Talk:Circumcision/Archive 21

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Perspective

I've been concerned that the reader lacks perspective judging potential benefits.

For example, the risk of UTI for infant girls is much higher than the risk of UTI for uncircumcised boys. The absolute risk of UTI's in infants is strongly (off the charts more than circ benefits) correlated with breast milk feeding and close mother/child contact at birth. In the US, breast milk feeding is strongly correlated with incomes, and incomes are strongly correlated with circ rates. The relative lower incidence of breast feeding among the uncircumcised (in the USA) easily "explains" the difference in UTI's (between circ'd and intact).

Firstly, this is a classic example of cum hoc ergo propter hoc Secondly, it is pure original research, unless you can find a reliable source that published this. -- Avi 00:56, 8 November 2006 (UTC)

Third, it appears to be factually wrong. The Swedish study reporting on UTI rates gave 2.2% for boys and 2.1% for girls below 2 years of age (I'm quoting from memory, as the AAP's site is not working at present). UTIs become more common in girls than boys after infancy. The only study on breastfeeding and UTI with a reported relative risk that I can find is Pisacane et al. The RR is 0.38, which is protective, but less so than the 0.13 that Singh-Grewal's meta-analysis reported. That meta-analysis also commented that "Both socioeconomic status and ethnicity were associated with circumcision status in several studies but there was no evidence of an association between these factors and UTI outcome between the circumcised and uncircumcised groups." Jakew 13:38, 8 November 2006 (UTC)

I was going off a September 1, 2006 New York Times article: On the Job, Nursing Mothers Find a 2-Class System, plus that article I submitted to discussion on breast feeding, mother/neonate contact, and the incidence of UTI's ... I tried to go back in the archive but it's been stored in a way I can't figure.

As another example, penile cancer is very strongly correlated with diet, and with cigarette smoking…not circumcision.

Funny, the peer reviewed journals cited seem to disagree, both with you and each other. -- Avi 00:56, 8 November 2006 (UTC)

With the exception of Fleiss and Hodges BMJ letter (for which they were criticised for misrepresenting their references), I'm not aware of any journal article that found no correlation with circumcision. Every study that I've seen has found an association. Jakew 13:38, 8 November 2006 (UTC)

Perspective was the point. The correlation is relatively weak.[1] online, but look into the China Study nutrition and smoking data...[2]. The incidence of penile cancer is zero where they eat whole plant foods and don't smoke ... though they are intact.TipPt 23:21, 8 November 2006 (UTC)

Finally, the HIV benefit may easily be offset by decreased use of condoms, and we have only measured the infection rate in men. The infection rate in women may go up. Circ'd are less likely to use condoms.TipPt 00:32, 8 November 2006 (UTC)

Also, the HIV benefit may be offset by the tidal cycles of the moon and barometric pressure in the Gulf states as well. And the infection rate of rhinovirus may increase as well. In other words, this completely unproven logical chain may not be valid and is completely irrelevant unless you can bring a reliable source that says this. Otherwise, another example of original research. Thanks. -- Avi 00:56, 8 November 2006 (UTC)

And again, this is factually inaccurate. As I pointed out in a letter to PLoS Medicine, of the four studies to investigate the risk for women, three have shown decreased risk among women with circumcised partners. And of four studies to investigate condom use and circumcision, three found that circ'd men were more likely to use condoms,[3] [4] [5] and one reported no difference.[6]

Original research is bad enough. OR based upon ideas contradicted by the available evidence is even worse. Jakew 13:38, 8 November 2006 (UTC)

From your [7]"Several studies have found more high-risk behavior among circumcised men than among uncircumcised men, suggesting that confounding by sexual behavior may actually underestimate the protective effect of circumcision."...and I don't find any (other than they rarely use them)reference to condoms.TipPt 23:21, 8 November 2006 (UTC)

You may have missed "Fewer uncircumcised men reported a history of condom use." Jakew 09:13, 9 November 2006 (UTC)

Not controlled for wealth.TipPt 16:02, 9 November 2006 (UTC)

I used your first link jakew, and immediately find a study finding higher HIV risk to women if the man is circ'd [8]TipPt 23:21, 8 November 2006 (UTC)

Yes, Tip. Now scroll down a little to the link I gave, and you'll find that of four studies, this was the only one to do so. The other three showed the opposite result. Jakew 09:13, 9 November 2006 (UTC)

Video

I added this google video of a circumcision in the external links; i hope nobody will disagree. Username9 15:58, 8 November 2006 (UTC)

I've added a short NWS warning to the video, for anyone silly enough to click on it and not expect to see surgical techniques. :)Draffa 17:37, 9 November 2006 (UTC)

An activist's video at Google Video? I don't think it's a terribly encyclopaedic link. Jakew 17:40, 9 November 2006 (UTC)

This is not a representative of the genital integrity movement .

In the second paragraph of the Topic find this sentence: The genital integrity movement condemns infant circumcision as a form of male genital mutilation that they consider comparable to female circumcision, and does not differentiate between religio-ritualistic versus purely elective circumcision of minors.[9]

That representative link should be replaced with [10]TipPt 23:38, 8 November 2006 (UTC)

I disagree. One is a paper published in a peer-reviewed journal. The other is seems more like a shock site. -- Avi 00:32, 9 November 2006 (UTC)

I think the major requirement for a shock site is that the site has to be shocking. IMO that page is not shocking. I agree with you however, the link should not be changed. Christopher 06:50, 9 November 2006 (UTC)

I agree, that is not appropriate. However, the initial source does not support the claim. Jakew 11:32, 9 November 2006 (UTC)

