Talk:Circumcision

Studies

It's hard for me to tell, but have the studies referred to in this article been taken into consideration? 69.243.66.74 (talk) 21:11, 20 December 2008 (UTC)

Not really. HPV's link to circumcision seems covered in the article, perhaps a mention that HPV increases the risk of cervical cancer in women seems unrelated to male circumcision. Then again, this is a secondary source, and they saw fit to mention the link, and its concerns seem related to ethics and this one level of indirection may be a valid addition to the article. What do others think?

It also interestingly mentions that "[Dr. Ronald Gray of Johns Hopkins University in Baltimore and colleagues] noted that the American Academy of Pediatrics does not recommend routine circumcision for newborns." Also, we quote the AAFP as stating, "Evidence regarding the association between cervical cancer and a woman’s partner being circumcised or uncircumcised, and evidence regarding the effect of circumcision on sexual functioning is inconclusive" in the footnote reference. Maybe you feel should be mentioned in the prose instead? Perhaps the news source is indeed reliable, and should be used in the article. Blackworm (talk) 23:14, 20 December 2008 (UTC)

In general, it's best to avoid citing the popular press on medicine and science-related subjects; they are not sufficiently reliable (see WP:MEDRS#Popular press. Thus, although it is a secondary source, the peer-reviewed papers themselves would be preferred. The abstracts of these studies may be found at PubMed: Nielson, Warner, and Auvert.

The study by Nielson et al. is interesting and doubtless valuable as a part of the literature, but by itself it is no more important than any of the other dozen or so (at a rough guess) observational studies of HPV and circumcision that have been conducted to date. While Warner et al. is a study of HIV rather than HPV, the situation is otherwise similar. It would probably be reasonable, I think, to include both in the detailed article, medical analysis of circumcision. I can't think of any particular reason to select these particular studies for inclusion here: the question "why these studies rather than one of the tens (or perhaps hundreds, in the case of HIV) of other studies?" would be difficult to answer.

The Auvert study is somewhat different. It is the first randomised controlled trial to report results on HPV and circumcision, and as such it is a high standard of evidence (see WP:MEDRS#Assess evidence quality). I think it would be wise to include it as well as meta-analyses of observational HPV data. Jakew (talk) 11:18, 21 December 2008 (UTC)

Is it my correct understanding of the Auvert study that HPV was not measured in the two groups at the start of the study, but was only measured once 21 months later? If so, wouldn't that effectively make this an observational study with respect to HPV, rather than a randomised controlled trial? Conceivably the HPV rates could have been 14% and 22% in the two groups at the start of the study as well, unless I'm not understanding something. Blackworm (talk) 19:39, 7 January 2009 (UTC)

As far as I can tell (from what is, I admit, a brief reading of the full text), your understanding is correct in that HPV testing was performed only at 21 months after randomisation. However, this does not mean that it isn't an RCT. The most important difference between an RCT and, say, an observational cohort study is that circumcision status (or more generally, the intervention) is assigned at random as part of the experiment. By contrast, in our hypothetical cohort study, men are either already circumcised or they aren't, and there might be associations with behaviour, etc., that we are unaware of (for example, circumcision might be associated with religion, and in turn with higher or lower levels of alcohol consumption, promiscuity, etc). The rates could have differed significantly at the start of the study, but it is rather improbable. Consider what it would mean. Because you're assigning men to one of the two groups on the basis of a random number - say a flip of a coin - any pre-existing characteristics of those men will tend to be distributed roughly equally in the two groups (given reasonably large groups). The randomisation process could 'preferentially' assign HPV positive men to one group, just as a non-weighted coin could give a sequence of fifty consecutive 'tails', but in both cases that outcome would be unlikely, and one could calculate exactly how unlikely. Jakew (talk) 22:26, 7 January 2009 (UTC)

Thank you for your comment. I think you're generally correct, and the key lies in determining exactly how unlikely it would be, and putting the results in perspective. The probability that 234 men, randomly assigned to group A or B based on a fair coin toss, would result in one group having 140 members or more and the other group having 94 members or less, is 0.032%, or about 1 in 300. On the other hand, the probability that randomly assigning 234 men to two groups results in at least 130 men in one of the groups (104 or less in the other) is about 10%, or one in ten. It doesn't seem a stretch to believe in the possibility that the groups may have been significantly skewed at the start, even if circumcision was ultimately a factor. Of course, I'm not arguing for any change at the moment, as all of this analysis is OR (but I hoped you would find it interesting).

To compare your analogy, the probability of a trial of 50 coin tosses turning up all tails is .5 to the power of 50, or about 0.000000000000089%, 1 in a quadrillion.  :) Blackworm (talk) 00:21, 8 January 2009 (UTC)

Thanks for your comments, Blackworm. As you say, this analysis (and indeed much of our discussion) is OR, but I do indeed find it interesting. I think there must be a mistake: 0.032% is not 1/300 but 1/3,125. I think you meant 0.32%, but I'm not sure about this figure either - unless I've made a mistake of my own (which is quite likely), it ought to be about 0.16%, or 1/600. I think what I wanted to emphasise is that virtually all results in epidemiology could be explained as statistical flukes, but the nature of such flukes is that they're rare (especially for extraordinary ones such as the 50 coin flips). When interpreting results, I believe it's important to consider just how unlikely such a result is, as well as contextual information from the rest of the literature. In the case of this particular study (and I hope you'll forgive me for expressing my personal opinion), I would like to see other RCTs, but because the result is unlikely to be due to chance, and because the previous observational studies have fairly consistently shown the same result (for an overview of the literature as of about 2006-7, see Table 1 of Castellsague 2007), I regard the evidence as persuasive. Jakew (talk) 10:48, 8 January 2009 (UTC)

Oops, yes, I meant 0.32%, not 0.032%. I think you're getting half that number (0.16%) because you're insisting say, Group A has at least 140, where in my example either of the two groups can have at least 140 (i.e. I was including both extreme ends of the distribution, where you're including only one end... I hope that makes sense). And yes, I agree that this evidence suggests that it is not due to chance. It's the precise extent of the effect that seems difficult to pin down.

Complicating the issue is that HR-HPV is only "high risk" for the man's female partners, and there may be ethical questions involved with cutting off parts of male's penises to obtain a lesser degree of risk for that male's future partners. How much weight an editor would want to give this issue seems to depend on that editor's ethical assessment of doing that to males to slightly benefit the females who choose to mate with that male. Blackworm (talk) 19:49, 8 January 2009 (UTC)

Right, Gardisil seems a better alternative for everyone. Garycompugeek (talk) 20:02, 8 January 2009 (UTC)

It should be duely noted that this study was headed by Bertran Auvert. He has been a long-standing circumcision evangelist and has produced other studies promoting circumcision in the past. He is biased and would most likely skew the information in his "studies" in favor of circumcision. One should approach this "study," whos sole purpose is to advocate circumcision and condemn the foreskin as a factor increasing the risk of cervical cancer in women. The wording is suspect, pointing out a higher insidence in HPV in normal men, and immediately jumping to the conclusion that "this explains a higher risk in cervical cancer in women." The study comes short of suggesting all men should be circumcised to bring down the risk of HPV to the level of circumcised men, which, even according to this study, was still an 14.8%. There are other factors that make this study suspect, including, but not limited to the fact that these studies were performed in Africa, where the medical and political climate are different to that of other, more advanced 1st world countries. The study seems to focus on the presence of a foreskin as a risk factor, but leaves out others; IE, promiscuous risky behaviour, and cigarette smoking. Again, what is this study's aim? HPV risk reduction, or circumcision promotion? Assuming these "studies" are correct, would the immediate conclusion be to suggest circumcision "reduces the risk of HPV in men/women," and thus that "all men should be circumcised, and infant circumcision is vindicated on these medical grounds?" Even if these studies were to be correct, that 22.3 percent of the anatomically correct men in them had studies, what about the 77.7 percent that weren't? What about the fact that 14.8 percent of the iatrogenically defecient men still had HPV? Shouldn't studies be looking for ways in which HPV can actually be thwarted, not focusing on new ways to promote a midieval torture method? Why would an anatomically correct male in the 77.7 group who didn't get HPV have to get circumcised if he and his wife are faithful to each other? If he is faithful, but his wife is not, wouldn't his WIFE be a risk factor in contracting HPV?

