Circumsion in the news

[The Spartan]

MSNBC.com

Should all males be circumcised?
Some U.S. doctors are reconsidering their position
By Charles Hirshberg
Mens Health
updated 7:30 a.m. CT, Wed., April. 1, 2009
The day your wife gives birth to a baby boy, the kind, bespectacled face of Marvin L. Wang, M.D., is one that you want to see coming through the recovery-room door. Co-director of newborn nurseries at Massachusetts General Hospital in Boston, Dr. Wang has a perky, conversational bedside manner that puts everyone at ease.

I have to hustle to keep up with him as he strides energetically between hospital rooms. Right now he's congratulating a pair of new parents. Larry is standing on wobbly legs, looking both ecstatic and shell-shocked, while Joy sits serenely, holding their newborn son to her breast.

Dr. Wang jokes with the new parents a bit and then says, "I understand you may want to have a circumcision for your baby."

Larry and Joy don't answer immediately. At last Larry says, "Well ... we don't know."

Dr. Wang smiles. He's familiar with the befuddled expression on Larry's face.

Circumcision, of course, is the surgical removal of the penile foreskin from the glans — the fleshy crown of the penis. It is one of the most commonly performed procedures in American hospitals, and except for abortion, it may be the most controversial. The procedure has long been known to reduce the spread of a few rare, serious diseases, and to prevent a few annoying, uncomfortable ones. But in 1999, the American Academy of Pediatrics (AAP) determined that the risk of surgical complications, though small, nearly canceled out the benefits. They neither discouraged nor recommended the procedure. Since then, 16 states have eliminated Medicaid coverage for nearly all circumcisions.

But two years ago, a consortium of experts convened by the World Health Organization and UNAIDS (the United Nations' HIV program) announced that circumcision should indeed "be part of a comprehensive HIV prevention package." It did so because three separate, meticulous medical trials in Kenya, Uganda, and South Africa, involving more than 10,000 men, had proved that circumcision could reduce the risk of female-to-male HIV infection by approximately 60 percent. This discovery is one that, over the next two decades, could save three million lives in Africa alone.

Now, no one believes that the potential health benefits for American males are nearly as great, or as urgent, as they are for men in Africa, where HIV is spread mostly through heterosexual intercourse. Still, similar study results are turning up on this continent, as well. A team of researchers from the CDC, Johns Hopkins, and the Baltimore health department examined the records of more than 1,000 African American males — all heterosexual — who tested positive for HIV at Maryland clinics. Uncircumcised men were 50 percent more likely to be infected.

These results have caused many U.S. doctors to reconsider their positions. "I've always told families that the health benefits of circumcision are real, but not enough to warrant advocating that all boys be circumcised," says Lise Johnson, M.D., the director of healthy-newborn nurseries at Boston's Brigham and Women's Hospital. "But I find these HIV studies pretty striking. The weight of scientific evidence might be shifting in favor of circumcision."

Larry, the new dad, is circumcised himself but never thought much about circumcision until his wife became pregnant. "Joy kept saying, 'It's up to you,'" Larry tells Dr. Wang, "but when I finally said I wanted to do it, she said, 'Whoa! We have to talk.'"

After a few uneasy moments, the new father's feelings spill out.

"I guess I don't feel too strongly either way," he says, looking at his son tenderly. "But if there's a risk of hurting him ..."

Health benefits of circumcision
Pain, of course, is the first question that comes to mind whenever the words cut and penis are used in the same sentence. Ask Marilyn Fayre Milos about pain — or better yet, don't. The founder of the National Organization of Circumcision Information Resource Centers (NOCIRC — get it?) first witnessed the procedure in 1979 while training for her nurse's degree. The unlucky baby, she later wrote, was "strapped spread-eagle to a plastic board... struggling against his restraints — tugging, whimpering, and then crying helplessly" while awaiting the knife. Then as the doctor, using no anesthesia, began cutting into the penis with a scalpel, "the baby began to gasp and choke, breathless from his shrill continuous screams..."