Perspective

Funny AVI, it seems like you would understand the idea of perspective since reading (in the CPS review) of that large study finding a ~50% UTI rate among ritual circ'd in Israel!TipPt 15:36, 9 November 2006 (UTC)

Read it again, Tip. Jakew 16:23, 9 November 2006 (UTC)

I'll place the sentence here for all to read:

"An epidemiological study of UTI during the first year of life involving 169 children born in Israel found that 48% (27/56) of the male infants presented with UTI within 12 days after ritual circumcision.51 The incidence of UTI among male infants was significantly higher just after circumcision (from 9 to 20 days of life) than during the rest of the first month of life and significantly higher in the first month of life than during the rest of the year.TipPt 18:53, 9 November 2006 (UTC)

Thank you. They're saying that, in a study of children with UTIs in the first year of life, 48% of those in males occurred in that time period. They are not stating that there is an risk of 48% overall. Jakew 19:05, 9 November 2006 (UTC)

I'm still looking for that article placing the focus (UTI prevention) on breast feeding and early mother/infant contact.TipPt 15:36, 9 November 2006 (UTC)

Jakew, I'll settle for this perspective to the reader ... UTI's in intact boys during the first two years of life approximates that for infant girls.TipPt 16:05, 9 November 2006 (UTC)

Just more proof of pro-circ BIAS

The current version:

The genital integrity movement condemns infant circumcision as a form of male genital mutilation that they consider comparable to female circumcision, and does not differentiate between religio-ritualistic versus purely elective circumcision of minors.[8] When discussing non-religio-ritualistic neonatal circumcision, some explain their views in terms of the perceived medical benefits of the procedure.[7][9]

Gives the reader a link to one article [11] that has to do with legal issues, not the topic (as stated) of genital mutilation. You have to read through fairly thick legalese to find discussion of specific harm, which is the focus of the genital integrity movement. Again, the paragraph is about the increased discussion of elective neonate circ's.

The proposed link [12] is representative of the "genital integrity movement," and facilitates the reader understanding of potential for mutilation. It is a fact based website, with little "shock" value.

Finally, the current version gives the reader two links. One which details harms and benefits and finds to not recommend, the second to a pro-circ article with serious factual (gross exageration ... my own bold where it's extreme) problems. Look at his conclusion: "The multiple benefits of newborn circumcision are additive over a lifetime and include prevention of cancer of the penis, of balanoposthitis, and protection against the effects of phimosis and poor hygiene as well as prevention of UTI and STD, particularly of HIV."

It's wrong to provide the reader such trash [13].TipPt 15:53, 9 November 2006 (UTC)

Wikipedia is based on reliable sources, Tip. By all means find a better source that represents the views of the GI movement, but a webpage from "boystoo.com" does not meet the necessary standards. As for the ADC article, it's a published article in a peer-reviewed journal. It meets WP:RS, is represented fairly and neutrally, and is therefore fully acceptable. Wikipedia does not have any requirement for User:TipPt's agreement with the content of an article. Jakew 16:29, 9 November 2006 (UTC)

Specifically, why do you find [14] to violate reliable sources? Can you find any information that is false or exagerated (as I've demonstrated above in your schoen quote included in the Topic)?TipPt 17:23, 9 November 2006 (UTC)

RS is primarily about the nature of a source rather than the veracity of its claims, Tip (though if you're interested in the false and exaggerated claims, see here).

As WP:RS reminds us, "Anyone can post anything on the web." We usually rely instead upon published sources in peer-reviewed journals, books from non-vanity publishers, etc. It also tells us that "Exceptional claims should be supported by multiple credible and verifiable sources, especially with regard to historical events or politically-charged issues." And that "Widely acknowledged extremist or even terrorist organizations or individuals, whether of a political, religious, racist, or other character, should never be used as sources for Wikipedia." And "Cite peer-reviewed scientific publications and check community consensus" Jakew 17:56, 9 November 2006 (UTC)

You did not define why boystoo is improper for wiki, either by nature or presented facts.

By the nature of the sentence, we are looking for a representative position statement from the genital intregity movement. The current link certainly fails horribly, boystoo is better. I'll keep looking for a more representative link.TipPt 18:21, 9 November 2006 (UTC)

If you do not grasp why it is inappropriate by nature, then I can only assume that you have read neither the policy itself, nor the quotes I gave.

I would certainly agree that a better source should be found, but I should point out that the boystoo link didn't even mention female circumcision, nor did it mention mutilation. This means that even in the (frankly unlikely) event that it were published in a reliable source, it would still be a pretty appalling source for the claim in the article. Jakew 18:29, 9 November 2006 (UTC)

PS ... you point to Google groups, but you should point to Schoen ... both demonstrate exagerated claims. Schoen does it with the badge of a DR. Scary.TipPt 18:24, 9 November 2006 (UTC)

I'm sorry, I only mentioned my post to GG as an aside because you expressed an interest in the errors in that particular webpage. Please forget it. Jakew 19:08, 9 November 2006 (UTC)

Australasia "policy statement"

The current version is biased and dishonest because it excludes the phrase "there is no evidence of benefit outweighing harm," excludes the phrase "routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit," and orders the quotes very oddly.

Australasia

The Royal Australasian College of Physicians position is as follows:

The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision. [emphasis in original statement]

...

If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment.

In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents.

— ROUTINE CIRCUMCISION OF MALE INFANTS AND BOYS - SUMMARY STATEMENT, Royal Australasian College of Physicians

The current version should be changed to:

Australasia

The Royal Australasian College of Physicians position is as follows:

The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision[emphasis in original statement] ...there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate.

In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents.

If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment.

