Rethinking Circumcision for my son...

[Anonymous]

Anonymous wrote:23:52 Here. Regarding 00:27 comments.

First, I did not say FACT. I was responding to someone who claimed that it is a FACT that no other country's doctors would advocate circumcision. This is not true.

I stated that the "best" studies show benefit. By that I mean that these are the best constructed studies out there (RCT), and they are showing a real benefit. Other studies had been done with mixed results, but these are observational studies and not controlled trials. In other words, these are the first studies to actually take a population and randomly assign half the group to be circumcised and half not, and then see what happens.

PP here. How on earth can you call these studies the "best" when they were stopped way early and had no follow up? Public health policy is now being based on a year and a half study?

And where are the real world examples of this studies results? Do nations that don't practice circumcision (Latin America, Europe, Australia and Asia) suffering from vastly higher HIV infection rates? No. In fact, almost all the nations in Europe and Latin America have lower HIV prevalence rates than the circumcising United States.

It is not fair to say the results are highly controversial. There are critics (there always are), but the weight of the community including the largest world body, WHO, is behind these studies and it's because they are really compelling.

Uh, the Brazilian health minister bluntly said dismissed these studies, Australia wouldn't be banning infant circ and condeming these studies, and researchers in France wouldn't be calling for a re-evaluation of these studies.

You say the weight of the community is behind promoting circumcision, and yet, I've yet to see any nation with large population of uncircumcised men (Europe, Canada, Latin America etc.) anounce a campaign to promote circumcision for "health" reasons. The funny thing about these studies and their claims of "saving" Africa is that African men were already more circumcised than not. I believe it's something like 60 cut/40 not. And yet, AIDS has decimated the continent in astonishing numbers. Circumcision did little to prevent the HIV epidemic yesterday, it won't fix a thing tomorrow.These studies, engineered by pro-circ advocates like Dr. Bailey and Schoen, even with their inflated claims of protection, aren't enough to convince many nations to roll out circumcision campaigns.

And finally if you take apart the criticism, the most persuasive parts address not the HIV findings, but that there are tradeoffs (complications, personal beliefs, alternative methods of HIV prevention, future methods of HIV prevention). And the tradeoffs might look much different for the US compared to sub-Saharan Africa.

I am not trying to be pro-circ or anti-circ. And I never use the word FACT. But it is not a stretch to say that these studies are the best ones to date.

Disagree again. The most persuasive parts to me are the fact the trials were ended early and that, again, this trend just doesn't hold up in the real world:

Prior to the three RCTs, observational studies of HIV in relation to circumcision status showed conflicting results. This should caution the world health community to question the RCTs’ unanimous conclusions. Recent survey data of circumcised versus uncircumcised males in several African countries show considerable variation in HIV rates. In some African populations, HIV infection rates are lower for circumcised males, while other studies and reports have shown opposite results [8,12,105]. For example, the 2005 survey data for Rwanda show an HIV-infection rate of 3.8% in circumcised men and only 2.7% in uncircumcised men [106]. Data for Malawi in 2004 show a 13% HIV-infection rate in circumcised males, but a lower 9.5% infection rate in uncircumcised males [9,107]. Clearly, circumcision status is not the only or determining factor in HIV prevalence patterns.

[Anonymous]

It is reasonable to circumcise or not to circumcise, and I'm not trying to push an agenda. But the above statement is not true The best research is showing that circumcision reduces the risk of contracting and passing on STD's, particularly HIV. Lots of studies exist on this, but the best are a pair of controlled studies in Africa, where one group of subjects were circumcised and one group not. In those studies, circumcised males contracted HIV at half the rate of the uncircumcised males This corroborated other observations within populations of circumcised and uncircumcised men in Africa. http://www.msnbc.msn.com/id/16184582/

These results were a bombshell to the researchers. They had to halt the study because the results were so compelling that they believed it was unethical to continue the study because the uncircumcised group was at such clear risk.

Now WHO and UNAIDS are recommending circumcision campaigns. http://aids.immunodefence.com/2007/03/who_support_male_circumcision.html Also, Rwanda has launched a circumcision campaign.

Here is what CDC has to say: http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm Note that this also mentions a lower rate of transmission of other STDs, including HPV.

Now I'm not trying to get everyone wrapped around the axle over HIV or STD's. Circumcise or don't. But seriously, it's not right to throw around claims like this when the epidemiologists are going nuts over the circumcision study data and the press is so full of articles saying that international bodies are pushing circumcision.

The media frenzy over this is only taking place in the United States. These studies are being categorically dismissed in other developed countries who do not circumcise, such as Canada, Mexico, Brazil, England, Japan, Scandanavia, Australia, etc etc. Again, we think it is suddenly "all over the place" because it is what we see here in the US. The CDC is a US organization. The WHO and UNAIDS are being advised by US authorities. The vast majority of international bodies are NOT pushing circumcision.