Is that what Dr. Wang is offering to do to Larry and Joy's innocent baby boy?

Not quite. Dr. Wang says the operation rarely hurts much anymore; since the 1990s, it's become routine in U.S. hospitals to anesthetize babies before the procedure. For every 1,500 circumcisions, there are maybe three complications, nearly all of which amount to a little unexpected bleeding or a treatable infection. In return, according to the AAP, circumcised boys have a lower risk of urinary-tract infections and penile cancer, and, indeed, "a slightly lower risk of getting sexually transmitted infections (STIs), including HIV, the virus that causes AIDS." But weighed against the potential risks, says the AAP, "these benefits are not sufficient ... to recommend that all infant boys be circumcised." (The AAP is now reviewing its guidelines, in light of recent scientific news.)

Larry seems to search the doctor's face for a hint of what to do, but Dr. Wang is as neutral as his white hospital coat. "You need more time to think about it," he says encouragingly. "I'll be back."

He heads off down the hall.

Circumcised or not, every man owes his foreskin a great debt of gratitude for its service in the womb. In the third month of gestation, when the nascent penis begins to bloom, the foreskin forms a little protective blanket under which the rest of the penis can safely grow. But once you and your penis are fully baked, the advantage of a foreskin is not clear. Some scientists speculate that it protected the prehistoric penis as it swung, naked, through thick forests and over tall grasses; and unless you take your penis on that sort of excursion, they argue, you don't need a foreskin.

That perceived uselessness may be one reason circumcision has such a long and varied history. Archeological evidence suggests that the practice may be at least 6,000 years old. Muslims and Jews, along with the aborigines of Australia, the Aztecs and Mayans of this hemisphere, and many other cultures all independently adopted this squirm-inducing practice, and it seems unlikely they'd have done so unless they were convinced that it conferred some earthly benefit.


Here in the United States, foreskins were left mostly undisturbed until the second half of the nineteenth century. But it wasn't until the North Africa campaign of World War II that American doctors turned into enthusiastic circumcisers. More than 145,000 American GIs based there slacked off on their cleaning regimens and came down with foreskin-related ouches — chiefly, balanoposthitis (inflammation of the foreskin and glans), phimosis (a foreskin that's too tight to retract over the glans), and paraphimosis (a foreskin stuck in the retracted position). After the war, doctors advanced a theory that circumcision reduces rates of cervical cancer — a hypothesis now confirmed by scientific research.

Circumcision became routine, but anesthesia wasn't part of the plan. That, more than any other factor, may have provoked the fiery anti-circumcision movement that casts its long shadow over the Internet.


Anesthesia now used during procedure
Isaac is a newborn whose mother, months before she gave birth, made the decision to circumcise him. He awaits Dr. Wang atop a small operating table. His expression is blasé until a nurse standing over him slides a sugar-coated pacifier into his mouth. His eyes open wide and he commences sucking with gusto. Sugar, Dr. Wang says, is known to send a rush of endorphins to certain parts of the brain, dulling sensitivity to pain.

Dr. Wang gently wraps Isaac's legs in a soft harness. Until fairly recently, he remarks, it was standard practice to restrain babies' arms, too. "But it's distressing to them to be tied down like that, and it's really not necessary."

Fortunately, Dr. Wang says, circumcision is no longer performed in American hospitals without anesthesia, as Milos described it. After a quick examination of Isaac's manhood (if that's the right word for it), Dr. Wang administers four evenly spaced injections of lidocaine around the base of the baby's penis; Isaac shows no distress. At that point, Dr. Wang waits 5 minutes for the anesthetic to take effect, then swabs Isaac's privates with sterilizing iodine and gets down to business. He arranges a clamp that pulls the foreskin forward, off the penis, where it can be safely cut off with surgical scissors in one snip. Isaac became agitated only once — when his sugary pacifier fell from his mouth. "Usually," says Dr. Wang, "the part they hate most is being washed off afterward. They don't like to feel the cold."

A few weeks later, I call Larry to find out what he's decided to do.

