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)

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

Girls Protection Act provides girls less protection than MGMBill

Two amendments have been proposed to the U.S. FGM Law of September 30, 1996. H.R. 5137, Girls Protection Act of 2010 was introduced in the 111th Congress on April 26, 2010. MGMBill, Genital Mutilation Prohibition Act has not yet been sponsored in Congress. There are some similarities and differences between the two amendments, which I will refer to as GPABill and MGMBill.

Both amendments address the problem of female genital cutting outside the borders of the United States, but cover different circumstances and have different penalties. GPABill makes it a crime to knowingly transport a female outside of the United States for the purpose of medically unnecessary genital cutting while under the age of 18. GPABill provides for a penalty of a fine or up to 5 years in prison, or both. MGMBill makes it a crime to arrange, plan, or procure medically unnecessary genital cutting on a female under the age of 18 outside of the United States. MGMBill provides for a penalty of a fine or up to 14 years in prison, or both.

This means that that MGMBill provides more girls protection under a wider variety of circumstances in which female genital cutting may occur, and provides a longer potential prison term for violators than GPABill. Under GPABill, it is only a crime to arrange the genital cutting of a female minor outside the United States if doing so involves international transport of the child. For example, GPABill does not prohibit an American from arranging the genital cutting of a young female family member who resides outside the United States. An American could even travel outside the United States to personally facilitate one or more acts of female genital cutting without penalty. However in all of these cases, MGMBill provides for up to 14 years in prison. MGMBill also provides a longer potential prison sentence than GPABill for female genital cutting within the United States.

MGMBill is a stronger, more comprehensive amendment than GPABill for the protection of girls. MGMBill is also a stronger, more comprehensive amendment than GPABill for the protection of boys. MGMBill provides equal protection from medically unnecessary genital cutting for males and females under the age of 18. GPABill does not provide equal protection under the law for male and female minors.

To provide strong, comprehensive protection of children from Americans who would cause their genitals to be cut without medical necessity at home or abroad, Congress should be urged to pass GPABill and MGMBill into law. Alternatively, a similar level of protection for children could be achieved by passage of MGMBill alone.

Dialog on AAP's new Female Genital Cutting policy

The American Academy of Pediatrics has released it's Policy Statement on Ritual Genital Cutting of Female Minors. What little response I've seen to it thus far has come from individuals and groups which take a position on some or all medically unnecessary genital cutting on children. The response indicates controversy over the policy.

I have a lot of thoughts on this which I haven't fully sorted out. I intend to write several blog posts about it, and your comments will help shape the direction of the discussion.

Exemplifying the controversial statements in the policy is the following:

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.

This statement troubles those who take a zero tolerance view of applying sharp objects to the genitals of children without medical necessity. It also seriously disturbs individuals and groups who would build a "wall of separation" between male and female genital cutting practices and find any comparison between male and female genital cutting to be offensive.

Here are some of my initial thoughts and questions.

Why has the AAP issued a policy statement on FGC at all? The practice is forbidden by law in the United States, which is the only nation they represent.

Is this news reported by Equality Now really just a random coincidence?

On 26 April 2010, ironically on the same date as the issuance of the AAP Statement, the United States Congress introduced new legislation amending the 1996 federal law prohibiting FGM to make it illegal to transport girls out of the country for purposes of FGM, also known as the “vacation provision.”

Will the sponsor and co-sponsor of the "vacation provision" amendment, Rep. Joseph Crowley (D-NY) and Rep. Mary Bono Mack (R - CA), also introduce MGMBill, which not only extends protection to American girls outside the borders of the United States but also extends protection to boys?

Does this policy signal anything about the stance the AAP will take on genital cutting of male minors when they release their policy on it?

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.