Talk:Circumcision

Stanford School of Medicine

Please watch the three "Professional Education," "Neonatal Circumcision: An Audiovisual Primer procedure instruction clips found here[[1]]. See how the gomco, mogen, and plastibell instruction clips discuss breaking adhesions or crushing and cutting the band sometimes found on the ventral side of the penis from the corona. The "Modern circumcision procedures" section in wiki lacks mention of this common (I see 20 - 30% of the time elsewhere in wiki) technique. I found it in a surgical manual. I'm working on adding something to that section.Zinbarg (talk) 18:00, 20 November 2009 (UTC)

I think this might be a little complicated, and would therefore ask that you propose any change here, on the talk page, so that we can agree on what needs to be done before changing the article itself. Jakew (talk) 18:42, 20 November 2009 (UTC)

Modern circumcision procedures

For infant circumcision, modern devices such as the Gomco clamp, Plastibell, and Mogen clamp are available commonly used.

With all modern these devices the same basic procedure is followed. First, the amount of foreskin to be removed is estimated. The inner lining of the foreskin (preputial epithelium) is then bluntly separated from its attachment to the glans, and the foreskin is retracted to ensure that the glans can be freely and completely exposed. The frenulum band may need to be broken or crushed and cut from the corona near the urethra to free the foreskin. The device is then placed (this sometimes requires a dorsal slit) and remains there until blood flow has stopped. Finally, the foreskin is amputated[[2]].Zinbarg (talk) 00:45, 21 November 2009 (UTC)

I hope you don't mind, Zinbarg, but I've added highlighting to the above to show changes from the current version. I'll comment in a moment. Jakew (talk) 10:09, 21 November 2009 (UTC)

I oppose these changes, for the following reasons:

• Change of "With all modern devices the same basic procedure is followed" to "With all devices..." — we don't know that this procedure is used for all devices. We only know that it's used for the modern devices mentioned in the previous paragraph.
• Addition of "The foreskin is retracted to ensure that the glans can be freely and completely exposed." — this sentence is partly redundant, since we've already stated "The foreskin is then opened via the preputial orifice to reveal the glans underneath and ensure it is normal."
• Addition of "The frenulum band may need to be broken or crushed and cut from the corona near the urethra to free the foreskin." — this is not supported by the cited source (the AAP's 1999 policy, see section "Methods of circumcision"). Jakew (talk) 10:19, 21 November 2009 (UTC)

Thank you for highlighting the changes, which make things much easier to follow. I agree with your criticisms. I simply objected to the word modern when we're talking about medical devices that have been used for so very long. I added "these" above. I also changed the order of the sentences, and got rid of the redundancy. We could use the stanford instructional material as citation (short version added above) to support the statement about basically properly dealing with frenular breeve and chordee as they become apparent during circumcision. We could cite good cosmetic and functional result? Do you want to include those medical conditions in the text? There is still redundancy, in that much of the common procedure above is repeated in the descriptions of using the specific devices. I'll probably work on those sentences next, but it will just be taking stuff out.Zinbarg (talk) 05:41, 22 November 2009 (UTC)

Thanks for changing the above, but I'm still uneasy about the frenulum sentence. The problem is, if we cite two sources at the end of a claim then the implication is that both sources support that statement. But here, it's a synthesis of the two sources that, together, support the statement. We ought to avoid that.

Here's an alternative suggestion: why don't we add the following sentence after the main material (and after the AAP citation). "Sometimes, the frenulum may need to be broken or crushed and cut from the corona near the urethra to free the foreskin." Jakew (talk) 10:51, 22 November 2009 (UTC)

Parent's Resources Link

Circumcision Decision-Maker [3] I found this refreshingly different approach to circumcision information for parents. Let's face it, the most frequent visitor to these pages are people researching the circumcision decision, as opposed to say, students, doctors, lawyers or academics. It isn't pro or con on the circumcision issue, but rather pro-parent as it looks at the reasons parents might chose circumcision and then explores them individually. I suggest a new "External Link" section be created for this, something like "Circumcision Information for Parents. Frank Koehler (talk) 02:00, 21 November 2009 (UTC)

As far as I can tell, this is just another anti-circumcision website: having spent some time browsing through the various issues, every single page seemed designed to persuade people not to circumcise. I can't see that it offers anything that isn't already provided.