And finally, with the release of Gardisil, isn't any study with regards to HPV prevention, esp. one that suggests that circumcision brings down HPV infection rate by a mere ratio of 0.66 kind of IRRELEVANT? May common sense prevail.Kogejoe (talk) 03:19, 21 January 2009 (UTC)

Just as a reminder, ladies & gentlemen, the purpose of a talk page is to discuss the article, not our personal views about the subject matter. Jakew (talk) 10:58, 21 January 2009 (UTC)

Tidying up

I've added a recently-published meta-analysis of circumcision & HPV by Bosch et al. This has, unfortunately, increased the length of the section somewhat, and the obvious solution is to move to medical analysis of circumcision (if not already there) some of the primary sources. I therefore propose to move the first two sentences (and four references), which read: "In several studies, uncircumcised men were found to have a greater incidence of human papilloma virus (HPV) infection than circumcised men.[134][135][136] One study did not find a statistically significant difference in the incidence of HPV infection between circumcised and uncircumcised men, but did note a higher prevalence of urethritis in the uncircumcised.[137]" Any thoughts? Jakew (talk) 10:58, 21 January 2009 (UTC)

Having checked medical analysis of circumcision#Human Papilloma Virus (HPV), I've found that these four references are already cited there. I shall therefore delete these sentences from this article. Jakew (talk) 12:39, 26 January 2009 (UTC)

O.k, then what about this sentence:Two studies have shown that circumcised men report, or were found to have, a higher prevalence of genital warts than uncircumcised men.

Those are primary sources. Should they be removed too? Tremello22 (talk) 17:44, 26 January 2009 (UTC)

Hmm, interesting point. There is a difference between the primary sources you mention (which I'll call "group B") and the ones I mentioned above ("group A"). The difference is that the subject matter covered by group A (the association between HPV & circumcision) is already covered through secondary sources (meta-analyses, etc) that are cited in the article. As such, the primary sources in group A add a lot of bulk but relatively little value to the reader. That isn't the case with the subject matter covered by group B (the association between genital warts & circumcision), and I'm not sure whether the reader would be served or not be removing them — I can think of arguments either way. An ideal solution would be to include secondary sources instead of group B; as soon as I have the time I'll search for some. Jakew (talk) 19:20, 26 January 2009 (UTC)

Complications section

The complications section of the article is somewhat disorganised, and needs some attention. I've made a couple of minor changes that are unlikely to be controversial (or so at least I hope), but I have some remaining concerns. These include (paragraph numbers refer to this revision):

• The discussion of absolute complication rates seems fractured, as it is presented in several different places: the first paragraph, the second sentence of the second, and the first sentence of the third. Consequently, it is somewhat difficult to follow.
• In the second paragraph, the words "A major survey of circumcision complications by Kaplan in 1983 revealed that" fall short of NPOV. "Kaplan reported in 1983 that" or "In Kaplan's 1983 review" would be somewhat better.
• The third sentence of the second paragraph is troubling for several reasons. Most importantly, it is potentially misleading. While it may be technically correct to say "haemorrhage occurred in 52% of the boys", this can easily be taken to mean "haemorrhage occurred in 52% of boys who were circumcised" rather than "haemorrhage occurred in 52% of the boys who were seen for any circumcision complication". The placement of the sentence adds to this problem: because it appears immediately after Kaplan's estimate of the absolute incidence of bleeding complications, it is natural to expect that it is another such estimate, rather than a relative measure of the frequency of specific complications. I don't understand what this sentence is intended to achieve, anyway. We've already cited a secondary source stating that haemorrhage and infection are the most common complications in the first sentence, so I don't see why we need to cite a primary source to make the same point again.
• The purpose of the third paragraph seems to have been lost somewhere. This series, which found a 0.2% complication rate, logically belongs in the first paragraph, together with estimates by the CPS and Williams and Kapila. But although this (Christakis) was a large study, it is still a primary source, and it is questionable whether it should be included at all. It would be more logical to cite a few more reliable secondary sources in the 1st paragraph - such as the AAP, etc.
• 4th paragraph: meatal stenosis. We're still spending too many words here. As a minimum we ought to delete the last sentence, which is highly indirect, being about possible complications of meatal stenosis, itself a possible complication of circumcision. Also, why cite 3 sources? Why not just cite one secondary source - say, W&K?
• 5th paragraph: 3rd sentence onwards ("Van Howe states that..."). Well, yes, Van Howe does state this, but not in connection with phimosis nor apparently any other complication. Instead, his words are in the context of his observation that there are differences in the appearance of circumcised penes. So why do we dedicate 3x as much text in this paragraph to a quote that isn't even about complications? Inexplicable.
• 6th paragraph. Should be joined to 5th after deleting Van Howe quote.

Jakew (talk) 17:49, 17 January 2009 (UTC)

Thanks for your comments, Jakew.

• Re Kaplan: one way might be just changing "revealed" to "reported". Re the study of 48 boys: how about changing it to "A 1999 study in Nigeria found that, among a set of 48 boys who were seen for complications from traditional male circumcision, haemorrhage occurred in 52% of these cases, infection in 21% and one child had his penis amputated."
• The third paragraph looks OK to me. How about joining the 1st and 3rd paragraphs together, followed by the 2nd paragraph?
• Deleting the sentence about effects of meatal stenosis is OK with me; I see your point, that we don't discuss the symptoms of HIV etc. That's handled by wikilinks.
• Re the van Howe quote: I think you're right. Apparently placing this quote in this context amounts to OR. I suggest just deleting it, or replacing it with this quote from Williams and Kapila (1993): "one of the commonest complaints is of an unsatisfactory cosmetic result."
• I agree with joining the very short Cathcart paragraph onto the previous paragraph.

☺Coppertwig(talk) 20:29, 18 January 2009 (UTC)

And thank you for your comments, Coppertwig. :-)

Re Kaplan, I think changing "revealed" to "reported" would be a good idea, but I'm still uncomfortable with "major survey". It raises some difficult questions. What, I wonder, is a major (as opposed to minor) survey, and how does one distinguish between the two? Also, given that we cite dozens (at a rough guess) of literature surveys, but do not introduce these in such a way, is this one more major than the others? I guess we could say "A survey of circumcision complications by Kaplan in 1983 reported that", but it seems unnecessarily long-winded and perhaps a little redundant given the context (after all, it's hardly likely to be a survey of cabbage farming techniques).

Re the study of 48 boys, I think your suggestion is good, particularly if this sentence is moved so that it immediately follows the second sentence. However — and I'm sorry to repeat myself — I don't understand the function of this sentence. We've already stated that bleeding and infection are the most common complications, so why do we need to repeat ourselves? More to the point, what is so important about these 48 boys that we dedicate as many words to them as to the secondary source (AMA)? If the purpose is to describe the situation in Africa, then there are probably better (and secondary) sources - for example a systematic review by Muula et al.

I wouldn't be strongly opposed to keeping a shortened version of the third paragraph, as you describe. However, I do think it should be shortened considerably, as the discussion is disproportionate: in the first paragraph, we dedicate 26 words to 2 secondary sources (CPS and Williams & Kapila), but then we dedicate roughly 4 times this amount — 107 words if I've counted correctly — to a primary source in what is currently the 3rd paragraph. If our coverage of secondary sources was reasonable, then I suppose this might seem reasonable, but it is actually fairly poor, and several important secondary sources (eg AAP, AMA, etc) are left out. It would seem a far better use of the available word count to discuss secondary sources than to go into such depth about a primary source. (I also have some concerns about the tone of this paragraph, which seems poorly balanced, and due to selective quoting is more negative towards circumcision than the source itself, which concluded "Overall, routine newborn circumcision appears to be a relatively safe procedure. It is not without some risks, however, and these risks do not seem to be mitigated by the hands of more experienced physicians." Unfortunately addressing these concerns would increase the word count further.)