— ROUTINE CIRCUMCISION OF MALE INFANTS AND BOYS - SUMMARY STATEMENT, Royal Australasian College of Physicians

TipPt 16:32, 9 November 2006 (UTC)

Tip, this is simply POV pushing on your part, by cherry-picking the parts that are most anti-circ from the statement, rather than those that summarise it well. For crying out loud, the sentence referring to the alleged human rights violation is immediately followed by: "Whether these legal concerns are valid will be known only if the matter is determined in a court of law." Jakew 16:46, 9 November 2006 (UTC)

I pulled that from something Dan wrote, see I've taken that quote out.TipPt 16:53, 9 November 2006 (UTC)

"there is no evidence of benefit outweighing harm" also lacks the qualifier in the end of that sentence: "for circumcision as a routine procedure in the neonate."

Cherry-picking is bad enough. This is cherry-picking and misrepresentation. Jakew 16:59, 9 November 2006 (UTC)

There's also the subject of Parental Responsibility to consider. If, after a review of all the available, modern, unbiased literature, the parents decide to circumcise, I doubt they could be charged with Human Rights abuses (IANAL), as they believed they wer acting in the childs best interests..Draffa 17:21, 9 November 2006 (UTC)

I took "for circumcision as a routine procedure in the neonate." out for AVI (since it's in the prior quote linked by the ...). I don't mind saying it again if you want.TipPt 17:05, 9 November 2006 (UTC)

If you insist on its inclusion, then yes, the qualifier must be present. It should also be last in the quotation (as per the source). The paragraph beginning "If the operation is to be performed" should also be before the one beginning "In all cases", as per the source. You can't just rearrange paragraphs - it's not an honest representation of the source. Jakew 17:10, 9 November 2006 (UTC)

How about this Australasia

Australasia

The Royal Australasian College of Physicians position is as follows:

The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision[emphasis in original statement]

The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law.

If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment.

In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents.

Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate.

— ROUTINE CIRCUMCISION OF MALE INFANTS AND BOYS - SUMMARY STATEMENT, Royal Australasian College of Physicians

—Preceding unsigned comment added by TipPt (talk • contribs)

Hmm. Now let's remember that we're trying to summarise and condense this information. This is similar to writing a lead section for an article: we want to keep it short, summarise the key facts, while leaving the complex and inconclusive for discussion later on.

2nd paragraph: inconclusive. Cut it out.

Last paragraph: doesn't give much more information than the first. Cut it out.

Can you guess what's left? :) Jakew 17:45, 9 November 2006 (UTC)

Hmmm gross bias. We know from the first paragraph that there is no medical indication for routine neonatal circumcision, but we currently miss Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate. That last paragraph says something very different and very important (weighing benefit and harm) for the reader ... that you force them to miss. Why?

For weeks this section was very long (complete). Then BOOM it's distorted and short. Who's to judge length, especially when all those medical "benefits" and detailed at least three times? Harms (judged to be equal or worse by med assoc's) currently get the extreme short shift.

I don't mind leaving out the second paragraph.TipPt 18:10, 9 November 2006 (UTC)

Schoen should be removed ... factual problems

False statements, violating reliable sources

"In the US, the great majority of newborn boys (about 1.4 million annually) are circumcised." ...a "slight" or 5% majority (55%) would be honest.

"Moreover, about 70 million circumcised US males currently attest to the lack of effect of circumcision on either emotional health or sexual performance, and no objective studies indicate otherwise." ...not honest and not true.

"The multiple benefits of newborn circumcision are additive over a lifetime and include prevention of cancer of the penis, of balanoposthitis, and protection against the effects of phimosis and poor hygiene as well as prevention of UTI and STD, particularly of HIV. Protection against these diseases constitutes a substantial public health advantage and provides a strong argument in favour of instituting universal newborn circumcision in Europe." ...Use of "prevention" is gross exageration and dishonest.

Why do we link or quote such trash?TipPt 18:43, 9 November 2006 (UTC)

Perhaps you could point to the section of WP:RS that requires the agreement of User:TipPt? Jakew 19:11, 9 November 2006 (UTC)

May you be known for you affection for Adler and Schoen; giving the reader poor then misrepresented science, and exagerations and false statements from a doctor, respectively.TipPt 01:07, 10 November 2006 (UTC)

I doubt that anyone agrees with the content of every source cited in this article, Tip. Fortunately, we don't have to, because policy requires that we don't judge them. Policy further requires verifiability, not truth. In cases where they disagree, we represent the views fairly and neutrally.

In the start of this section, you claimed that false statements violates reliable sources policy. I would like you to show me where that policy states this requirement, because I've read that policy many times and I've never seen it. Furthermore, given that WP:NPOV prevents us from endorsing one of differing views, and that WP:NOR prevents us from determining a statement to be false ourselves, I can't see how it's possible for us to do so. Jakew 11:26, 10 November 2006 (UTC)

Here's the UTI ... perspective ... article. I'll look up the Lancet study.

The best protection from UTIs comes not from cutting off a small piece of the baby's skin, but from the mother herself. Jan Winberg et al (the Lancet, March 1989) concludes that the number of UTIs in newborn males could be reduced by strict rooming in of mother and baby or by active colonization of the baby with his mother's anaerobic gut flora. In this research, UTIs in newborn males were caused by Escherichia coli, bacteria not of maternal origin; therefore, infants had no passive resistance to these pathogens.

During delivery in a natural setting, the infant acquires aerobic and anaerobic intestinal flora from the mother, together with the necessary immunoglobins to resist infections from these agents through the placenta and breastmilk. When an infant is born in a sterile hospital setting, he is carefully protected from the possible contamination caused by his mother's body fluids, and then isolated in a nursery. His first contact with the E. coli strain is from the hospital environment itself, against which the infant has no resistance.