Actually, looking at their "Panel of experts" page leaves little doubt as to the anti-circumcision nature of the site: "The panel’s consensus is that the foreskin is a vital, functional part of the male genital anatomy—is not a birth defect—and, if there is not a strong, valid, and immediate medical reason for removing it, for ethical reasons, it should remain intact. The owner of the penis should decide how it looks and works, when he is old enough to do so." Jakew (talk) 10:22, 21 November 2009 (UTC)

Granted, they tend to advise against it more than recommend it, but that doesn't make them anti-circ any more than it makes them pro-circ. The other links tend to be more adamant about being pro-circ or anti-circ than this one. At least they strive for balance. Regardless, I think it is more important that it be provided to readers than some of the other links, some of which are personal opinion websites, not organizations. And, this group lists all the names of their editorial panel, not something that some of the other websites do. No one has suggested it not being listed. Frank Koehler (talk) 12:57, 26 November 2009 (UTC)

The page I cited clearly states that, except for special circumstances, the "foreskin ... should remain intact", in other words circumcision should not be performed. If that isn't an anti-circumcision sentiment, I'd like to know what is. If it is included, it should be listed under "Circumcision opposition". To do otherwise would, in my view, be misleading. Also, if it is included, it should replace one of the existing links, since we're trying to preserve balance between links representing each point of view. So I guess the question is, what link would you propose to delete? Jakew (talk) 13:24, 26 November 2009 (UTC)

I think it is important to include because parents want quick, online answers. I understand the need to keep balance in this article. Konig mentions this below in keeping the same number of links. I would replace the link to the Circumcision Information Resource Pages (CIRP). CIRP is not an organization, it is a ersatz library. To me, it is redundant since many of the CIRP articles important to this discussion are already referenced here. And, these articles are easily found using any search engine, plus the medical libraries like MedScape and PubMed. If no one objects, I'll make that change in a day or two. Frank Koehler (talk) 14:59, 26 November 2009 (UTC)

I strongly oppose that proposal. Per WP:ELYES item #3, CIRP is suitable for inclusion, precisely because it is a large library of (mostly) neutral, accurate, peer-reviewed papers. As such, in my opinion, it is the most encyclopaedic of all the opposition links. Organisations are probably suitable per the apparent intent of WP:ELYES item #1. I would suggest removing circumstitions.com, as that site is neither encyclopaedic information nor an organisation, but is basically just one man ranting about circumcision. Jakew (talk) 15:37, 26 November 2009 (UTC)

I hear what you are saying, and still CIRP is redundant. And, Circumcstitions was my second choice. I think we can go with that. I'll make the change if no one objects in the next day or two. Frank Koehler (talk) 16:41, 26 November 2009 (UTC)

Agree, I think a mix of encyclopaedic information, as well as resources for prospective parents, are key for a balanced approach to this issue. Jkonig (talk) 14:41, 1 December 2009 (UTC)

New Circumcision Opposition Link

My name is Jennifer Konig, and I am the Senior Project Manager at IntactAmerica.org. I am writing to ask that our website be added to your list of Circumcision Opposition links. Our organization, headed by Georganne Chapin, has grown exponentially this last year, and has become the leading national voice in the movement to stop infant circumcision in the United States. We are well positioned to replace smaller grassroots efforts, as we have received national media attention: MSNBC, The Today Show, and several nationally syndicated radio programs, as well as articles in The New York Times, The Chicago Tribune, and other publications. Given our national prominence, we ask that you add Intact America to your list, and in an effort to keep things balanced, perhaps remove the SexAsNatureIntendedIt site, as it's not an organization, but more of a sales site. Please visit [4] as well as [5] for more information. Thank you for your consideration.Jkonig (talk) 18:49, 24 November 2009 (UTC)