"We opted not to do it," he says. "When you go on the Internet and read about this," he says, "you find out that there's really no reason for doing it. People try to think up new justifications for it, and when one doesn't work, they come up with another."

If you go on the Internet, you'll "find out" precisely what Larry found out. The problem is, it's not true.

I Googled the word "circumcision," and two of the first three sites that popped up were the Circumcision Research Center and the Circumcision Information and Resource Pages — titles that suggest unbiased collections of data. In fact, both sites are run by anti-circumcision crusaders. A seemingly unending list of similar sites followed: Mothers Against Circumcision, Doctors Opposing Circumcision, Stop Infant Circumcision Society, and Milos' NOCIRC. Many of these activists have spent decades arguing that circumcision has no medical value, and recent scientific revelations have left them red-faced — not with embarrassment, but anger. According to Milos, for instance, all three of the Africa trials were part of what she calls an "ill-fated plot to circumcise everyone regardless of AIDS status!" She and others often demonize the scientists whose research has produced facts that contradict their extremist views.

Daniel Halperin, Ph.D., spent much of the 1990s poring over epidemiological studies of AIDS, looking for places in Africa and Asia where HIV rates were relatively low and then trying to figure out why. Halperin, a senior research scientist at Harvard's school of public health, concluded that circumcision played a role and he paid a high price for saying so — many people thought he was nuts. In some ways, since he's been proved right, the price has become steeper. To get a flavor of it, look at his inbox.

"F**K OFF," begins one e-mail, "with your PRO-CIRCUMCISION BIASED BULLS**T .... [forcing] genital surgery on young boys who haven't done anything wrong." Another e-mail calls him "a Super Racist" devoted to the murder of Black Africans under the guise of helping them.

"It's been quite a struggle," Halperin sighs, shaking his head.

But it's not without its rewards. The Africa trials add substantial weight to a mounting pile of evidence that circumcision also reduces the spread of other sexually transmitted illnesses, including several types of cancer and venereal disease. The journal BMC Infectious Diseases published a study (co-authored by Halperin and four others) that compared rates of cervical cancer — caused by the sexually transmitted human papillomavirus, or HPV — in more than 100 countries in Asia, Africa, and Latin America. In countries where fewer than 20 percent of men were circumcised, cervical-cancer rates were about 70 percent higher than in countries where more than 80 percent were circumcised.



All of this makes many public-health experts in the United States lament the decision of some states to withdraw Medicaid coverage for routine circumcision. "Because uncircumcised males face greater risk of HIV and other sexually transmitted infections," a different study concludes, "lack of Medicaid coverage for circumcision may translate into future health disparities for children born to poor families."

Verdict still out on circumcision
So what's the verdict? Should all males be circumcised? Not one doctor or scientist interviewed for this article expressed that opinion. Robert Bailey, Ph.D., a professor of epidemiology at the University of Illinois at Chicago, feels that "American parents should definitely factor all of this in, but it's not an automatic. Most of the diseases [circumcision] is known to prevent are pretty rare in the United States."

But, Halperin notes, "those illnesses may be rare at least partly because circumcision has been so widespread here."

But whatever you decide for you and yours, do not let anyone tell you circumcision can't slow the march of HIV. At a time when billions of American tax dollars are pouring into Africa to fight AIDS, it is extremely important that money is spent on methods that have been proved to help.

Elliot Jones (not his real name) underwent circumcision at age 35. He had a painful case of phimosis, a condition in which the foreskin tightens around the head of the penis, and surgery was the solution. "I heard you lose a lot of sensitivity, but at that point I was in enough pain that I didn't care," says Jones.


"It's a simple surgery, but people think it's painful because it has to do with the penis," says Larry Lipshultz, M.D., chief of the division of male reproductive medicine at Baylor College of Medicine. Most patients choose general anesthesia for the hour-long surgery and go back to work the next day, says Dr. Lipshultz.

For a week after the surgery, Jones would wake up in pain from a morning erection pulling at the dissolvable stitches. But after 2 weeks, his wife was more than ready to test out his newly shorn package. The sensation? "This is better than before," says Jones, now 7 years post-op. "The skin under the foreskin used to be very sensitive — sometimes too sensitive. Now that it's aired out, it's a nonissue."