We seem to agree re meatal stenosis, Van Howe, and Cathcart. :-) Jakew (talk) 22:56, 18 January 2009 (UTC)

Jakew, I have looked at most of the literature on circumcision and it seems that Kaplan, and Williams and Kapilla are the 2 main surveys of circumcision complications out there. If you know differently then please explain and tell me of the others. It would be helpful if you could list all the survey studies on circumcision complications (that you know of). That way we have the same information and we can decide which is major, which is minor etc and what that means. I hope that isn't too much trouble.

On the subject of complications arising from circumcision in Africa, it is probably best if that comes under a new section heading. This is just to avoid confusion between circumcision in a developed country and in a non-developed country. It must be noted though that circumcisions are performed in many ways in Africa (i) in the hospital - similar to developed countries, (ii) in a hut, (iii) out in the open. (ii) and (iii) usually being part of a tribal ritual. It will be tricky to condense all this info into one section entitled "circumcision complications" I think you will agree.

In regards to your discussion of secondary sources vs. primary sources. Couldn't the same thing be levelled at the sections on sexually transmitted diseases, hygiene and Penile Cancer. Seems like double standards to me. If we address that in this section then I hope to see you doing the same in those sections. Tremello22 (talk) 16:22, 20 January 2009 (UTC)

Hello Tremello22. I'm afraid that I don't intend to prepare a list of literature reviews re circumcision complications, because even if you and I were to agree on a scheme to classify these articles as "major", "minor", etc, that scheme would be original research and thus unusable in a WP article. Even if we agreed that Kaplan's review was "major" (and I'm not saying that it isn't), two fundamental problems would remain: to describe it as such would be unverifiable, and it would serve to advance that position (since by presenting one source as "major" we imply that the viewpoint attributed to it is particularly important), thus potentially creating WP:NPOV problems.

I would oppose creation of a sub-section entitled "complications of circumcision in Africa" (or similar), for several reasons. It would invite creation of similar sub-sections for the other continents in order to avoid giving Africa special treatment. It would tend to increase the word count, when the article is already too long. Also, it would introduce uncertainty about where material belongs (is source X about "complications of circumcision" or about "complications of circumcision in Africa"?). Finally, if - as you say - it would be difficult to keep such discussion short, then that may indicate that this material is better suited to an in-depth article such as medical analysis of circumcision.

Re secondary vs primary sources, I agree that there is too much emphasis on primary sources (and too little on secondary sources) in much of the article. This is more of a problem in some sections than others. I encourage you to read the archives (or simply ask) rather than making assumptions about my views; I don't think it is particularly constructive, nor particularly civil, to make accusations of double standards, but I trust you will have the grace to apologise. Jakew (talk) 19:49, 20 January 2009 (UTC)

In regards to accusations of original research. As editors we have to choose what goes in to an article We have to make a judgment on what to include, particularly in an article such as this, due to lack of space. So then we must decide what is major and what is minor, surely? Hence why a list of surveys would have been helpful.

On the second point. It was just a suggestion. But leaving it out, means that readers do not learn that there are high complication rates in Africa. That could be seen as hiding undesirable(?) information.

I think I have a good handle on your views on circumcision. I don't feel I have anything to apologise for. I said it seems like double standards. If you say it isn't then, OK. Tremello22 (talk) 21:44, 20 January 2009 (UTC)

Yes, I suppose we might decide what is a "major" source in the sense of that which is significant and/or important enough to include. But that doesn't seem to be an issue here: nobody is suggesting that Kaplan should be excluded. So the only purpose of deciding whether it is "major" or not would be to say so in the article, which would be OR. Jakew (talk) 10:19, 21 January 2009 (UTC)

OK, I concede this point. We needn't use the word 'major', if you have a problem with it. Tremello22 (talk) 21:57, 22 January 2009 (UTC)

Neutrality / Naming conventions

I'd like to start a discussion on how this article could be merged in with Genital modification and mutilation and whether this article should be renamed male genital mutilation. In my opinion the naming reflects Western bias of circumcision being socially acceptable whereas female genital mutilation is not. This is reflected in the names of the respective articles as well as their general tone.

One option would be to rename this male genital mutilation and make it more symmetric with the article on FGM. However circumcision is arguably a subset of male genital mutilation - so that may not be optimal. Brianrusso (talk) 05:01, 18 January 2009 (UTC)

After giving this some more thought, I think leaving the article name as-is is best as it best meets the wikipedia naming policy of 'most recognizable for readers', but changing the redirect for male genital mutilation to this article is appropriate as the current redirect led to a general topic, not a male-specific one. I have also re-added a reference to the alternate term for this class of procedures in the title along with one citation. Calling it solely either circumcision and male genital mutilation is not NPOV; therefore I believe the best solution is to reference both as both terms are used in the english world - the primary one being the article title. Adding a subsection to this article discussing the controversy over terms for the procedure is also a good idea IMO. Brianrusso (talk) 05:21, 18 January 2009 (UTC)

Wikipedia is not here to correct Western bias. If the terminology used in reliable sources is asymmetrical, then we need to reflect that, whether or not it is tempting to "fix" the problem. Inclusion of the term "male genital mutilation" would give undue weight to a neologism that is rarely used in the literature. Using Google Scholar, I find 330 hits for "male genital mutilation" and 61,600 for circumcision (of which 6,280 contain the exact phrase "male circumcision"). See also a related discussion.

The term "male genital mutilation" could conceivably refer to any of a number of procedures that, in the speaker's opinion, mutilate the male genitals: for example, subincision, castration, piercing, etc. It is therefore appropriate for "male genital mutilation" to redirect to a general article such as genital modification and mutilation. It could, in principle, redirect to the specific section discussing the male genitals. Jakew (talk) 12:31, 18 January 2009 (UTC)

Then again, where the terminology used in reliable sources is symmetrical (e.g, "female genital mutilation" vs. "female circumcision"), we choose a third, uncommon term for the article title (female genital cutting) and avoid the use of either of the much more common terms. This seems a contradiction. Blackworm (talk) 19:56, 19 January 2009 (UTC)

Indeed it is. Garycompugeek (talk) 16:15, 20 January 2009 (UTC)

Problem with lead

I noticed that at some point the extra info I added was deleted. In this discussion, Gary mentioned that the lead was too long. Well i disagree with that. It is a big topic and so per WP:LEAD guidelines it should be able to function as an article in itself. Coppertwig raises a few questions. He says that if this information is included, it gives extra weight to English speaking countries. I don't see that it does. This is an English-speaking encyclopedia after all. There are other language versions of this article on the foreign wikipedia sites - and they are not a carbon copy of this one. As to why it needs to be added. Well, basically, read what Dan bollinger says. That is exactly my thinking. I mentioned that when I added the info originally. But just to go over it again, so everyone gets it. The lead needs to put across that circumcision only became popular in English speaking countries. It is also needs to be stated when this happened - the late 1800's. Jakew disagreed with me in the original discussion here saying that the reasons as to why it started should not be included. I acquiesced on that. Any suggestions for a new compromise version?

On a different point. Should it be mentioned that circumcision is not required in Christianity, and that various passages in the New testament discourage it. I don't see why not. Failure to do so could be seen as non-NPOV.