This seems a reasonable request to me. Unless there are any objections in the next 24hrs or so, I intend to replace sexasnatureintendedit.com with intactamerica.org. Jakew (talk) 18:55, 24 November 2009 (UTC)

Its a reasonable addition, to me, too. Frank Koehler (talk) 22:34, 24 November 2009 (UTC)

Agreed as well. -- Avi (talk) 23:20, 24 November 2009 (UTC)

Thank you for making this change. It's very much appreciated. Jkonig (talk) 14:41, 1 December 2009 (UTC)

Circumcision much less relevant to HIV in the US

Please see this text from the cited reference[[6]]:

Conclusion 7: Programmes should be targeted to maximize the public health benefit

The population level impact of male circumcision will be greatest in settings (countries or districts) where the prevalence of heterosexually transmitted HIV infection is high, the levels of male circumcision are low, and populations at risk of HIV are large. A population level impact of male circumcision on HIV transmission in such settings is not likely until a large proportion of men are circumcised, although benefit to the individual is expected in the short term. Modelling studies suggest that universal male circumcision in sub-Saharan Africa could prevent 5.7 million new cases of HIV infection and 3 million deaths over 20 years.

The greatest potential public health impact will be in settings where HIV is hyperendemic (HIV prevalence in the general population exceeds 15%), spread predominantly through heterosexual transmission, and where a substantial proportion of men (e.g. greater than 80%) are not circumcised.

Other settings where public health impact will be considerable include those with generalized HIV epidemics where prevalence in the general population is between 3% and 15%, HIV is spread predominantly through heterosexual transmission and where relatively few men are circumcised.

In settings with lower HIV prevalence in the general population, including where HIV infection is concentrated in specific populations at higher risk of HIV exposure, such as sex workers, injecting drug users or men who have sex with men, limited public health benefit would result from promoting male circumcision in the general population. However, there may be individual benefit for men at higher risk of heterosexually acquired HIV infection such as men in sero-discordant partnerships and clients presenting at clinics for the management of sexually transmitted infections. There is insufficient evidence to suggest that circumcision reduces HIV transmission among men who have sex with men.

The US (and all other English speaking and Western countries; added 12.6.09)) meets none (less than 1% prevalence, and spread primarily by homosexuals) of the above criteria for inclusion in the UN programe. Therefore, the last sentence in the introduction is misleading because this information is not relevant to most readers. But it's in the introduction! Why is this minor medical info in the introduction at all?.

At a min, we could "add public health benefits are minimal where prevalence is below 3%" to that last sentence. But again, as I think about it, the whole sentence should be deleted.Zinbarg (talk) 00:18, 2 December 2009 (UTC)

If this were USPedia, you might have a point, but since it isn't, you don't. Wikipedia is global in scope, and is about circumcision in general. The population of the US is 308 million, that of the globe is 6,800 million. To imply, as you do, that 95% of the world's population don't matter, is frankly offensive.

The second mistake you've made is to conflate two issues. The first, which is mentioned in the introduction, is whether circumcision reduces the risk of female-to-male transmission of HIV. A secondary issue is whether circumcision programmes should be introduced as a result, and if so, where. Jakew (talk) 09:51, 2 December 2009 (UTC)

You're smarter than that Jakew. The same statement (using the 3% threshold for "consideration" of circ as a health measure) can be said for nearly all the countries in the world. Rates in Muslim countries are all far far less than 3%. HIV/circ info is not relevant to the vast majority of the world's population.