During the first few days of the infant's life, he should be handled by the mother and other members of his immediate family as exclusively as possible, whether circumcised or intact. The mother's resistance to the pathogenic effects of her own gut flora and that of the other family members should protect the infant from early UTIs. Once the infant has established his own gut bacteria colony, this will help protect him from colonization by stray pathogens.

The baby born in a typical hospital labor setting who is then removed to the nursery is at much greater risk for UTIs from stray bacteria than the infant born at home. Circumcision is no guarantee of health; contact with the mother and her breastmilk are an infant's first and foremost protection from infections. -Diana Haught, Midwifery Today Issue 14

If I'm not mistaken, this seems to be merely the opinion of the author. An opinion piece is very weak evidence. However, Haught cites Winberg, which may be a appropriate for the article, if it refers to circumcision. Jakew 11:11, 10 November 2006 (UTC)

A couple links for the second paragraph genital intergity/mutilation citation

[15]

[16]

Peer reviewed, published, and both more to the point (of the sentence) than the current version link.[17]TipPt 01:18, 10 November 2006 (UTC)

Neither seem to support the claim in the article (as an aside, both are letters, which are rarely peer-reviewed. Most tend to receive editor review instead, with less scrutiny in the case of e-letters. That doesn't make them unreliable, I'm just pointing it out for the sake of correctness). Jakew 11:07, 10 November 2006 (UTC)

I have found a much better source ([18]) which describes the formation of some of these organisations, explicitly refers to mutilation and FGC, and fully supports the stated claim. The primary author is Marilyn Milos, founder of NOCIRC, and the article is by no means neutral, but that's not a problem - we're describing strong views, after all. Jakew 12:04, 10 November 2006 (UTC)

Last night I realized saying peer reviewed was exagerating; sorry. Your source/article is better than the ones I found, and much better than what's in the Topic. Could you please put it in (I haven't learned to use the detailed format)the paragraph?TipPt 14:43, 10 November 2006 (UTC)

Already done. :) Jakew 14:59, 10 November 2006 (UTC)

There is no NET medical benefit

Waisberg wrote, "The intro needs more balance. It tends to be anti-circumcision. It only cites data against it and does not talk anything about any of the potential benefits."

Waisberg, there is a very broad consensus in the international medical community that there is no NET medical benefit to cutting off a boy's healthy foreskin. Circumcision of healthy boys is nothing more than a form of permanent body modification motivated by culture or religion. Trying to present non-therapeutic circumcision of healthy boys in the article as anything other than a medically unnecessary intervention is pushing a pro-circumcision point of view. -- DanBlackham 04:40, 10 November 2006 (UTC)

Maybe nobody told these doctors about the broad consensus. Fan-1967 04:48, 10 November 2006 (UTC)

I hadn't actually read that link, sorry. You're still left to weigh the harms against benefits; note that the study author is probably making that consideration when he concludes: "evidence is insufficient to support routine neonatal circumcision." And I don't see anyone weighting sexual harms at all.TipPt 15:43, 10 November 2006 (UTC)

That's not a quote from the study authors, Tip, that's the journalist writing the article. The quote from the study authors follows shortly afterwards and is: "The public health issues raised by these findings clearly involve weighing the longer-term benefits of routine neonatal circumcision in terms of reducing risks of infection within the population, against the perceived costs of the procedure." Jakew 10:26, 11 November 2006 (UTC)

You're right about that sentence from the article's author, but from the research study author ..."involve weighing...benefits...against the perceived costs of the procedure." We don't know this researchers net conclusion, but we do know the Assoc stance (not recommend) based on reviews of this and other research.TipPt 18:45, 11 November 2006 (UTC)

No, we have the associations' stance based on reviews of the literature as of the date of their statement. To my knowledge, none have issued a statement since this study came out (unsurprisingly, since was only published a few days ago).

The president of the AAP responded to this study, incidentally:

In light of the new study and concern over this issue, it's time to reconsider the evidence, says Jay Berkelhamer, president of the pediatrics academy. "People feel very passionate on both sides, but I'm going to recommend that we take another careful look at this."[19]

Jakew 19:20, 11 November 2006 (UTC)

The official policy statement of the Royal Australasian College of Physicians says, "After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision." (emphasis in the original document)

The RACP policy statement is supported by a broad consensus in medical communities in Australia and New Zealand.

"The policy represents an agreed position adopted by the following:

• Paediatrics & Child Health Division of The Royal Australasian College of Physicians
• Australasian Association of Paediatric Surgeons
• New Zealand Society of Paediatric Surgeons
• Urological Society of Australasia
• Royal Australasian College of Surgeons
• Paediatric Society of New Zealand"

The point of view of pro-circumcision advocates should not be given the same weight in the article as the official policy statements of professional medical organizations. -- DanBlackham 06:59, 10 November 2006 (UTC)

Dan, the statement of the RACP has always been in the article. What are referencing when you discuss pro advocacy? Everything in the article cites reliable sources, at least the hundred or so I have checked. Please elucidate the logical connection between the antecedent and the consequant in your statement. Thanks -- Avi 07:06, 10 November 2006 (UTC)

Dan may be getting confused between routine and elective circumcision. Most, if not all, organisations seem to be against the former but not the latter. To quote the AAP:

Scientific studies show some medical benefits of circumcision. However, these benefits are not sufficient for the American Academy of Pediatrics (AAP) to recommend that all infant boys be circumcised. Parents may want their sons circumcised for religious, social and cultural reasons. Since circumcision is not essential to a child's health, parents should choose what is best for their child by looking at the benefits and risks. AAP: Circumcision Information for Parents

With careful reading of the policies from the AAP (and, as Dan quotes, the RACP), we can see that both are opposed to routine circumcision (ie. of all newborn boys) but that doesn't mean that they're opposed to parents choosing it for their son.