I still feel the last 3 paragraphs are too distinct from each other. It might work better if they were melded into 1 or 2 paragraphs. At the moment they are more statements than anything else - which isn't good for an encyclopedia article - it is supposed to be written in fluid prose. Tremello22 (talk) 16:05, 20 January 2009 (UTC)

The existence of other articles elsewhere doesn't justify having imbalance in this article. See Wikipedia:Neutral point of view/FAQ#Anglo-American focus and systematic bias, particularly the 3rd numbered point listed. ☺Coppertwig(talk) 01:54, 21 January 2009 (UTC)

Paraphrasing the 3rd number point listed: An article on the effects of male circumcision that notes the views of academics from circumcising cultures, but does not note the views of academics from non-circumcising cultures, when their views differ substantially from those of their counterparts from circumcising cultures, suffers from a POV problem that is rooted in systemic bias. -- DanBlackham (talk) 03:12, 21 January 2009 (UTC)

Good point. Wasn't there a comment on this page at some point saying we should read the literature in other languages to get a proper perspective? ☺Coppertwig(talk) 03:20, 21 January 2009 (UTC)

I'm not sure what is meant by "circumcising" vs "non-circumcising" culture — since a certain number of circumcisions are inevitably performed due to medical necessity, presumably a circumcision rate more or less than an arbitrary value — but I suspect that English-speaking countries include both classes of culture. Jakew (talk) 10:26, 21 January 2009 (UTC)

This discussion seems to have gone off on a wrong tangent. Coppertwig, you assume that my suggestion would imbalance the lead (or the full article?). Which it won't. The NPOV issue that you point to is therefore kind of irrelevant. All I am saying is that at the moment, there is no mention of the medical introduction of circumcision in the late 18th century. I fail to see how including that key piece of 'circumcision's history' would imbalance the lead. Nor do I see how simply stating where medicalized infant/routine circumcision is popular would imbalance the lead or not be neutral.

On this tangential issue. Jakew, the 'circumcising culture' would be where children are routinely circumcised like the USA or an Islamic country. A non-circumcising culture would be one that doesn't routinely circumcise. Anyway, as I said, that wasn't the issue I raised. There is no NPOV issue if all you are trying to do is give the complete story. Tremello22 (talk) 21:55, 22 January 2009 (UTC)

Uncircumcised Males

It should be mentioned to anybody who reads this page! The page is guarded by a small number of highly biased editors. If one produces scientific evidence empirically demonstrating uncircumcised males to be at greater risk of STDs and other infections, this edit will likely be removed or challenged using dubious sources.

Weiss et al (2008) found that circumcised men are at significantly lower risk of acquiring syphilis, chancroid, and genital herpes. While Christakis et al (2008) found that six urinary tract infections can be prevented for every 1 complication endured during circumcision. Schoen (1991) found that only 10 of the 50,000 cases of penile cancer in the USA from 1930 to 1990 were in circumcised men, while the rest were seen in uncircumcised males.

Fink (2002) study found that newly circumcised men reported having better sex, while Laumann (1997) found that erectile function was superior in circumcised men, and that circumcised males also enjoyed more oral sex from their partners. Ozkan et al (2004) found that men circumcised for non-medical reasons showed an increase in ejaculatory latency time. That is, circumcised males also lasted longer in bed.

Reference list: 

Christakis D.A, Harvey E., Zerr D.M., Feudtner C., et al (2000). A Trade-off Analysis of Routine Newborn Circumcision. PEDIATRICS Vol. 105 No. 1 January 2000

Fink K.S., Carson C.C., deVellis R.F. (2002). Adult circumcision outcomes study: Effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol 2002; 167: 2113-6.

Laumann E.O., Maal C.M., Zuckerman E.W. (1997). Circumcision in the United States. Prevalence, prophyactic effects, and sexual practice. J Am Med Assoc 1997; 277: 1052-7.

Ozkan S, Gurpinar T. (1997). A serious circumcision complication: Penile shaft amputation and a new reattachment technique with a successful outcome. J Urol 1997; 158: 1946-7.

Schoen E.J. (1991). The relationship between circumcision and cancer of the penis. CA Cancer J Clin 1991; 41: 306-9.

Weiss H.A, Thomas S.L., Munabi S.K. and Hayes R.J. (2006). Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect 2006;82:101–110 unsigned ip 70.68.174.22

Please assume good faith. Comment on content not editors. Garycompugeek (talk) 16:18, 24 January 2009 (UTC)

Please sign your name with the squiggly thing. This is the main page and we have to work out what to put here, as opposed to the medical analysis of circumcision page. Currently there seems to be no method as to how things are chosen, but there you go. Personally, I think all the primary source medical studies should be restricted to the medical analysis of circumcision page. Tremello22 (talk) 21:33, 24 January 2009 (UTC)

Some thoughts:

• "Weiss et al (2008) found that circumcised men are at significantly lower risk of acquiring syphilis, chancroid, and genital herpes." -- this is already included in "Other sexually transmitted infections", see ref 144.
• "While Christakis et al (2008) found that six urinary tract infections can be prevented for every 1 complication endured during circumcision." -- Christakis is already cited as ref 102, see "Complications from circumcision". As can be seen in the first paragraph of "Medical analysis", studies have reached various conclusions about risk vs benefit; we can't single out one of these as "fact" and ignore the others.
• "Schoen (1991) found that only 10 of the 50,000 cases of penile cancer in the USA from 1930 to 1990 were in circumcised men, while the rest were seen in uncircumcised males." -- It would be more accurate to say "argued" or "stated" - Schoen didn't personally review every set of records. Regardless, this is a somewhat old paper, and more recent material exists. We cite two more recent epidemiological studies containing observed measures of relative risks, one of which (ref 163 in "Penile cancer") has Schoen as the primary author.
• "Fink (2002) study found that newly circumcised men reported having better sex..." -- close, but this isn't quite right. But there is a larger problem here. As you can see from Sexual effects of circumcision#Satisfaction, at least eight studies have reported related findings, some of which were similar, and some were not. Why select Fink's finding?
• "...while Laumann (1997) found that erectile function was superior in circumcised men, and that circumcised males also enjoyed more oral sex from their partners..." -- similar problems here (slightly inaccurate representation and selective citation - see Sexual effects of circumcision#Erectile function). In fact, this is an excellent illustration of the problems inherent in selective citation, because Fink also reported findings regarding erectile function. Fink, though, reported findings re erectile function that were roughly the opposite of those reported by Laumann. So why ignore one while reporting on the other? The neutral point of view is not served by reporting "just the good bits" any more than it is served by reporting "just the bad bits".
• "Ozkan et al (2004) found that men circumcised for non-medical reasons showed an increase in ejaculatory latency time. That is, circumcised males also lasted longer in bed." -- I regret that I don't currently have access to this paper, however I wonder if the citation can be correct - the title appears unrelated. Even if it is correct, then again, selective citation is a problem. See Sexual effects of circumcision#Ejaculatory function.

Jakew (talk) 23:27, 24 January 2009 (UTC)

I would have to agree with the unsigned comment. The article is slanted. And, Garycompugeek, you are right about not commenting on other editors. But, in this case, the unsigned user is talking about systematic biased editing. Such editing is invariably linked to certain users. Nonetheless, for the purposes of this discussion, it's important to analyze only the comments, not those who make them. The users are not relevant per policy.

Also, I haven't read the article that you are citing, Jake, but I suspect it is a small study. Or maybe I'm wrong. You'd have to tell me or provide a link. The reason I bring it up is that this article is jam-packed with small studies of consequently questionable significance. And that ultimately leads to a rather sprawling article that, at times, lacks focus. If we really scruitinize the article, it should only contain accredited, large group studies. There are lots of studies on this topic that one can be used to prove just about any hypothesis or viewpoint. However, only some of them are large enough and contain enough variable-limiting factors to be meaningful under reasonable terms. Cheers, ask123 (talk) 18:08, 26 January 2009 (UTC)

Male Circumcision may Decrease Risk of HPV Infection and Cervical Cancer

http://www.genengnews.com/news/bnitem.aspx?name=47258277

Removed data that is easily read by clicking above link. Garycompugeek (talk) 16:11, 24 January 2009 (UTC)

Oh, I see: the material you removed was apparently a copyright violation. Thanks. ☺Coppertwig (talk) 17:43, 24 January 2009 (UTC)

Sexual effects section

I don't see why this contentious line should be quoted from the 1999 AAP statement: "They continued, "Masters and Johnson noted no difference in exteroceptive and light tactile discrimination on the ventral or dorsal surfaces of the glans penis between circumcised and uncircumcised men."[15] "

The later Sorrells study (2007) illustrated significant problems:

"It is difficult to compare our data and results with those claimed by Masters and Johnson [1]; no method is documented, only their assertion of no difference in fine-touch reception on the glans. Nevertheless, their results, even if they were verifiable, are of little value to the question of the long-term sensory consequences of infant circumcision. First, the glans has virtually no fine-touch neuroreceptors [11–14]. Second, when determining the aggregate sensory impact of circumcision, the sensory effects of circumcision on the glans are of secondary significance, because the glans is not removed during circumcision. Instead of measuring changes in the glans after circumcision, it is more important to measure the sensory investment of the parts of the penis removed by circumcision."