The United States has the highest HIV infection rate of the developed world. The United States is also the only country practising routine infant circumcision. Circumcision does not prevent or even reduce HIV or STDS. The studies were unreliable for a variety of reasons that are quite easy to determine if anyone takes the time to research it, rather than read the news reports of these studies. One glaring problem with the African studies is that they gave the men who were circumcised condoms after the surgery, so that if they had sex their wound would be protected. Additionally, they did not in any way compare sexual activity between the two groups -- perhaps the men who had just been cut were not having as much sex as the other men. These types of questions were not even asked. Completely unreliable studies.

The US is a circumcising country, and we as a culture grasp at anything to justify its practice. "My brother, cousin, friend, whoever needed to be circumcised at age 4, 10, 16, etc". Again, the reality is that in other countries that do not practice circumcision, they do not wind up "needing" to circumcise their children or men. Most doctors in the US are ignorant about the correct way to handle or treat the foreskin, so whenever any problem arises, they say that they recommend circumcision. Foreskins are not the problem here, folks.

[Anonymous]

Anonymous wrote:23:52 Here. Regarding 00:27 comments.

First, I did not say FACT. I was responding to someone who claimed that it is a FACT that no other country's doctors would advocate circumcision. This is not true.

I stated that the "best" studies show benefit. By that I mean that these are the best constructed studies out there (RCT), and they are showing a real benefit. Other studies had been done with mixed results, but these are observational studies and not controlled trials. In other words, these are the first studies to actually take a population and randomly assign half the group to be circumcised and half not, and then see what happens.

It is not fair to say the results are highly controversial. There are critics (there always are), but the weight of the community including the largest world body, WHO, is behind these studies and it's because they are really compelling.

And finally if you take apart the criticism, the most persuasive parts address not the HIV findings, but that there are tradeoffs (complications, personal beliefs, alternative methods of HIV prevention, future methods of HIV prevention). And the tradeoffs might look much different for the US compared to sub-Saharan Africa.

I am not trying to be pro-circ or anti-circ. And I never use the word FACT. But it is not a stretch to say that these studies are the best ones to date.

PP - can you provide the citation of the RCT study you refer to? I'm interested in the sample size, statistical and clinical significance. Were these infants who were randomized to be circumcised or not? Or young adults? I am a clinician-scientist with MD and research training.

Agree with posters who question how generlizable these studies from Africa on reduction of STD/HIV are to Western population. You'd have to take into account other variable that could alter the risk - # partners, use of condoms, differences in at risk population - in western society - higher in IV drug users, male homosexual. Probably not the same profile in Africa.

You sound like a scientist -so you should appreciate that while RCTs yield good internal validity - the study must also have good external validity - ie how generalizable are the results? I'd like to review the study and agree the findings are intriguing. But to claim this is the best evidence to support circumcision (in western countries) in the absence of external validity is just hogwash.

[Anonymous]

For the PP, here are the citations. The first two appeared in Lancet. So you can probably get them, but I am having difficulty finding copies or summaries for the general public.

The third is the French and SA sponsored study, and it does have a link to the full report. But I do hope you can get online and pull the Lancet papers.

Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369:643-56.

Gray RH. Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:557-66.

Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Med 2:e298.

http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371%2Fjournal.pmed.0020298&ct=1

[Anonymous]

Anonymous wrote:For the PP, here are the citations. The first two appeared in Lancet. So you can probably get them, but I am having difficulty finding copies or summaries for the general public.

The third is the French and SA sponsored study, and it does have a link to the full report. But I do hope you can get online and pull the Lancet papers.

Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369:643-56.

Gray RH. Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:557-66.

Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Med 2:e298.

http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371%2Fjournal.pmed.0020298&ct=1

Thanks. I will get the Lancet papers.

I read the paper in PLoS Med from the link you provided. I wouldn't put a lot of weight on that study. That journal requires a $2850 fee to get your study published. A respectable peer reviewed journal does not require publication fees.

Also - the paper itself discusses the lack of generability of the results, as does the WHO statement that you refer to.
http://www.who.int/mediacentre/news/releases/2005/pr32/en/

There are also obvious problems with a RCT of this type - it can never be done blind. It's possible that male adults who are circumcised through randomization reduce their risk of HIV /STD through changes in behavior as a result of intervention. There are other problems with the study eg less than 2 year follow up, drop out rate, unclear HIV status in control and randomization groups at baseline.

Even in the data were valid in supporting circumsion in male *adults* to reduce HIV in Africa (where transmission is largely heterosexual, not homosexual or IVDU as in the US), there's absolutely no justification to use these data to support circumcision of male infants elsewhere.

[Anonymous]

Re: sexually transmitted diseases- hasn't anyone heard of a condom? I admit that I am not a scientist and haven't read these studies, but I'm assuming they are referring to sexual contact without a condom, since with a condom the state of the foreskin would be irrelevant. So, it seems to me that if a man practices safe sex and decent basic personal hygiene none of these so-called health benefits of circumcision would be an issue at all. We women do it every day. Can it be that difficult for a man?