Certainly, there is no consensus that there's no net benefit: both the AMA and BMA explicitly say that there's considerable disagreement on that matter. Jakew 11:02, 10 November 2006 (UTC)

Excuse me, but the BMA says "The medical harms or benefits have not been unequivocally proven except to the extent that there are clear risks of harm if the procedure is done inexpertly," the RACP says: "Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate," and the CPS says: "The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending." Those all say no net benefit. Why is so much text in this Topic devoted to "benefits," and so very little to "harm?"TipPt 15:41, 10 November 2006 (UTC)

How do you read ""The medical harms or benefits have not been unequivocally proven" to mean "there is no net benefit"? It is one thing to say net benefit is not proven. It is a totally different thing to say there is none. Fan-1967 15:43, 10 November 2006 (UTC)

Indeed. It's even more bizarre to claim that this means "there is no net benefit" when one considers the paragraph in full:

There is a spectrum of views within the BMA’s membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. The medical harms or benefits have not been unequivocally proven except to the extent that there are clear risks of harm if the procedure is done inexpertly. The Association has no policy on these issues. Indeed, it would be difficult to formulate a policy in the absence of unambiguously clear and consistent medical data on the implications of the intervention. As a general rule, however, the BMA believes that parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices. What those limits currently are is discussed below, together with the legal and ethical considerations for doctors asked to perform non-therapeutic circumcision. (emph added)

Jakew 16:02, 10 November 2006 (UTC)

You're cherry-picking again, Tip. You know that controversy exists, because you've referred to my argument previously. Furthermore, with the exception of the BMA (who do not review the medical evidence) the medical organisations all discuss the benefits at considerable length, so it is perfectly reasonable for us to do the same. Jakew 15:49, 10 November 2006 (UTC)

I'm not cherry picking. Find a sentence from the BMA, CPS, or RACP (as a group) that says other than no net benefit. Remember all that discussion about cost/benefit ... that says no net benefit and forms "the basis of policy." The Associations all discuss the alleged benefits because they are following the literature and convention. Schoen...Adler... Repeating penile cancer like it's a relevant risk ect., UTI's like they are a relevant risk (as long as antibiotics and behaviors ...feeding and contact ... work), HIV as though there's anything that works other than safe sex and good hygiene... Our readers suffer.

The controversy so much with respect to the science, but it's application. The science says "not recommend," but parents ask for the procedure based on misconceptions about hygiene (hygiene = a look). Doctors look the other way, figuring no great harm anyway. But then there's that ~30% rate of frenectomy...some doctors should surely fear hell.TipPt 16:09, 10 November 2006 (UTC)

The wording on all these statements was very, very carefully chosen. They should be interpreted for exactly what they say and don't say: "not recommend" is not the same as "recommend not". If they had meant "we recommend you do not" they would have said so. They said "we do not recommend". Fan-1967 16:13, 10 November 2006 (UTC)

I'm thinking ... what did that editor mean to say? Their (the Assoc's) wording is not changed or biased. It's just been omitted (the RACP closing paragraph) by pro-circ folks.TipPt 00:55, 11 November 2006 (UTC)

DanBlackham said that "there is a very broad consensus in the international medical community that there is no NET medical benefit to cutting off a boy's healthy foreskin". Being a MD myself and being a member of the international medical community I would like to say that this statement is nothing more than his point of view and is clearly an inconsiderate comment. I do read the literature and policies about circumcision frequently and I have been doing so for quite a while and so far I have not seen any american medical organization stating that there is no NET benefit to the procedure (if there is one, I would think that this is an isolated case). Quite contrary, most reliable medical organizations say that there are risks AND benefits and that, at this point, it is rather difficult to decide if the risk/benefit ratio is biased to any side. Therefore performing circumcision is right now a matter of informed parental choice rather than a recommended procedure. That is the only conclusion allowed by the literature and all the policies about it. Waisberg 20:59, 16 November 2006 (UTC)waisberg

The RACP is in Australia and New Zealand

The Royal Australasian College of Physicians (RACP) is the professional medical organization in Australia and New Zealand.

"The RACP is a diverse and vibrant organisation responsible for training, educating and representing over 9,000 physicians and paediatricians in Australia and New Zealand." http://www.racp.edu.au/public/index.htm

The heading should be "Australia and New Zealand", not "Australasian", because those are the two countries represented by the RACP. -- DanBlackham 07:26, 10 November 2006 (UTC)

But the name of the society is AUSTRALASIAN. If they call themselves that, why do you wish to change it? -- Avi 07:29, 10 November 2006 (UTC)

According to the RACP web site it is a professional organization for physician in Australia and New Zealand, not in other countries. (see the quote above) The RACP has offices in Australia and New Zealand, not in other countries. If you can find any evidence, other than the name of the organization, that indicates countries besides Australia and New Zealand are included in the organization I will agree the title should be "Australasian". -- DanBlackham 07:57, 10 November 2006 (UTC)

Dan, the quote above doesn't support your claim that it is not for physicians in other countries. Logically, "in X and Y" does not imply "not in Z". I agree with Avi - we should in general adopt the title that the organisation chose for themselves. Jakew 11:44, 10 November 2006 (UTC)

The Heading for the Topic section is: "4.9 Policies of various national medical associations" and the purpose is to educate not confuse the reader. RACP is not a single nation association, and the heading for it's policy should reflect it's makeup ... not be AUSTRALASIAN, implying one nation that includes asia? From another discussion ... RACP does say "shows there is no evidence of benefit outweighing harm" which sounds to me like no net benefit, pointing to harm ... no wonder some editors refuse to permit it's inclusion.TipPt 15:21, 10 November 2006 (UTC)