The introduction has already treated medical issues fully in the pro/con, and in the medical assiciation sentences. Medical associations have considered HIV protection benefits when making their recommendations. Your forcing minor hiv prevention benefits into the introduction after the medical association position statement is biased pro circ, and POV unacceptable.

"Consideration" is a strong word, because for example in Africa spending on circ's would crowd out spending on vaccinations which return 100x the cost equivalent longevity benefit. Your "frankly offensive" is therefore grossly misplaced.Zinbarg (talk) 15:30, 2 December 2009 (UTC)

I've placed a POV tag on Circumcision until this issue is resolved.Zinbarg (talk) 15:54, 2 December 2009 (UTC)

Zinbarg, first if you mean "the US and other countries" then you need to say that. If you say "the US" then you can't blame me for assuming that you actually mean "the US".

Second, I'm not sure where you've found the word "consideration". The source you cited above uses the term "considerable". Is that what you mean?

Third, the source you've cited does not present 3% as a reversible "threshold". It states that "settings where public health impact will be considerable include those with generalized HIV epidemics where prevalence in the general population is between 3% and 15%..." (emph. added). Note the use of the word "include", which indicates that this is not an exhaustive list of criteria, and it is not therefore a reversible statement.

Fourth, even if ignore my previous point for the sake of argument and assume that public health impact is not "considerable" in a particular country, that does not mean that circumcision or information about it is irrelevant. It just means that the expected public health impact of circumcision programmes is less than considerable.

Fifth, most of the other medical association sentences, and certainly the 1999 AMA statement quoted in the lead predate the three randomised controlled trials that led the WHO and CDC to issue their statements. In order to give a more complete picture, therefore, it is necessary to cite these medical associations as well. Also, doing so helps to "explain why the subject is interesting or notable" and "summarize the most important points" (WP:LEAD). Jakew (talk) 15:59, 2 December 2009 (UTC)

The vast majority of readers of this wiki article are english speaking Americans. I see other languages have their own wikis, which implies a focus of this version on US readers. Regardless, it's only relevant to a few countries or a minority of global readers but you have it in the introduction as though its a VERY important part of the article. You make it much more important than other medical considerations and costs. That's POV bias.

Yes, consideration is from "considerable." If it's not considerable, it's left out of consideration (out of the range of high enough significance).

The sentence states that under 3% will have less than considerable impact on public health. "Include" means that other issues may not be considered here. For example, positive impact (of circs) requirements would "include" availability of hygenic procedure settings and methods. We already covered medical issues in the introduction in the two prior paragraphs.

We use the AMA only because we can quote them thus covering ~all other associations. Most individual association statements are recent enough to have considered hiv benefits found in studies (cited by WHO and CDC), most conducted between 2000 and 2005. For example, the AAP is 2005, CPS 2004, BMA 2006, and the AAFP reaffirmed in late 2007. Don't just look at the dates of the WHO and CDC statements (look to the underlying research).

Again, it is a benefit already covered in the introduction as a medical issue. Without bias. Placement after the AMA paragraph, and placement in the introduction puts undue weight on the information and is pro circ bias.Zinbarg (talk) 17:24, 2 December 2009 (UTC)

First, Zinbarg, there is little doubt that HIV/AIDS is an important aspect of circumcision, as can be seen from the attention given to the subject by reliable sources. A considerable fraction of papers about circumcision have focused HIV, and this fraction is increased further if you consider papers published in the past few years.

Second, you've misunderstood the sentence. As I explained, the word "include" indicates that prevalence of >3% is one of several factors leading to considerable public health impact. Consequently, as I stated, although a prevalence >3% may indicate considerable public health impact, that's not reversible: considerable public health impact does not require a prevalence >3%.

