the same article says about those studies:

A number of studies in African nations have found that circumcised heterosexual men were up to 60 percent less likely than uncircumcised men to contract HIV during the study periods.

Nope. It's not even-handed caution. Evidence which favors circumcision is stated as a fact. Despite weaknesses in those studies, there's no hedging whatsoever. No admission that they could be wrong. No call for further evidence. But when evidence emerges that circumcision is useless, the headline tells us it still may work, and the researchers tell us it needs more study.

future studies, with larger samples of uncircumcised men, should continue to look at the question of circumcision and HIV transmission among men who have sex with men.

I'm just going to come out and say it. Some of these researchers have a cultural bias. They favor circumcision for reasons unrelated to HIV prevention, and they want more funding to study circumcision. Some of the reporters, too, are culturally biased to accept information favorable to circumcision.

Mohawks preferred over other hairstyles: study

Those claiming to do science sometimes fail. One way they may fail is by profound selection bias. For example:

Perform a study in which volunteers receive a free head shaving leaving only a strip of hair down the center (Mohawk). Ask participants how they feel about their hairstyle before and after. Find that more participants like their Mohawk better than their original hairstyle. Conclude Mohawks are very well liked compared to other hairstyles.

Really? Are Mohawks so well liked, or is there another explanation? Can you really walk down the street and Mohawk a random person and expect them to prefer it? No, but if you put up a "free Mohawk" stand along the street and let participants self-select, then yes, volunteers probably will like it.

And so it is here:

Sex equally satisfying with circumcised men: study

They put up a sign: "Free circumcision" for your partner when you both participate. Some couples selected themselves to participate. Women who recognize the positive role their partner's foreskin plays in their sexual experience didn't sign up. Men who find their foreskins lots of fun didn't sign up, either. Couples who wanted their male circumcised could sign up for one at no cost (although may need to wait for it). It's a profound bias.

Bad science happens. Science is good because the bad science is eventually seen for its flaws, but very bad policy may result more quickly.

Bailey said the finding might also help counter a growing reluctance of some parents to have their infant sons circumcised. "In the US, there is currently a strong movement against circumcision, especially on the West Coast," he said.

I (@IntactByDefault on Twitter) have an agenda, and that is for freedom from non-therapeutic circumcision to be recognized as everybody's right (hence the #i2 campaign). I am a part of this growing reluctance to deprive children of their right to choose genital integrity. Others have their own agendas. Some even want the world Mohawked.

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If you think this blog post helps shine light on how bad science may influence bad policy, you are welcome to republish it in its entirety.

The #i2 twitter campaign for freedom from non-therapeutic circumcision

Born of Twitter, with its emphasis on brevity and custom of hash tagging, is the #i2 campaign. We reach out to potential supporters and ask them to include #i2 in a tweet. Tagging a tweet with #i2 is simple but powerful. It says you're on the side of guaranteeing everybody, even males, the right to keep their whole sex organ. Hundreds have tweeted #i2 comprising thousands of tweets.

Viewing non-therapeutic circumcision of children as ethically dubious (at best) and a violation of one's right to bodily integrity is increasingly mainstream, and policy statements from medical organizations have begun to reflect this attitude. The College of Physicians and Surgeons of British Columbia, Canada released in September 2009 a statement including:

Until recently, only public health and religious views were taken into consideration in the debate over infant male circumcision. However, our understanding of medical practice must change as research findings become available.

Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries.  Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit.  Routine infant male circumcision performed on a healthy infant is now considered a nontherapeutic and medically unnecessary intervention.

Routine infant male circumcision is an unnecessary and irreversible procedure.  Therefore, many consider it to be “unwarranted mutilating surgery”.

Many adult men are increasingly concerned about whether their parents had the right to give consent for infant male circumcision.  They claim that an infant’s rights should take priority over any parental rights to make such a decision.  This procedure should be delayed to a later date when the child can make his own informed decision.  Parental preference alone does not justify a non‐therapeutic procedure.

 

This physicians group is not alone. In August 2009 The Royal Australasian College of Physicians, Paediatrics & Child Health Division released a statement expressing substantially similar medical findings and ethical concerns.

The American Academy of Pediatrics is said to be reviewing its policy. Supporters of #i2 hope they will shift their policy in the same direction as their Canadian and Australia/New Zealand counterparts. We're also asking they do that by sending a "call to conscience" facilitated by the non-profit group Intact America.

The Centers for Disease Control have also stated they will issue a statement, and many thousands have petitioned them to continue our national trend away from this painful, unnecessary, and costly surgery performed on children unable to consent.

Using Twitter we are able to organize our #i2 campaign for freedom from non-therapeutic circumcision, reach potential supporters, and get their simple and public statement that they are with us. We've established a vibrant community working to bring the change we know American boys deserve: The right to be free from an invasive, unnecessary surgery.

We're hopeful that new #i2 tweeters we'll see in the future will include Penn Jillette and Mr. Teller who have their own way of making a statement on non-therapeutic circumcision of children.

Search #i2 on Twitter.