1. Australasian does not imply the inclusion of Asia. Australasia: Australia, New Zealand, and neighboring islands in the S Pacific Ocean.[20]
2. (off-topic) Benefit not greater than harm does not imply net harm. $a\not >b$ is equivalent to $b\geq a$. Jakew 15:37, 10 November 2006 (UTC)

That's not something the average reader knows, why confuse them? Again, the statements generally say no net benefit, which seemed to be what you were arguing about. Personally, the sentence structure smacks of a hint of net harm.TipPt 15:49, 10 November 2006 (UTC)

“smacks of a hint of net harm” is your interpretation, which regardless of how accurate it is, is original research. If you can find someone who specifically interprets the RACP in that manner in a published reliable source, fine. Otherwise, we can do no more than an accurate (either all or main points, NOT cherry picking) quote of the RACP . -- Avi 16:02, 10 November 2006 (UTC)

See all the policy paragraphs included. I don't mind the whole thing, but just policy the point.TipPt 16:42, 10 November 2006 (UTC)

Avi's speculation that the RACP represents other countries besides Australia and New Zealand not supported by many quotes on the RACP web site. Every time the RACP web site mentions a country it says "Australia and New Zealand". No where on the RACP web site is there any indication that the RACP includes countries besides Australia and New Zealand. The following references from the RACP web site should resolve this issue:

• Addresses in Australia and New Zealand http://www.racp.edu.au/
• "The RACP is a diverse and vibrant organisation responsible for training, educating and representing over 9,000 physicians and paediatricians in Australia and New Zealand." http://www.racp.edu.au/public/index.htm
• "The RACP is a varied and energetic organisation responsible for training, educating and representing over 9,000 physicians and paediatricians in Australia and New Zealand. ... The RACP believes it has a duty to better the health of all Australians and New Zealanders through development of health and social policy and advocating for its implementation." http://www.racp.edu.au/public/racp2.htm
• "The College advocates for health and social policies to improve the healthcare of all Australians and New Zealanders." http://www.racp.edu.au/public/racp3.htm
• "Yes, physicians are often called specialists, specialist physicians and consultant physicians and are also known as internists in the USA, but all these terms mean the same thing and in Australia and New Zealand we call them physicians. ... In Australia and New Zealand a physician completes over eight years more education and training to specialise in a particular area of medicine." http://www.racp.edu.au/public/phys.htm
• "Becoming a Fellow - Registered practitioner in Australia or New Zealand" http://www.racp.edu.au/public/fellow1.htm
• "... as the MOPS program has been registered under the appropriate legislation in both Australia and New Zealand." http://www.racp.edu.au/public/mops_about.htm
• "Physicians or Paediatricians who are not Fellows or members of the College but are registered as specialists by the Australian Health Insurance Commission or are on the vocational register of the Medical Council of New Zealand on the basis of overseas qualifications ... Australian/Overseas Residents ... New Zealand Residents" http://www.racp.edu.au/public/mops_enrol.htm
• "MOPS Fee Schedule 2006 - Category | Australia | New Zealand" http://www.racp.edu.au/public/mops_cost.htm

The words of the RACP from its own official web sited should carry more weight than original research based on one word in the name of the organization that is not supported by any other evidence. Avi and Jake, if you have any evidence that the RACP represents countries besides Australia and New Zealand please post it. -- DanBlackham 00:15, 11 November 2006 (UTC)

I can't speak for Avi, but I don't intend to look for evidence, let alone post any. The RACP choose to call themselves Australasian, and I've yet to see any evidence that they do not cover islands other than Aus and NZ. Therefore, I have no reason to believe that their choice of name is incorrect. Jakew 10:07, 11 November 2006 (UTC)

From discussion above...the Australia and New Zealand RACP misrepresentation

Dan, the statement of the RACP has always been in the article. What are referencing when you discuss pro advocacy? Everything in the article cites reliable sources, at least the hundred or so I have checked. Please elucidate the logical connection between the antecedent and the consequant in your statement. Thanks -- Avi 07:06, 10 November 2006 (UTC)

AVI, your current version of the RACP statement is dishonest, because it omits "Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate." Shame.TipPt 15:43, 10 November 2006 (UTC)

The source contains ten paragraphs, Tip. Are you seriously suggesting that we're being "dishonest" if we omit any one of those ten? Or is it only dishonest when you'd like to quote a particular sentence to advance your POV? Jakew 15:52, 10 November 2006 (UTC)

Again, we are trying to give the reader "national policy" ... not another review of the "benefits". But I don't mind showing the whole statment properly. It would be better to just include policy ... leaving out the closing paragraph which weighs benefits and harms is dishonest.TipPt 16:22, 10 November 2006 (UTC)

I hope you got their permission to release the summary under the GFDL first. If not, you've now caused Wikipedia to violate their copyright.

Design & Content © 2001 The Royal Australasian College of Physicians Revised October 2004

Jakew 16:29, 10 November 2006 (UTC)

Looks like we've got to remove all the long quotes in Wiki. See the version with just policy.TipPt 16:35, 10 November 2006 (UTC)

It's all policy, Tip. That's why we're supposed to summarise it.