Third, the AMA discusses other associations at the time. However, the randomised controlled trials cited by the CDC and WHO were published in 2005 and 2006. Very few statements have been published since then; the AUA's statement is the only one that springs to mind. Jakew (talk) 17:55, 2 December 2009 (UTC)

"Attention given" is subjective. Recent attention doesn't mean it belongs in the lead. It's a known health benefit, but you present the information so that it subjugates the prior pro/con (includes medical) advocacy and the medical association paragraphs. You overweight the importance of HIV benefits relative to religious and cultural reasons, which are the primary reasons for almost all circumcisions.

We won't agree on "reversible." You know statistics; it's actually reversible. Instead look to the next paragraph in the WHO statement: "In settings with lower HIV prevalence in the general population, including where HIV infection is concentrated in specific populations at higher risk of HIV exposure, such as sex workers, injecting drug users or men who have sex with men, limited public health benefit would result from promoting male circumcision in the general population." In other words, VERY limited benefit for the vast majority of our readers, or of those who circumcise. But you force it into the lead, apart from the prior medical related paragraphs. VERY few circumcisions are done for medical reasons. This presentation in the lead is POV.

The HIV preventive benefits from circumcision were known well before 1999 (pre AMA statement) with the first meta in 2000. Looks like the WHO cited studies are 2000, 2007, 2005 and 2007. The CDC cited studies from 1999 to 2007 (2000, 2006, 2000, 2003, 2000, 1999, 2005, 2007, 2007, 2006). The RACP statement came out in 2009, the CPS in 2004, the AAP reaffirmed (not recommend) in 2005, and the BMA in 2006, so all would have considered HIV benefits. Note the CDC doesn't recommend circumcision in the US, and the WHO recommends conditionally.Zinbarg (talk) 00:50, 3 December 2009 (UTC)

Zinbarg, the present arrangement, consisting of the sentence about the WHO, etc., as well as the AMA sentence, has been the subject of long-standing consensus for a long time. It represents an attempt to represent the views of most medical associations via the 1999 AMA statement (admittedly outdated, but the best we have), and also documents another, more up-to-date statement from a globally influential medical organisation - the WHO. The two serve to balance each other: citing the AMA but not the WHO would give an outdated view skewed against circumcision, whereas citing the WHO but not the AMA would, perhaps, suggest stronger support for circumcision than is the case.

To an extent, the attention given to HIV is objectively verifiable. By checking Google Scholar, for example, we can confirm that there are 87,300 articles referring to circumcision, of which 14,800 (17%, roughly 1 in 5) discuss HIV. If we consider papers published in the last decade (since 1999), 14,400 and 9,100 (55%, roughly 1 in 2) respectively. The conclusion is difficult to escape: as a fraction of the text in the lead, the single sentence given to HIV is about the same as even the lowest of those percentages, let alone the more recent papers that represent more current scholarship on the subject. To remind you, Wikipedia articles are supposed to reflect the weight given to various aspects of the subject in reliable sources.

As I've stated several times now, the randomised controlled trials that led the CDC and WHO to publish their statements were published in 2005 and 2007 (Sorry, I erroneously said 2006 before; that was the date of the press release announcing the results of the latter two, the respective papers were not published until early 2007). It is true that papers have been published on the subject dating back to 1986, but due to the design of other studies, they were not considered sufficiently strong evidence (see, for example, the 2003 Cochrane Review and compare with the current Review. Also see this August 2006 press release from WHO stating that "WHO, UNFPA, UNICEF and the UNAIDS Secretariat emphasize that their current policy position has not changed and that they do not currently recommend the promotion of male circumcision for HIV prevention purposes. However, the UN recognizes the importance of anticipating and preparing for possible increased demand for circumcision if the current trials confirm the protective effect of the practice."). You might find Circumcision and HIV helpful.

So, if we consider the policies that you mention: the 2009 RACP update appears to have been withdrawn (at any rate it doesn't seem to be on their site any more), and in any case was a preliminary document lacking a detailed discussion of the evidence. The 2004 CPS statement and 2005 AAP reaffirmation predated the trials. Only the BMA post-dates the publication of one trial, and that document specifically avoids discussion of the medical harms or benefits, stating "The Association has no policy on these issues", so it can't meaningfully be included.