"My wife and I joke that she's the only one who's had the new penis," says Jones. "It's like I was a virgin again."

...again. And the winds seem to be shifting towards it. If I'm reading the article right.

[General Zod]

More correlation =/= causation bullshit. I read something similar the other day, if not the exact article and they seem to be stating the disease reduction nonsense as if it's lowered because of circumcision and not in spite of it, which is annoying to no end.

[Kodiak]

We're expecting a boy any day now and we haven't really decided one way or the other. If there's no pain for the baby by doing a circumcision and there are tangible (albeit minor) health benefits, then I would lean towards having it done.

[Darth Onasi]

Circumcision? Dr. Wang?
I call April Fools.

[The Spartan]

Circumcision? Dr. Wang?
I call April Fools.

Then you better call up MSNBC.

I know a doctor, I shit you not, named Dr. Butts. He's a proctologist. No April Fools; I'm dead serious.

[Kodiak]

Circumcision? Dr. Wang?
I call April Fools.

I thought so too, but there's nothing funny or outrageous about the article other than "hurr hurr, Dr. WANG!"

[General Zod]

Circumcision? Dr. Wang?
I call April Fools.

Turns out Wang is a common Chinese name? Who knew! Incidentally googling the name turns up a number of results. The article is genuine.

[Edi]

We're expecting a boy any day now and we haven't really decided one way or the other. If there's no pain for the baby by doing a circumcision and there are tangible (albeit minor) health benefits, then I would lean towards having it done.

As long as basic hygiene is followed, it leaving it intact should not be a problem. Use the search function with my user name and circumcision to get a viewpoint from someone who had to have it done as a medical necessity.

I call bullshit on the article, as the procedure is mostly absent here and there are no increased rates of the diseases they talk about compared to places like the US where circumcision is much more common.

The article incidentally does not make any mention on the methodologies of these studies and the author seems to be nothing if not a pro-circumcision idiot. If that's neutral, factual reporting, the standards for it at MSNBC are fucking laughable.

[General Zod]

Circumcision? Dr. Wang?
I call April Fools.

Turns out Wang is a common Chinese name? Who knew! Incidentally googling the name turns up a number of results. The article is genuine.

Ghetto edit: And by genuine I mean not an April Fools joke. Not genuine as in legitimate science.

[Cairber]

Wow the African studies return! This is the same data from the trials two years ago; they are just trying to keep us fresh by releasing it piece by piece

But ask yourself, why do these same three trials keep getting in the news over and over and something like this gets ignored by all but one news outlet:

http://www.ncbi.nlm.nih.gov/pubmed/1828 ... t=Abstract

RESULTS: Of the 499 men studied, 201 (40.3%) had been circumcised by age 3 years. The circumcised and uncircumcised groups differed little in socioeconomic characteristics and sexual behavior. Overall, up to age 32 years, the incidence rates for all STIs were not statistically significantly different-23.4 and 24.4 per 1000 person-years for the uncircumcised and circumcised men, respectively. This was not affected by adjusting for any of the socioeconomic or sexual behavior characteristics. CONCLUSIONS: These findings are consistent with recent population-based cross-sectional studies in developed countries, which found that early childhood circumcision does not markedly reduce the risk of the common STIs in the general population in such countries.

When it comes to STIs, results in Africa don't work too well when we try and apply them to the developed world.


I have about a hundred links like this; you won't see them on MSNBC because of numerous reasons, the cultural bias of the USA not the least of them.

[Dark Flame]

Turns out Wang is a common Chinese name? Who knew! Incidentally googling the name turns up a number of results. The article is genuine.

So, now that that's out of the way..

Even assuming their facts are right (which I don't believe, but I haven't checked anything yet), where do they have the right to decide to cut things off of their baby boy? Assuming there really is a tangible benefit to circumcision, it's still not a parent's choice.