Incidentally, please stop editing your comments after others have replied. It makes it very hard for readers to understand the conversation. Jakew 16:37, 10 November 2006 (UTC)

Sorry, my connection is slow and my writing ... I often don't know there's been a reply. Likewise, please wait awhile before reverting my edits to the Topic ... you might as well do it all at once later and I often crash into the reverted. You can't deny the bias in omitting the closing paragraph that addresses benefit and harm!TipPt 16:48, 10 November 2006 (UTC)

As Fan-1967 remarked above, they chose very specific wording. For whatever reasons, they did not discuss benefit and harm in general, but discussed it in the specific context of "as a routine procedure in the neonate". I'm not going to speculate about why they added that qualifier, but I would like to quote the AAP's Task Force: "The Task Force found the evidence of low incidence, high-morbidity problems not sufficiently compelling to recommend circumcision as a routine procedure for all newborn males. However, the Task Force did recommend making all parents aware of the potential benefits and risks of circumcision and leaving it to the family to decide whether circumcision is in the best interests of their child." Jakew 16:57, 10 November 2006 (UTC)

It's not for us to edit out critical content. Point stands that when you summarise a statement, you don't leave out all of the content from the closing paragraph!TipPt 23:42, 10 November 2006 (UTC)

Actually, to avoid violating their copyright, we must ensure that we delete (ie, edit out) most of the summary from the quote. What we select to include should be most representative of their position, not necessarily that which most closely approximates yours. Jakew 12:21, 11 November 2006 (UTC)

Which is why you insist on violating the CPS copyright by including their complete 1996 statement ... so you can list all those medical benefits again. What a joke.TipPt 16:41, 11 November 2006 (UTC)

Tip, we don't include their complete 1996 statement. It's very tiresome that you keep misrepresenting things. Jakew 16:58, 11 November 2006 (UTC)

Sorry, but the point stands that the CPS "summary" is much more detailed than the RACP summary ... which fits your purpose of misleading the reader with tons of medical benefits. You force the omission of critical points in the RACP summary, specifically, these three key points:

1. "The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law.

2. "Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate."

3. "In recent years there has been evidence of possible health benefits from routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis."TipPt 17:21, 11 November 2006 (UTC)

this does not belong in second intro paragraph!

Look what Jakew keeps putting in the intro paragraphs:

"(i.e. reduced incidence of urinary tract infection in infant males, decreased incidence of penile cancer in adult males, and possibly decreased susceptibility to certain sexually transmissible diseases, including human immunodeficiency virus)"

1. That info is properly delivered ... at least 3 times in the body of the Topic.

2. That info is not balanced with known risks and harms.

3. That info is covered in the links at the end of the sentence.

Do you want to list known harms at the same time?TipPt 23:28, 10 November 2006 (UTC)

Firstly, check the page history. This information was inserted by another user, removed by yourself along with several other dubious changes, and then reverted by myself.

Secondly, the lead section is supposed to summarise the rest of the article, and yes, that means repeating some points.

Thirdly, the emphasis is different from the rest of the article because in this particular part we are summarising the arguments of certain people (eg Schoen) in the ongoing debate. Just as we summarise the arguments of anti-circumcision groups ("condemns infant circumcision as a form of male genital mutilation that they consider comparable to female circumcision"), we also summarise the arguments of those in favour.

Lastly, such a summary of the argument must be honest and representative. If Schoen balances risks and harms, then we can certainly summarise his conclusion. But we cannot misrepresent him as saying something other than what he actually says, nor can we make original criticism of his arguments. Jakew 10:20, 11 November 2006 (UTC)

First, I try to make individual changes so other editors can revert that specific change. Why do you do blanket reverts? In doing so, you take responsibitity for that specific revert.

The intro paragraphs set the topic outline and introduces points. For example, the second paragraph is about discussion and introduces the idea of "perceived medical benefits of the procedure." That phrase serves to summarize the arguments in favor.

Third, as you note, all those potential benefits are in the Schoen link provided right after "perceived medical benefits of the procedure." Remember, the benefits are minor.

Leave Schoen (as is) to the link. I think he's an embarassment to the pro-camp.TipPt 16:19, 11 November 2006 (UTC)

So, taken to the logical extent, you'd prefer that the article consists of links only, since it's all in the links? Jakew 19:22, 11 November 2006 (UTC)

removing medical effects section

I don't want to be bold in such a controversial article, but I noticed there's already a fairly extensive article on the medical analysis of circumcision which is already linked from this article. This article is already enormous, shouldn't most of the material on the medical aspects be removed from this article, with just a brief summary and link remaining? Vicarious 01:14, 11 November 2006 (UTC)

It's a medical topic, so some discussion needs to be included. However, I'd certainly agree that the discussion is too long and does need to be condensed. Unfortunately that's very hard to do in a manner that all editors find acceptable. Jakew 10:22, 11 November 2006 (UTC)

Jakew would like to think circumcision is a medical topic, but factually it's a religious, then a ritual or cultural act (the decision to circ) according to all medical associations. Benefits exist, but are minor and have failed to justify the risks. Many editors love the emphasis on potential benefits (and the short shift on harms) because it misleads the reader into thinking the "benefits" are relevant. The very short text devoted to harms is much more telling...remember, harms roughtly equal benefits (according to cost'benefit studies); so they should be given equal representation...you can assume the pro-circ dominate this Topic!TipPt 16:28, 11 November 2006 (UTC)

Would you help me summarize the RACP?

Here's what I see as important points (in bold) in the statement (already condensed below)...

Australia and New Zealand

The Royal Australasian College of Physicians position is as follows:

The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision.[emphasis in original statement]

Circumcision ...remains an important ritual in some religious and cultural groups. ...The best recognised medical indication for circumcision is phimosis. ...In recent years there has been evidence of possible health benefits from routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis.

The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law.

Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate.

— ROUTINE CIRCUMCISION OF MALE INFANTS AND BOYS - SUMMARY STATEMENT, Royal Australasian College of Physicians

—The preceding unsigned comment was added by TipPt (talk • contribs) 12:30, November 11, 2006 (UTC)

It's fine as it currently is, TipPt, leave well enough alone and stop editing for POV. Draffa 17:40, 13 November 2006 (UTC)

The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision. [emphasis in original statement]

...