"A poorly documented study by Masters and Johnson, briefly mentioned only in their book [1] and never subjected to peer-review, claimed to find no difference in the fine-touch perception of the glans of circumcised and uncircumcised men."

Also, a presentation was given at the World Association of Sexuality Congress in Sydney in April 2007, contrasting the Sorrells study with the Masters & Johnson study that follows. See the poster here

And circumstitions.com illustrates further problems.

So it is pretty contentious and doesn't deserve a place on the main circumcision page where space should be limited to less contentious studies.

—Preceding unsigned comment added by Tremello22 (talk • contribs)

Tremello22, to summarise your argument, it is essentially that three sources of varying reliability have criticised Masters & Johnson: a peer-reviewed paper by Sorrells et al. (relatively high reliability), a conference presentation by Kimmell, Travis, and Young (borderline reliability), and a self-published webpage by Young (unreliable). In effect, "some other people have criticised Masters and Johnson, therefore we shouldn't mention what the AAP says about them."

There are several problems here.

1. We do not cite Masters and Johnson. We cite a secondary source: the American Academy of Pediatrics.
2. Because we're citing the AAP, the fact that Sorrells et al. have criticised M&J doesn't matter. It doesn't negate the fact that the AAP chose to cite M&J in their literature review, nor does it change what they said, nor does it change the fact that the AAP dedicated one of their three sexual effects sentences to M&J. A reasonable person might well conclude from the AAP's words that a) the AAP felt that M&J were worth citing, b) they felt that M&J were relatively important, c) the AAP intended the M&J sentence to balance and comment on their previous sentence ("There are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males"), and d) that they did not criticise M&J.
3. Selecting primary sources and commenting on them are useful functions, for which secondary sources are valuable. As noted in point (2), the fact that the AAP included this sentence gives the reader information about how a significant medical organisation views the subject of the sexual effects of circumcision, which sources they regard as important, and their view about the merits of those sources. In addition, including "There are anecdotal reports..." but not their M&J sentence paints through selective quoting a misleading picture of their assessment.
4. As indicated, of the sources you cite none are as reliable as the AAP policy statement (which is not only peer-reviewed but is also a policy statement of a reputable medical organisation). The only one that comes close is Sorrells et al., which is published in a peer-reviewed journal. To delete the AAP's comments about M&J on grounds that less reliable sources have published other views about M&J seems ... peculiar.
5. Even if we did cite M&J directly, your argument would still be highly questionable. We currently cite 191 sources in this article. I suspect that the majority of those sources have been criticised in at least one peer-reviewed article. (Sorrells, incidentally, is no exception.) Some have probably received more criticism than that, and it is likely that the more influential, more notable sources have received more criticism, since that's the nature of controversial subjects. Consequently, if we were to delete every source that has ever been criticised, we would likely end up with a small number of very dull sources of limited notability. You do not cite any policies, incidentally, in support of your argument that "space should be limited to less contentious studies".
6. The views of Sorrells et al. are already included (for better or worse) in the article. To use their view as an excuse to delete a different view is problematic from an NPOV perspective: we exclude the AAP because Sorrells et al. disagree with it, and we include Sorrells' findings because Sorrells et al. agree (obviously) with it. The net effect of that is diametrically opposed to NPOV: we're excluding a significant view of a mainstream medical organisation because of the existence of a minority viewpoint that disagrees with it, preferentially representing the minority view. Jakew (talk) 22:55, 24 January 2009 (UTC)

I agree with Jakew that we don't exclude sources just because they're contentious or have been criticized; instead, we present all significant points of view. How about if immediately after the AAP quote we say something like, "Sorrells et al. state that the Masters and Johnson study was not peer-reviewed" (or "criticize ... as not having been peer-reviewed"). ☺Coppertwig (talk) 02:30, 25 January 2009 (UTC)

I have three concerns about that suggestion. First, I think if we were to include Sorrells' criticism of M&J then to be even-handed we'd also need to include criticism of other studies, including criticism of Sorrells. I could easily see all this criticism adding substantially to the length of the section, but I'm not sure that it would add much to its value. Second, I don't think it would be appropriate to interrupt the AAP text by injecting Sorrells' opinion about one of their (the AAP's) sources. There are three main secondary sources used in this section: the AAP, AAFP, and Boyle, and I think it is clearer and easier to read if we present each in turn as a coherent 'block'. It's also wise, I think, to resist the temptation to view a secondary source as a sequence of points with which one can argue and/or try to prove (depending on one's own views), and instead simply respect and report it as a viewpoint. Third, we need to consider due weight. It would seem inappropriate to give Sorrells as much weight as medical organisations such as the AAP and AAFP. Jakew (talk) 11:00, 25 January 2009 (UTC)

OK. ☺Coppertwig (talk) 14:54, 25 January 2009 (UTC)

The sexual effects of circumcision didn't feature very highly in the AAP's survey of the literature. Maybe it would help to quote it in full to see how much they devote to it:

SEXUAL PRACTICE, SENSATION, AND CIRCUMCISION STATUS A survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men.13 There are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males. Masters and Johnson noted no difference in exteroceptive and light tactile discrimination on the ventral or dorsal surfaces of the glans penis between circumcised and uncircumcised men.31

13. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA. 1997;277:1052–1057

31. Masters WH, Johnson VE. Human Sexual Response. Boston, MA: Little, Brown and Company; 1966:189–191

So maybe there is a case for removing the AAP's view from this section altogether. We don't always quote medical associations in other sections. Tremello22 (talk) 19:18, 26 January 2009 (UTC)

This argument doesn't make much sense to me. Are you saying that the AAP should be excluded because their discussion is concise? Jakew (talk) 19:25, 26 January 2009 (UTC)

I find this arguments baffling as well. For the longest time it has been argued that a great deal of weight should be given to policy statements by medical associations. Is the argument now that they should be given weight except when they fail to condemn circumcision? Jayjg ^(talk) 02:09, 28 January 2009 (UTC)

Possible bias?

As can be seen below, Ask123 has requested that I make a copy of the following at this talk page. I intend to comment on these issues shortly. Jakew (talk) 17:53, 26 January 2009 (UTC)

Hi Ask123,

I wonder if you could explain this edit on Talk:Circumcision? Your edit summary seemed rather too vague a statement of the problem(s) which you perceive. Jakew (talk) 16:26, 26 January 2009 (UTC)

I'd be happy to answer your question. I placed the tags there because the article is unmistakably slanted toward the view that circumcision is a negative procedure. For example, the section Sexually Transmitted Diseases begins with the sentence: "The origin of the theory that circumcision can lower the risk of a man contracting HIV is disputed." This sentence is clearly biased toward the idea that circumcision has no effect on the transmission of illnesses. However, there is plenty of research indicating that circumcision does have an effect in this area and in a number of other areas as well. You can find many articles whose conclusions support circumcision in the following medical journals: the British Medical Journal, Sexually Transmitted Infections, the Journal of Urology, the International Journal of Urology, the Obstetrical & Gynecological Survey, the American Journal of Pathology and many others. There is also material published by the American Centers for Disease Control and Prevention (drawn from articles in accredited medical journals) on the subject that demonstrates, in no uncertain terms, the benefits of circumcision. Given that there are numerous accredited studies supporting this practice, the section on STDs should begin with a neutral sentence, not a biased one whose sole purpose is setting up an argument against the procedure.