Please correct me if this is wrong, but I see it a lot like having tonsils. Yeah, there could be infections, but why just start pre-emptively cutting things away? Why not wait until either the kid can decide for himself, or until it's shown that having tonsils/a foreskin isn't good for him?

[Losonti Tokash]

Doesn't the United States actually have higher rates of those disorders that circumcision is supposed to protect against when compared to Europe where it relatively rare?

[Cairber]

I also really enjoyed the British take on this:

BBC article

UK scepticism

The reason why a foreskin might increase the risk of infection with various viruses is unclear.

However, research has suggested that a man with a damp penis has a greater risk of being infected by HIV.

Various reasons for this have been put forward, including wetness allowing viruses to stick more easily to the penis, or creating tiny ulcers on the surface of the penis through which a virus might enter.

Dr Colm O'Mahony, a sexual health expert from the Countess of Chester Foundation Trust Hospital in Chester, said the US had an "obsession" with circumcision being the answer to controlling sexually transmitted infections.

He said: "Sure, a dry skinned penis is a bit less likely to contract HIV, herpes and possibly genital warts but it will get infected eventually."

Dr O'Mahony also said pushing circumcision as a solution sent the wrong message.

"It suggests that it is women who infect innocent men - let's protect the innocent men.

"And it allows men who don't want to change their irresponsible behaviour to continue to sleep around and not even use a condom."

Keith Alcorn, from the HIV information service NAM, also warned against a knee jerk reaction.

He said: "We have to be careful not to take evidence from one part of the world and apply it uncritically to others.

"Male circumcision will have little impact on HIV risk for boys born in the UK, where the risk of acquiring HIV heterosexually is very low.

"Girls can be vaccinated against HPV and so protected from cervical cancer, and condoms protect against herpes."

[Cairber]

Even assuming their facts are right (which I don't believe, but I haven't checked anything yet), where do they have the right to decide to cut things off of their baby boy? Assuming there really is a tangible benefit to circumcision, it's still not a parent's choice.

That's my big thing. Let the child decide. It's their body, their rights.

here is some more circumcision news:

family awarded 2.3 million for botched circumcision

A jury in Georgia's Fulton County awarded $1.8 million to a boy whose penis was severed in a botched circumcision, and another $500,000 to the boy's mother, the Atlanta Journal-Constitution reported Monday.

The jury made the award Friday. The child, identified only as D.P. Jr., was born at South Fulton Medical Center in 2004.

His mother filed a lawsuit two years later claiming that the doctor who circumcisedher son removed too much tissue and that his pediatrician failed to respond when a nurse complained of excessive bleeding.

Defense lawyer David J. Llewellyn, of Atlanta, said the tip of the penis was placed in a biohazard bag and that doctors might have been able to reattach it if they had acted within eight hours of the procedure.

The jury found the pediatrician, Dr. Cheryl Kendall, and Dr. Haiba Sonyika, the physician who performed the circumcision, negligent. The hospital was cleared of liability.

This same lawyer has 4 more cases of glan amputation pending right now.

[ray245]

Turns out Wang is a common Chinese name? Who knew! Incidentally googling the name turns up a number of results. The article is genuine.

You do know that Mike's surname Wong can be pronounced as Wang in Mandarin right? Moroever, Wang pronounced in Mandarin sounds different from the word Wang in English.

[Pint0 Xtreme]

I have about a hundred links like this; you won't see them on MSNBC because of numerous reasons, the cultural bias of the USA not the least of them.

Is there a compiled list of these links somewhere, Cairber?

[Surlethe]

To be fair, horrific stories of botched circumcision aren't really anything more than anecdotes. I'm more interested in whether the statistic reported in the article - 1/500 chance of a mishap in circumcision - is correct.

[Cairber]

Folder on my computer I can email a bunch to you if you would like, I have my favs pretty handy here.

Doesn't the United States actually have higher rates of those disorders that circumcision is supposed to protect against when compared to Europe where it relatively rare?