Since the sentence is about an effect of circumcision, rather than asserting a reason for it to be performed, I don't see the relevance of your comments about reasons. Jakew (talk) 11:02, 3 December 2009 (UTC)

Doing away with the indentation, you're correct in that HIV/circumcision is a hot topic recently in research. I guess I don't mind mention of the WHO and CDC statements in the lead, but that should be in the AMA (ie medical) paragraph and carefully written. It should be clear to the reader that the CDC does not recommend circumcision in the US, and the WHO effectively recommends only several countries in Africa (see[[7]]). Those conditions mean they don't recommend in English speaking countries, or in countries where almost all circumcisions currently take place.

I have very limited experience with "consensus." Please focus on verifiable fact without propaganda. Putting the HIV info in it's own paragraph in the lead is propaganda, made worse by its' placement at the end of the introduction, placement away and after the medical and pro/con paragraphs and, and by not noting the WHO conditions for relevant public benefit.

I understand the gold standard studies in 2005 and 2007. Regardless, the RACP, BMA, and AAP statements came after at least the 2005 study (confirmation). Lets not speculate on the RACP. The relevant BMA quote is: "The medical benefits previously claimed, however, have not been convincingly proven, and it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks. It is essential that doctors perform male circumcision only where this is demonstrably in the best interests of the child." The BMA has no opinion about religious circumcisions. The AAP came out in April 2005, but one of the gold standard studies came out in Feb 2005, so it would have been considered. If you believe the WHO, the primary basis for Assoc. decisions (cost/benefit) isn't changed where the incidence low and the disease in small (homosexual) demographic clusters. They all do not recommend routine "medical" neonatal circs.Zinbarg (talk) 16:04, 3 December 2009 (UTC)

It's difficult to imagine how the information you propose including could be expressed concisely, accurately, and with appropriate sourcing. However, I'm willing to consider a concrete proposal. What specific changes do you have in mind? Jakew (talk) 16:25, 3 December 2009 (UTC)

I agree with Zimberg in wondering why that statement is in the introduction. It isn't a primary or defining point about what circumcision is, it is controversial (the African studies researcher bias has been debated in their journals), and the effect and application is limited in a number of ways. This is a biased statement. At best, it goes down in the HIV section where its scope can be properly qualified. Because this topic has been in the news doesn't mean it deserves 'top billing' here. That would negate the factual, NPOV goals of WP. This isn't a news column or a blog, its an encyclopedia. My opinion is for deletion. Frank Koehler (talk) 16:23, 5 December 2009 (UTC)

I haven't been able to add the gist (removing mucosa reduces m/f intercourse infection) without undue emphasis. The only way I could think of making it relevant was to say it was a hot item in research recently. It's well covered in the HIV section. The lead is much more professional without the HIV paragraph/information.Zinbarg (talk) 19:30, 5 December 2009 (UTC)

(ec) I'm not convinced of Zinbarg's statement that the vast majority of readers of this article are English-speaking Americans, and suspect that's probably mistaken. Even if it were true, I would still oppose writing this article with a pro-US bias or favouring US readers; it should be NPOV, treating all countries of the world equally.

The weight placed on various subtopics should reflect the weight on those subtopics in reliable sources; this should determine the weight in the lead as well as in the body of the article. To get a feel for the weight of the circumcision-and-HIV subtopic, I looked at the first 10 Google Scholar hits in a search for "circumcision" for each of the following years. The number of hits mentioning "HIV" in the title (for the years I happened to check, if I counted right; I worked backwards from 2009, so found myself doing mostly odd years and filled in 2006 and 2008 afterwards) was:

year		1981	1991	2001	2003	2005	2006	2007	2008	2009
Google scholar hits mentioning HIV in title among first 10 hits		0	0	4	3	5	3	8	4	3

While the large amount of attention to HIV might be called "recent", since it seems to pretty well span at least the past 10 years, it's not just a brief spate of media attention, but a significant subtopic in the overall reliable sources. So the paragraph in the lead looks reasonable to me as a reflection of this amount of weight. If some of you feel that the paragraph leaves out some significant points of view about HIV, you can suggest different or additional wording to add to the paragraph, along with arguments that those points of view to be added are given a significant amount of weight in reliable sources. However, I think that the last part of the sentence ("minimal protection", etc.) already gives balance by presenting an alternative point of view, although from the same source.