To be honest with you, I found bias similiar to that present throughout the article, and it's quite intense, undue and consuming of the entire entry. The article doesn't so much describe circumcision as it sets out with the agenda of negating the potential benefits of it. And it does this despite the fact there is a lot of evidence to the contrary.

Now, please understand, I am not suggesting that there is a consensus among medical professionals that circumcision is something for all men. There is certainly some controversy over whether circumcision is an imperative procedure, one that should be recommended for all males or, alternatively, should be optional. Many doctors feel that it should be elective, the administration of which is determined by the child's primary or the adult patient. But this doesn't change the unmistakable POV of the writing contained in this entry.

I hope this sheds light on my edit for you. Please feel free to ask me any further questions you may have. I am happy to work with other editors. ask123 (talk) 16:54, 26 January 2009 (UTC)

Hi Ask123. Thanks for your response.

I wonder if you'd mind if one of us copied the above to Talk:Circumcision, and continued our discussion there? I would prefer it if others interested in that page can read and understand your objections. I'd like to comment further, but would rather do so there than here, again so that others can read. Thanks! Jakew (talk) 17:07, 26 January 2009 (UTC)

Yes, Jake, that's fine. Please do so.

Also, please allow me to add the following points: there are many sections in the article devoted to certain issues surrounding circumcision like the transmission of illness, the loss/gain of sensativity, and ethical issues. Rather than presenting both sides equally and in an unbaised manner, many of these sections are structured to prove the point that circumcision has a negative effect on the individual in that given regard. These sections sometimes, in my opinion, stray from the topic in an effort to dispute circumcision, marginalize evidence that supports it, and, almost invariably, present supporting evidence after negating evidence and in a less prominent way. The overall effect is the minimization and deflation of very credible studies supporting circumcision. Whether intentional or not (I presume not), these tactics are designed to push an agenda, prove a point, sway a reader.

There are also a number of viewpoints in the article that are extremely controversial but are still presented as issues that undergo only minimal (in any) debate in the medical community. An example of that would be the idea that circumcision creates psychological trauma. This is not an idea held strongly by the medical community. The number of doctors that disagree with this opinion is many multiples of the number that supports it. Yet the section on the issue states first and most prominently, "it is now widely accepted..." The contrary position is given one marginal sentence.

Now I'm not trying to parse out each sentence in the article, but I am concerned with the overall tone and structure of the article. And I don't think that the tone and structure of the current version is even-handed. So thank you, Jake, for posting my comments on the talk page. I look forward to a productive discussion and, hopefully, changes. ask123 (talk) 17:46, 26 January 2009 (UTC)

This article is watched by many who are for and against circumcision. Great care is taken to try and be as neutral as possible in this highly contentious and controversial topic. There is science supporting both sides of most arguments which further clouds the issues. I for one feel it leans towards pro circumcision which is the opposite of your view so you see perspective also plays its part. Your concerns and contributions are welcome but what is needed is detail not vagueness plus please backup your data with professional sources. It is also highly recommended that you lay your concerns here on talk to discuss them with other involved and experienced editors. Garycompugeek (talk) 18:24, 26 January 2009 (UTC)

To ask123, I disagree with everything you have said. Are you even aware that the USA is the only 1st world country that still performs routine infant circumcision? If circumcision was as great as you suggest then other countries would be doing it. Also, do you not see the ethical problems with performing a needless operation on a boy without his consent? In order to get over that major ethical problem, circumcision would have to be a lot more beneficial for it to be worthwhile to perform it routinely on newborn babies.

One of the major problems with the article is that it isn't clear if it is about routine infant circumcision, circumcision in adulthood for whatever reason, or circumcision for religious reasons. There is a tacit assumption that we are talking about routine infant circumcision. This article actually spends a lot of space on listing circumcision's supposed benefits in preventing various conditions, so I fail to see how it is anti-circumcision. Not one medical association agrees with performing circumcision on a child without his consent. Another failing of this article is that because we have different sections promoting circumcision's various claims to a protective effect, the bigger picture is lost. The medical organisations see the bigger picture and they feel there is a net disadvantage to circumcision. So, circumcision may make you 3 times less likely to catch a UTI, but in the grand scheme of things, so what? It is easily treated with antibiotics and is very rare to start with - 1 in a 1000 chance. See what I am talking about? In order to apportion the correct weighting, this article should be a lot more anti-circumcision, because that is the opinion of most doctors. Circumcised doctors may feel differently, but that is usually due to cognitive dissonance or just basic ignorance.Tremello22 (talk) 19:06, 26 January 2009 (UTC)

Hello Ask123. Thanks for your replies.

I should start by saying that I do share your view, to a limited extent, that the article is "slanted toward the view that circumcision is a negative procedure". However, my impression is that you perceive a lot more bias than I do: my feeling is that, while there may be some bias, it's fairly close to neutral. I'm afraid that I don't agree at the present time that the tags are justified.

I should also say that I agree with Garycompugeek that "what is needed is detail not vagueness" (I'm sure Gary will be as surprised as I am to find that we're in agreement about something!). I'm afraid I don't know what to make of your more general comments (eg., "...I found bias similiar to that present throughout the article, and it's quite intense, undue and consuming of the entire entry"). When I'm trying to understand where and why you perceive bias, I need to be shown it, hit over the head with it perhaps, in order to understand. Asserting that it's there doesn't work. Tedious as it is, I need to be able to see and dissect specific sections, sentences even, in order to understand how the presentation is skewed. With that in mind, I intend to address the two specific parts you identified (HIV & psychological effects).

You argue that the sentence "The origin of the theory that circumcision can lower the risk of a man contracting HIV is disputed" is "clearly biased toward the idea that circumcision has no effect..." I'm afraid that the bias isn't quite clear enough for me to see what you're saying, though I agree that the sentence is awkward and poorly placed. The problem, I think, is that although the origins of the theory are indeed disputed (ie., there is some disagreement over who was first to publish the idea that circumcision and HIV might be linked), to say so before mentioning that there is a theory is confusing to say the least. It also seems inappropriate to begin discussion of such an important subject with something so trivial as academics bickering over who was first to publish.

Regarding psychological effects, you take issue with (I think) the BMA sentence, arguing that this isn't widely accepted among the medical profession. Maybe you're right, maybe not, but unsubstantiated claims aren't perceived to have much value at Wikipedia, and (I'm sorry to say) for good reason. What's needed is evidence, or to use WP terminology, verifiability. What we have is a verifiable statement, sourced and attributed, that says that this idea (which is "psychological risks", not "psychological trauma") is widely accepted. And it's a reliable source. I guess the question is, do you know of other sources making alternative assertions about the level of acceptance of these ideas?

Finally, to everyone: please remember that the purpose of a talk page is to discuss the article, not the subject matter. If we argue about the merits (or lack thereof) of circumcision, we will likely never agree, and will likely just get annoyed with each other. However, we can, in principle, discuss an article. Thanks. Jakew (talk) 20:32, 26 January 2009 (UTC)

Garycompugeek, I wanted to present my general thoughts on the matter before getting into the line by line details. People often find it aggressive when one jumps into nitty gritty details straight off the bat. Regarding the idea that the bias in the article is a matter of perspective, I do agree with you in principle. However, there are also specific elements of the any piece of writing that can be singled out as promoting bias. Thankfully, Wikipedia's policies attend to many of these writing elements or techniques if you will. One example of such a technique is the use of weasel words. That's just an example to point out that there are concrete pieces in any work of writing that indicate a skewed presentation. And the fact that such elements promote bias is not a matter of opinion but rather a fact. One cannot use weasel phrasing (again as an example) without promoting a particular bias. On the other hand, there are other writing elements and techniques that may or may not promote a bias, and whether or not a bias is being pushed in these instances would be a matter of opinion or perspective. We will have to differentiate between these two types throughout our discussion. ask123 (talk) 21:17, 26 January 2009 (UTC)