Here is a link about the number of STDs in the USA:
STD Nation


For a real shocker comparison, just look at a country like Finland and their circumcision rate in comparison to their STD rates. circumcision rate: 1 in 16667. aids rate: 35 in 1,000,000 link

USA circumcision rate: 57% (but was 80%+ just 10 years ago, so most adults are cut)
USA AIDs rate: 140 in 1,000,000 link

[Kamakazie Sith]

Circumcision? Dr. Wang?
I call April Fools.

Turns out Wang is a common Chinese name? Who knew! Incidentally googling the name turns up a number of results. The article is genuine.

I remember reading an article in the local newspaper regarding circumcision and that doctors name was Dr. De Cock.

Oh here he is... Dr. De Cock

[Cairber]

To be fair, horrific stories of botched circumcision aren't really anything more than anecdotes. I'm more interested in whether the statistic reported in the article - 1/500 chance of a mishap in circumcision - is correct.

It depends on who you ask and what their criteria are. The CDC claims that complications for adult circumcision are about 5% while infant is about 2%; however, when you look at the criteria you see that the CDC considers "pain" a complication for adults but not children! Plus, they don't even consider meatal stenosis or drying at all.

Meatal Stenosis is a complication of circumcision. Studies put it anywhere from 4%-10%. See here:

meatal stenosis

Would you consider skin bridges and tight erections in adulthood to be complications of circumcision as an infant? well, conveniently, those are left off as well!

If you are looking for botched circumcision stats alone, you have to look by device. The plastibell device, which is inserted on the penis, cut around, and remains there to let the foreskin fall off after it dies has a higher rate of infection (as you can imagine) than the Mogen clamp which is the one that tends to injure the glans because they pull the foreskin forward and then cut it:

Mogen clamp info
gomco and mogen clamp injury case study
105 injuries reported to FDA in 4 years due to circumcision clamps (plastibell injuries are not considered here)

So who knows; it has never been totally studied. Yet we have boys suffering for no reason.

[Uraniun235]

We're expecting a boy any day now and we haven't really decided one way or the other. If there's no pain for the baby by doing a circumcision and there are tangible (albeit minor) health benefits, then I would lean towards having it done.

Why can't it wait until your son is old enough to decide for himself?

[General Zod]

Turns out Wang is a common Chinese name? Who knew! Incidentally googling the name turns up a number of results. The article is genuine.

You do know that Mike's surname Wong can be pronounced as Wang in Mandarin right? Moroever, Wang pronounced in Mandarin sounds different from the word Wang in English.

You do know that my post had nothing to do with pronounciation right?

[Kodiak]

We're expecting a boy any day now and we haven't really decided one way or the other. If there's no pain for the baby by doing a circumcision and there are tangible (albeit minor) health benefits, then I would lean towards having it done.

Why can't it wait until your son is old enough to decide for himself?

I guess that's my question: Can it wait? I can't imagine a teenager (that's when I think my son would be capable of understanding the decision) electing such a procedure. Perhaps that's an answer in and of itself.

[Edi]

We're expecting a boy any day now and we haven't really decided one way or the other. If there's no pain for the baby by doing a circumcision and there are tangible (albeit minor) health benefits, then I would lean towards having it done.

Why can't it wait until your son is old enough to decide for himself?

I guess that's my question: Can it wait? I can't imagine a teenager (that's when I think my son would be capable of understanding the decision) electing such a procedure. Perhaps that's an answer in and of itself.

Yes, it bloody well can fucking wait. Did you go and take a look at what I've said on this subject?

There is no problem with an uncircumcised penis as long as basic hygiene is followed. It's your job as a parent to teach your son that. Barring a medical necessity, I advise you to just leave it the fuck alone.

[Aaron]

I guess that's my question: Can it wait? I can't imagine a teenager (that's when I think my son would be capable of understanding the decision) electing such a procedure. Perhaps that's an answer in and of itself.

Of course it can, I'm uncircumcised and as long as you teach your son how to use soap, he'll be fine. In fact our sons doctor told us when he was born that all the care required for his penis was just to let him sit in the bath water and it would get clean. Other then that, how do you feel about your infant son having his wiener chopped without anesthetic?