If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment.

In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents.

— ROUTINE CIRCUMCISION OF MALE INFANTS AND BOYS - SUMMARY STATEMENT, Royal Australasian College of Physicians

Circumcision in the early '40's

I recently read the book "Behind the mask of medicine" which was published in 1941. While I was reading Atkinson's cahpter entitled 'Excesses in Surgery' I was constantly comparing the color of the pages to the color of the copyright page, to be certain that someone had not slipped the pages in recently. His views are very modern, indeed if footnotes were added citing the appropriate modern studies, you would be able to convince me that it had been published in the 21st century. I wasn't sure how to work this into the history section, plus I don't have the time at the moment, so decided to post this here and invite another editor to help. Here are some quotes:

The terminal part of the organ is covered by a delicate membrane and is highly sensitive. The function of the foreskin is to preserve and protect the sensitiveness. Circumcision does away with this protection, the covering membrane becomes coarsened from exposure and sensation is impared. Worse still, the point of maximum sexual sensation is on the inner surface of the prepuce close to the frenum, and this point is bound to be removed. That the intensity if sexual sensation is impaired by circumcision is vouched for by men who have undergone the operation in adult life. This is surely an aesthetic tragedy that requires some justification, even if what you've never had you never miss.

On the psychological side, it does not seem probable that the procedure can have any beneficial effect, while it may bery easily have a harmful one. That most children recover from it is no argument in its favour. Aesthetically, it is undoubtedly bad - at best a mutilation, at worst a trajedy. Physically, it can be justified on one ground and one ground only, the existance of and exreme degree of phimosis, a state of affairs which is quite uncommon. Very few babies, therefore, actually require circumcision.

It would seem that doctors in the forties were not all completely clueless. Especially considering how much riskier circumcision is when antibiotics are not available and doctors didn't wash their hands. Christopher 20:57, 13 November 2006 (UTC)

Not sure why you'd think these views modern. I'd have thought that such claims might be common prior to 1966 (Masters and Johnson), but after that date would indicate a lack of familiarity with the evidence. :) But I guess it might belong somewhere in history of male circumcision. Jakew 21:17, 13 November 2006 (UTC)

Reference note

One note at the beginning of the references read like an attack on CIRP for 'bias'. I felt this was unbalanced. First, references are often linked to CIRCS, which is pro-circumcision and often highlights articles and opinions that support this point of view. However, this was not mentioned. It is more appropriate to refer to both websites, pointing out their point of view in non-judgmental language.Michael Glass 02:05, 15 November 2006 (UTC)

Fair point. Thank you. -- Avi 02:17, 15 November 2006 (UTC)

I have restored the even-handed wording. If anyone has a problem with this, please discuss. Michael Glass 02:05, 16 November 2006 (UTC)

I have to say that I find it surprising and somewhat misleading, Michael.

Firstly, it changes the emphasis from highlighting of passages (or worse: insertion of editorial) to the selection of articles. I don't think that this is appropriate, because we're only linking to specific articles, not the entire site. Consider this: if I suggest you read a book on fishing, does it matter whether you borrow it from Bob (who only has books on how fishing is ruining the environment) or Big Library (who have thousands of books on all subjects)? I would say no: it's the same book. Now suppose that Bob has underlined passages particularly hostile to fishing in the book (that, overall, is fairly neutral) and has added sticky notes attacking the author in places where Bob disagrees. That's a little different, because now it's no longer the same resource.

Secondly, I find it surprising that CIRCS should have a pro-circumcision point of view. As the site owner, I can tell you that a deliberate choice was made to express no point of view, which is why the library contains only indexes, rather than summaries. And if there is any point of view, it ought logically to be my own, which is pro-parental choice, as opposed to pro-circumcision.

Given my personal involvement in one of the sites concerned, I will avoid editing the notice, but I would ask you to address the above issues. Jakew 10:39, 16 November 2006 (UTC)

I find it quite surprising that you would describe yourself as not pro-circumcision, Jake. The comment that I revised - and which you restored to the article - was a straight-out attack on CIRP and only mentioned the fact that it highlighted articles in a particular way. In fact, both CIRP and CIRCS do this. While I have noted your other comments, I feel that the present wording is preferable to the previous wording for the reasons I have stated. Michael Glass 13:16, 16 November 2006 (UTC)

Specifically, CIRCS is pro-circ because it lists 26 articles on UTI's and 3 (two from Wiswell!) on complications. The sexual function section contains research finding primarily neutral or positive (beneficial) effects to circ's. The anatomy section does not contain relevant information about nerve systems that are generally considered erogenous. OMG you've got Wiswell in the anti-circ section!! Adler and his stupid multiple choice questionare (why didn't he include UTI's and HIV instead of only 'hygiene'?) Give us a break.TipPt 17:04, 22 November 2006 (UTC)

Swedish law

I have edited this section to make it easier to read, by using shorter sentences. Two other changes should be noted. I have removed the word 'controversial' from the beginning of the section. This value judgment is not appropriate under the NPOV rule. The whole section gives a fair description of the law and those who have objected to it. A second change is to replace the word 'noted' with 'stated'. 'Noted' implies that the comparison with the Nazis is true; 'stated' is a non-judgmental way of stating that this was said without implying anything about its accuracy.Michael Glass 01:52, 18 November 2006 (UTC)

Accurate quotations

I noticed that someone removed the emphasis from the quotation of the RACP policy. This policy has been criticised but that is beside the point. A quotation must be as accurate as possible. Certain words in that quotation were bolded in the original; therefore they should be bolded when they are quoted in Wikipedia. Michael Glass 02:08, 18 November 2006 (UTC)