Your Google hit table is novel, but all you've really done is show that HIV research began when AIDS was first discovered and named. In the grand timeline of circumcision going back millenia, the HIV aspect is just a blip, and it hasn't been proven that circumcision stops AIDS, which also makes the statement misleading. Frank Koehler (talk) 14:17, 6 December 2009 (UTC)

"Intervention" can mean something done to an individual, not necessarily a population-wide program. It's still a fact that these organizations have made these statements, regardless of what country one is in when one reads it or whether that information is relevant to decisions about programs in those countries. I think readers are smart enough to realize that reduction of risk of HIV transmission is relevant only in cases where there is an infected partner. ☺Coppertwig (talk) 20:09, 5 December 2009 (UTC)

I don't have the same confidence you do, Coppertwig. People still believe that smegma is carcinogenic, and that babies don't feel pain during circumcision. Let's not assume any more than we have to. Frank Koehler (talk) 14:17, 6 December 2009 (UTC)

Wait: I thought of a possible wording: appending at the end of the last sentence of the lead "... and also discuss how the health impact of circumcision programmes may vary with setting." (based on the same two references.)

I'm suggesting this to try to address the concerns raised by Zinbarg and Frank Koehler, but I myself don't think it's necessary. I note that the WHO/UNAIDS report also says "9.1 Countries should estimate the resources needed, develop costed national plans and allocate resources for male circumcision services without taking away resources from other essential health programmes." In other words, it seems to be recommending circumcision programmes in all countries. ☺Coppertwig (talk) 23:52, 5 December 2009 (UTC)

I think you are falling into the pitfall of trying to put everything in the introduction. There's an HIV section. Let it do its job. Circumcision is defined as the removal of the foreskin. It is not defined as a proposed AIDS prophylactic. If that were true, then circumcision would not have existed prior to 2001, according to the table above. Frank Koehler (talk) 14:17, 6 December 2009 (UTC)

Recommending only where there will be considerable public health benefit, as discussed above; Copper please read. That's true in no English speaking country. Our audience. It's not relevant to our audience because it's not a considerable health measure. There just isn't enough HIV in the English speaking countries. Medical associations considered the issue, and do not change their recommendations; as discussed above. Being in the news/research is not basis for introduction level relevance in a proper encyclopedia. This is not a blog.Zinbarg (talk) 00:12, 6 December 2009 (UTC)

Hi, Zinbarg. Thanks for your reply. Sorry: could you specify the particular sentence so I don't have to re-read this whole thread? Is it a different sentence from the one Jake explained uses 3% as a minimum but not as a maximum threshold? Perhaps they contradict themselves; the sentence I just quoted seems to recommend public health measures in all countries.

Our audience is not only English speaking countries, but people who read English regardless of whether they're native English speakers or not and regardless of whether they live in a country of predominantly English speakers. Even if the audience were only people in English speaking countries, we cannot assume these readers are uninterested in what happens in other parts of the world.

It's not only in news/research, but is also in secondary sources such as the cited documents, which is what makes it very relevant for this encyclopedia.

I'm not convinced that medical organizations didn't change their recommendations; I thought I remembered an updated set of recommendations from a medical organization that had subtly different nuances. Even if some medical organizations considered the information and didn't change their recommendations, that doesn't change the fact that the WHO and CDC made the statements quoted. If you can find a source that states that medical organizations didn't change their recommendations, possibly some wording could be added based on that.