Tremello22, I base my stance on one thing: medical/scientific information. And, last time I checked, there was plenty of research indicating the benefits of the procedure. Your own personal deductions as to why certain countries don't perform routine circumcisions is not relevant to the "Medical Analysis" portion of this article. Obviously, only medical science is relavent to it. Also, it's easy to understand why a nation without a history of performing routine circumcisions would not suddenly adopt it. Is it an imperative that all children be circumcised at birth -- absolutely not. Obviously again, one can lead a perfectly healthy and happy life without it -- i.e. being uncircumcised will not impare one's life in any way. It's a matter of statistics and the medical community getting a handle on the health of large populations. Also, you are wrong in your assumption that most doctors disapprove of circumcision. And those who support it do so because it's their medical opinion, not because of some psychobabble nonesense or, least of all, ignorance. I believe that ignorance on this issue falls upon those without medical degrees. ask123 (talk) 21:50, 26 January 2009 (UTC)

Ask, when I pointed out that we had a separate article on circumcision, I wasn't suggesting you take your POV to this article, from the Penis article, and push it. Wikipedia tries to present a worldwide view whenever possible, and worldwide circumcision is not really regarded as a necessary medical procedure, and studies have been conducted, worldwide, and suggest that a lot of what the US medical community pushes in regard to circumcision may not be holistically accurate. And generally, if such is the case, one must say, in order to be neutral, that the subject is disputed. --Honeymane_{Heghlu meH QaQ jajvam} 04:03, 27 January 2009 (UTC)

I think I see the problem re this sentence: "The origin of the theory that circumcision can lower the risk of a man contracting HIV is disputed." I think maybe the problem is that it's ambiguous, and that Ask123 has been interpreting it in a different way from the way the rest of us have been interpreting it. I think that Ask123 may have interpreted the sentence to mean that there's dispute about the basis for the theory. We can change the wording to be more clear what the sentence is supposed to be saying, perhaps by changing it to: "There is some dispute as to who was the first to propose the theory that circumcision can lower the risk of a man contracting HIV." Ask123, would this wording be better in your opinion? If not, can you explain in what way you find it biassed? I agree with Jakew that this is a minor point and can be moved to later in the section or a subarticle. —Preceding unsigned comment added by Coppertwig (talk • contribs)

I can't speak for Ask123, but to my eye that's a lot better - it seems to be expressed much more clearly. To reduce the length slightly, we could change "to propose the theory that" to "to propose that". Jakew (talk) 10:48, 30 January 2009 (UTC)

Straw poll: should tags be removed?

Currently, three tags are present at the top of the article: {{POV-title}} (dated June 2008), {{unbalanced}} (dated today), and {{misleading}} (dated today). I'm creating this straw poll to get a rough feel for the consensus (if any) about what to do about them.

Remove all three tags

1. Tags should be accompanied by a description of the problem that is sufficiently detailed that a competent Wikipedian can understand the problem. They should also indicate a problem that can be solved. Jakew (talk) 21:03, 26 January 2009 (UTC)
2. I fear I'm not sure I can assume a wholly good faith addition of these tags to the article, although I'd very must like to, and hope it is. That being said, without accurate description of the problem, and that problem being real, rather then perhaps imagined, we cannot simply add these tags to an article. Far too many articles are tagged, and nothing ever gets done with them, because it's never stated what exactly the issue at hand is.--Honeymane_{Heghlu meH QaQ jajvam} 04:03, 27 January 2009 (UTC)
3. At this point the tags are merely defacement; there is no clear indication of any actual issue with the article. Jayjg ^(talk) 02:06, 28 January 2009 (UTC)
4. Remove all three because none of them is associated with a specific section of the talk page clearly describing the problems that would have to be fixed in order to remove the tags. I consider this to be a good reason to remove the tags because:

   • They are not associated with any currently ongoing discussion as far as I know.
   • They give the reader the impression that the entire article is questionable, when the tag may be intended to refer to specific aspects of the article.
   • At least if they were associated with specific sections of the talk page, a reader could (hopefully) quickly find that section (preferably by a link from the template) and find out which parts of the article were being questioned.
   • Lack of a clearly identifiable section of the talk page (for example, by a link from the template) shows a lack of a certain minimal amount of effort on the part of those who want the tag there.
   • Editors who wish to remove the tags don't have a reasonable chance of doing so if there is no such identified section listing the problems posited as needing to be addressed in order to remove the tag.
   • I believe such tags are intended to be temporary.
   • The tags are very visible; if left as permanent or semi-permanent features of the page they represent undue weight given to certain viewpoints.
   • For example, with the title disagreement: rather than a highly visible and overly vague tag, if it were to be a permanent feature there may be better ways of doing it, such as putting a sentence at the end of the lead like "The use of the word "circumcision" in the title is not intended to imply that male circumcision is the only possible use of the word."; this would avoid seeming to tell readers that the entire article's neutrality is questioned.
   • We can't expect to change each others' philosophies so that we all agree on everything. We try to reach consensus on article content; failing that, compromise; failing that, rough consensus; if necessary, possibly a vote. I don't think we keep tags permanently on articles just because some editors disagree, when there is no ongoing or reasonably foreseeable process that could solve the disagreement. Note for example that at the Chiropractic article, there was a SYN tag for a long time and a lot of discussion, but finally an admin closed the discussion and the tag has been removed, even though some editors are still of the opinion that there's a WP:SYN violation. The discussion had been repetitive and didn't seem likely to get anywhere.

   I just edited the Template:POV-title so that (if I did it right) one can now put the name of a talk page section like this: {{POV-title|NameOfTalkPageSection}} and it will put in a link to that section. ☺Coppertwig (talk) 23:52, 29 January 2009 (UTC)

Remove the last two tags

# sign with ~~~~
COGITO ERGO SUM 11:08, 30 January 2009 (UTC)

Keep all three tags

# sign with ~~~~

1. If some editors feel that there are reasonable problems with the article, then the tags shouldn't be "silenced" so to speak. Their purpose is to point out to readers and editors that there are potential deficiencies in the article. Once those potential deficiencies are addressed, then the tags may be removed. But to remove them beforehand defeats the purpose of them and, frankly, plays down the given problem and misleads the reader into believing that there is none. ask123 (talk) 21:35, 26 January 2009 (UTC)
2. The neutrality of this article's title and/or subject matter is disputed. I agree with this tag. This article may be inaccurate or unbalanced in favor of certain viewpoints. I agree with that. Some parts of this article may be misleading I agree with that. So yes, I agree to all 3 tags. Tremello22 (talk) 19:28, 28 January 2009 (UTC)

Keep the POV-Title tag from June 2008

1. The POV-title tag since June 2008 is a reflection of an ongoing dispute regarding the article title and/or content. As "circumcision" is a topic affecting males and females,[1] this article's content should reflect that, rather than exclude all discussion of the circumcision of females while titling the article generally. Additionally, this inappropriate title cements as fact the view of activists that the circumcision of females is not to be regarded as circumcision (but rather as completely unrelated mutilation). No consensus for or against a title change was found in the most recent Requested Move. The tag is essential in both alerting the reader to the disputed status of the title, and inviting fresh commentary from editors wishing to resolve the dispute. Blackworm (talk) 23:15, 27 January 2009 (UTC)
2. Agreed. This tags main purpose is to bring attention to the title's unresolved name debate that was quite split resulting in "No consensus". I personally think we should rehash it but since I started that discussion last time I am content to let someone else have the honor. Garycompugeek (talk) 16:03, 28 January 2009 (UTC)

The definition of "routine"

I think it would help if we defined the definition of "routine" (as it is used in the phrase routine infant circumcision); that way, we are all reading from the same page. Plus I think if we create a heading on this topic, then any future debates can go here - that way we don't repeat ourselves. Jake has given his view here and here

I would like to raise a question though. Could not the word "routine" describe the routine after the baby is born - i.e it is taken away and circumcised . Rather than, "routine" describing the fact that boys are routinely circumcised (in this second interpretation, it would imply that all boys are circumcised - which has never been the case.) What I am saying is quite subtle and confusing so I will try to be more clear. In the first interpretation, "routine" is being used as a noun (the routine after the baby is born), in the second interpretation, it is being used as an adjective (describing how popular it is - 'it is done routinely'.