If medical organizations didn't change their recommendations, that in no way erases the fact that there is extensive coverage of this subtopic in reliable sources. ☺Coppertwig (talk) 01:55, 6 December 2009 (UTC)

Pasted from the top of this discussion, from the UNAIDS citation: "In settings with lower HIV prevalence in the general population, including where HIV infection is concentrated in specific populations at higher risk of HIV exposure, such as sex workers, injecting drug users or men who have sex with men, limited public health benefit would result from promoting male circumcision in the general population."

Also from above from me: The US (and all other English speaking and Western countries; line added 12.6.09) meet none (less than 1% prevalence, and spread primarily by homosexuals) of the above criteria for inclusion in the UN programe. Therefore, the last sentence in the introduction is misleading because this information is not relevant to most readers. But it's in the introduction of this article!

Copper you seem to suggest, and Jakew's purpose is to sow doubt on the current recommendations of medical associations; 1999 AMA, versus 2007 and 2008 for the UNAIDS and CDC statements. That's propaganda and without factual basis. We discussed above the fact that the RACP 2009, CPS 2004, AAP 2005 (3 months after the 2005 gold standard study was published) and BMA 2006 statements all came after strong ie gold standard, HIV studies (even by 2004, when the CPS came out with their update, a strong effect was well known). Pasted from above and tweeked: "The HIV preventive benefits from circumcision were known well before 1999 (pre AMA statement) with the first meta in 2000. Looks like the WHO cited studies are 2000, 2007, 2005 and 2007. The CDC cited studies from 1999 to 2007 (2000, 2006, 2000, 2003, 2000, 1999, 2005, 2007, 2007, 2006). Note the CDC doesn't recommend circumcision, and the WHO recommends conditionally." Again, it's logical that Assoc policy wouldn't change, given the low incidence and demographics of HIV in those (English speaking) respective countries.

Relevant to the article yes, but not in the lead because it's no more relevant (very minor in English speaking countries) than any other medical benefit. It's well covered in the body of the article, and in it's own article.

You said we should add something like "health impact of circumcision programmes may vary with setting." And I want the medical stuff in one paragraph without all those irrelevant dates and fluff. Not that I'm happy about it, but how about:

The Joint United Nations Programme on HIV/AIDS, and the Centers for Disease Control and Prevention state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides minimal protection and that limited public health benefit would result from promoting male circumcision in the general population. The American Medical Association states: "Virtually all current all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice."Zinbarg (talk) 16:30, 6 December 2009 (UTC)

We got bogged down in "English speaking" stuff. The point is that there are very few countries in the world where there is enough HIV in the population having heterosexual relations to make circumcision a relevant health issue. It could have great impact in some African nations, but that's it. And some African nations are not our audience Copper. So why is HIV in the lead at all? An attempt at propaganda.Zinbarg (talk) 16:43, 6 December 2009 (UTC)

I see several obvious problems with your proposal, Zinbarg:

• It's erroneous. Neither the CDC nor the WHO state that "limited public health benefit would result from promoting male circumcision in the general population".
• Because the AMA sentence appears in the same paragraph, it appears as though the AMA are commenting on the same issue.
• No dates are provided. This actually makes the problem noted above worse, because it appears as though the AMA is a response to the WHO's statement. Jakew (talk) 16:59, 6 December 2009 (UTC)

It's a direct quote (fourth paragraph in Conclusion 7) from the WHO and directly implied by the CDC statement, and it pertains to our audience.

The AMA is in a seperate sentence with it's own citation. The AMA sentence does not read as a response to the WHO statement; it's an associations do not recommend statement. You just feel that way because it doesn't meet your purpose (sow doubt on the current recommendations). No dates are needed because they all are very current.Zinbarg (talk) 17:15, 6 December 2009 (UTC)