Any thoughts? Any future discussions on this subject can go here. Tremello22 (talk) 19:59, 28 January 2009 (UTC)

The word "routine" is used routinely by the major medical associations. It would be a WP:OR violation for us to add a specific definition. We bring the sources, let the reader follow the sources and see how the different associations use the term. -- Avi (talk) 20:41, 28 January 2009 (UTC)

Avi, you fail to have seen the point of my post. I was asking for people's opinion on what the medical associations mean by the term because I wasn't sure. This post is preceded by Jakew's recent edits where he removed the term "routine" from the history of circumcision page and the opposition to circumcision page. So if he has misconstrued the meaning of the term then his edits weren't warranted. Obviously if someone is going to use the word or the phrase in future edits it would be helpful if we were sure on what it actually means. Tremello22 (talk) 22:36, 28 January 2009 (UTC)

Problematic edits to HPV section

A number of problematic edits have been made to the HPV section (see, eg., here). There are several problems:

• The discussion of Castellsague has been changed from "However, Castellsagué et al. maintain that this meta-analysis was flawed, and further note that a re-analysis of the same data "... clearly shows, no matter how the studies are grouped, a moderate to strong protective effect of circumcision on penile HPV and related lesions."" to "However, Castellsagué et al. disagreed with these findings." There are two problems here. Firstly, "disagreed with these findings" is too vague a description of their criticisms. It is only two words shorter than "maintain that this meta-analysis was flawed", and fails to indicate the nature of their disagreement. Secondly, it deletes all mention of the results of Castellsague's meta-analysis, which is difficult to justify — not only is it a meta-analysis (and hence a high standard of evidence) but a relatively influential one, as evidenced by the fact that it is cited by the WHO (table 3, p15, ref 135).
• Inexplicable addition of "Dickson et al. (2009) found circumcision offered no protective effect against HPV after following a birth cohort of men born in Dunedin, New Zealand in 1972 and 1973, from the ages of 3 to 32 years; the adjusted odds ratio (95% confidence interval) for HPV6/11/16/18 seropositivity among the circumcised compared with the uncircumcised was 1.4 (0.89-2.2)" I really do not understand why, only 4 days after primary sources were removed from this paragraph (per #Tidying up), we would want to add new observational studies. Not only is it highly questionable whether we should be citing primary sources when we have several perfectly adequate secondary sources, but to cite a single, non-representative observational study gives it undue weight in relation to other primary sources and the secondary sources.
• "More recently, an analysis by Auvert et al. of the prevalence of HPV in the two arms of a randomised clinical trial of circumcision in Orange Farm South Africa at the 21 month visit found that the prevalence was lower in the circumcised men than the uncircumcised participants (14.8% and 22.3% respectively, a prevalence rate ratio of 0.66) in the absence of any difference in reported sexual behaviour or gonorrhea prevalence." has been changed to "Auvert et al. (2009) looked at HPV prevalence in the two arms of a randomised clinical trial of circumcision in Orange Farm, South Africa, at the 21 month visit; he found that the prevalence was lower in the circumcised men than the uncircumcised participants (14.8% and 22.3% respectively, a prevalence rate ratio of 0.66) in the absence of any difference in reported sexual behaviour or gonorrhea prevalence." -- This is a relatively minor point, but one which could have been avoided by following the advice at the top of this page ("Please discuss substantial changes here before making them..."): "looked at" seems amateurish. "Examined" is better. "He found" is inconsistent with "Auvert et al." - should be "they found".
• Finally, there are a number of utterly perplexing edits to the paragraph on genital warts that cause it to be not merely self-contradictory but, to be blunt, wrong. Problems with this particular paragraph include:
  • Cook (1993) is cited as an example of "increased risk for circumcised men" (correctly, the study concluded "Circumcised men were more likely than uncircumcised men to have genital warts") and (incorrectly) "a decreased risk [for circumcised men]".
  • Dinh (2008) is incorrectly cited as an example of "a decreased risk [for circumcised men]", flatly contradicting the study itself ("The percentage of circumcised men reporting a diagnosis of genital warts was significantly higher than uncircumcised men, 4.5% (95% CI, 3.6%–5.6%) versus 2.4% (95% CI, 1.5%–4.0%").

Jakew (talk) 14:37, 30 January 2009 (UTC)

You are right about the genital warts edit - I guess I wasn't thinking straight on that one. To address the other points.

Are meta-analysis reliable secondary sources? Not really because the authors choose the studies that they want to analyse and choose the exclusion criteria. They also might adjust the results (to account for various confounding) before reaching their conclusions. So they are open to bias like other studies. In reality they could exacerbate the unreliability rather than make it more accurate. I would call meta-analyses primary sources. So I don't think Auvert's study is more reliable than Dickson's. Auvert's study has also been criticised extensively; yet there is no mention of that criticism. Why the double standards all the time? Also the word "maintain" assumes that Castellsagué et al. have a higher degree of authority. It is also one of the Wikipedia:Words_to_avoid#Insist.2C_maintain.2C_protest.2C_contend.2C_feel You also do not reference Castellsagué et al. meta-analysis study, you only reference a letter to the editor of the Journal of Infection. So which Castellsagué study are you talking about? The one in the WHO document only references the letter too. I think letters to the editor are the least reliable of the lot - hence why "disagreed with these findings" is more appropriate. Tremello22 (talk) 18:11, 30 January 2009 (UTC)

That's an interesting argument, Tremello22, but nevertheless meta-analyses are considered to be secondary sources, and their use is encouraged, by Wikipedia guidelines:

"In medicine, primary sources include clinical trials, which test new treatments; secondary sources include meta-analyses that bring together the results from many clinical trials and attempt to arrive at an overall view of how well a treatment works. It is usually best to use reviews and meta-analyses where possible, as these give a balanced and general perspective of a topic, and are usually easier to understand!" — WP:MEDRS

"Studies relating to complex and abstruse fields, such as medicine, are less definitive. Avoid undue weight when using single studies in such fields. Meta-analyses, textbooks, and scholarly review articles are preferred to provide proper context, where available." WP:RS

I don't see the connection between your assessment of the merits of meta-analyses and Auvert's study, which is not a meta-analysis but is instead a randomised controlled trial (these are primary sources but are considered very high quality in EBM; see WP:MEDRS#Assess evidence quality).

I am puzzled by your assertion that "Auvert's study has also been criticised extensively". Auvert's study (PMID 19086814) was published on the 1st of January — only 29 days ago — which is barely enough time for even the fastest journal to publish any criticism, let alone extensive criticism. I wonder if you'd be kind enough to provide a few literature references?

I am happy to change the word "maintain" to "state" or something similarly neutral.

The Castellsague meta-analysis to which I refer is one and the same as the Letter to the Editor which you mention. For better or worse, Letters to the Editor are the standard means by which papers are criticised; when serious errors in a paper slip past the peer-review process (which, sadly, does happen from time to time), it is probable that the errors will be highlighted in a Letter. In this respect (highlighting errors & providing correct results), Letters are an essential part of the literature. Jakew (talk) 19:37, 30 January 2009 (UTC)

Yes change it to "state" and leave out the quote - because the length of the quote gives undue weight to a source of low reliability. The RCT in Orange farm South Africa has been criticised on methodological grounds, though only in relation to HIV. This is where Auvert et al obtained the data. Presumably the same criticism applies. I still see no reason to omit the Dickson study - it is a longitudinal cohort study (very reliable), in a Western country (as opposed to a 3rd world one); it measures the effect of circumcision from birth; this is in contrast to a lot of the studies - for instance, Auvert which measured the effect of circumcision of adult men, over a very short period, in a 3rd world country (where lots of confounding factors abound). Given that this Medical analysis section tacitly implies that all these studies are in relation to routine infant circumcision, I think of all the studies, in relation to routine infant circumcision, the Dickson study is the most reliable. Tremello22 (talk) 22:01, 30 January 2009 (UTC)