Talk:Circumcision

Warning for those maintaining this article

Be warned, there are probably 1-7 people who may come here in the next few weeks to bias this article for the anti-circumcision crowd. If you don't have it on your watch list you might want to add it. — Preceding unsigned comment added by 76.102.43.93 (talk) 01:41, 27 May 2011 (UTC)

Has something happened that makes you think this article will be targeted? Jayjg ^(talk) 03:12, 27 May 2011 (UTC)

In California there are two cities (San Francisco and Santa Monica) proposing to ban male neonatal circumcision. I think that's the reason behind unsigned's warning. Claycrete (talk) 08:20, 27 May 2011 (UTC)

1-7 is an oddly precise range, though... Jakew (talk) 10:05, 27 May 2011 (UTC)

Without drawing attention to the source (because if they get any they will come in full force) Clay is correct. It's a small group of anti-circumcision fanatics who have already had a prior online discussion about "cleaning up wikipedia" of their rival view. I know a little less than nothing about wikipedia, but I rely on it for information, and adding propaganda to that is just wrong IMO. Keep eyes peeled for "citations" from sites such as noharmm.org, circumcision.org, historyofcircumcision.net, cirp.org, intactamerica an the like. I don't really care who believes what, or if there's a criticism section, or even an anti-circumcision argument section. I just really don't want it to become biased or slanted because I really like wikipedia's neutral structure. — Preceding unsigned comment added by 76.102.43.93 (talk) 13:59, 27 May 2011 (UTC)

It turns out you were right, and they have already arrived in full force:

• Earthsales5 (talk · contribs)
• Galateo46 (talk · contribs)
• Obamancrush (talk · contribs)
• Quabosman (talk · contribs)
• ApocalypseNow1 (talk · contribs)

Since they've already arrived, could you now explain what has brought them here? Jayjg ^(talk) 22:42, 1 June 2011 (UTC)

RACP, RDMA, WHO and CDC statements

User:Earthsales5 keeps adding the following statement to this article's lead:

After reviewing the currently available evidence, The Royal Australasian College of Physicians (2010) "believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand", and the Royal Dutch Medical Association (2010) called upon “doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications”.

Because the lede of this article is contentious, and has been arrived at through extensive discussion and negotiation, any change is bound to be controversial, and unbalance the material there. Could Earthsales please explain:

1. Why he quotes these specific medical associations, when hundreds of medical associations exist in the world? These associations represent sub-sections of medical professionals in three countries with fairly small populations: out of just over 200 countries in the world, Australia is 50th, the Netherlands 61st, and New Zealand 123rd in population. Their combined populations of 43 million equal approximately the population of Tanzania, out of a world population of almost 7 billion.
2. Why he uses these specific quotes?

If he objects to the statement by the AMA in the lede, to be honest, I'm happy to remove that too, and have suggested it should be done more than once in the past. Earthsales, please discuss and get consensus here before continuing to edit-war. Thanks. Jayjg ^(talk) 18:51, 29 May 2011 (UTC)

Your suggesting removing the AMA statement is very strange. Why would you seek to remove primary information content?

Properly, HIV shouldn't have its own paragraph in the lead, being a minor health issue in the West. It's addressed prior (by Schoen), and covered fully in the main body. Unless your a poor black baby the incidence on HIV is too low to be worth considering, and it would be unethical to recommend only those babies be circ'd, says a CDC DR. The paragraph does serve to topic current news, which must be evaluated by experts, like from the RACP and RDMA.

That sentence (jayg placed above) is needed because both the RACP and RDMA explicitly covered HIV prevention benefits to arrive at their conclusion. Please read the RACP comments on HIV:

HIV/AIDS Three recent randomised trials conducted in South Africa, Uganda and Kenya, all countries with high prevalence of HIV, reported benefit of adult male circumcision in reducing HIV incidence in men, with circumcision halving the risk of adult males contracting HIV through heterosexual intercourse.[80, 85, 86] (Level 1+) Prior to theseresults, a comprehensive assessment and systematic review of 37 observational studies undertaken in 2005 also showed a consistent association between male circumcision and prevention of HIV.[87, 88] A further systematic review has now been undertaken confirming these results.[89] (Level 1+) A population survey conducted in South Africa however failed to show benefit of circumcision in prevention of acquisition of HIV.[90] In addition there has been recent criticism of early cessation of clinical trials because of clear therapeutic benefit because of the tendency for this practice to over-emphasise benefit.[91] Nevertheless United Nations agencies emphasise that male circumcision should be considered as a part of a comprehensive prevention package in Africa, but that warn it does not provide complete protection against HIV.[92] (Level 1+) A systematic review published in 2008 was equivocal about the protective benefits of circumcision in protecting men who have sex with men from HIV transmission, but recommended further evaluation.[93] A Ugandan study showed that adult male circumcision did not reduce the acquisition of HIV by the female sexual partners of HIV infected, circumcised men, and suggested an increased risk of HIV acquisition in these women.[94] (Level 2) It is still not clear that the findings from African studies, where the predominant mode of HIV transmission is heterosexual intercourse, can be extrapolated to Australia and New Zealand or other western countries, which have much lower rates of HIV infection and where the predominant mode of transmission is penile-anal sex among men.[93, 95] A recent Australian report provides some information on this issue. A longitudinal study of 1427 initially HIV-negative homosexual Australian men showed that in the 53 who later seroconverted circumcision status was not identified as a relevant factor.[75] However among those with a preference for the insertive role in anal intercourse, being circumcised was associated with a reduction in risk of HIV seroconversion.

And the RDMA information on HIV:

Medical/preventative In the past, circumcision was performed as a preventative and treatment for a large number of complaints, such as gout, syphilis, epilepsy, headaches, arthrosis, alcoholism, groin hernias, asthma, poor digestion, eczema and excessive masturbation.10 Due to the large number of medical benefits which were wrongly ascribed to circumcision, it is frequently asserted that circumcision is ‘a procedure in need of a justification’.11 In recent decades, evidence has been published which apparently shows that circumcision reduces the risk of HIV/AIDS12, but this evidence is contradicted by other studies.13 Moreover, the studies into HIV prevention were carried out in sub-Saharan Africa, where transmission mainly takes place through heterosexual contact. In the western world, HIV transmission is much more frequently the result of homosexual contact and the use of contaminated needles.14 That the relationship between circumcision and transmission of HIV is at the very least unclear is illustrated by the fact that the US combines a high prevalence of STDs and HIV infections with a high percentage of routine circumcisions.15 The Dutch situation is precisely the reverse: a low prevalence of HIV/AIDS combined with a relatively low number of circumcisions. As such, behavioural factors appear to play a far more important role than whether or not one has a foreskin.

We have a news item in the lead, which must be professionally qualified or it is potentially misunderstood as significant to public health. Note that the CDC, UNAIDS ect statements only find public benefit where there relevant incidence.Earthsales5 (talk) 19:32, 30 May 2011 (UTC)

There isn't space in the lead to cover the policy of every organisation in detail, Earthsales5. We have a reasonable summary as things stand: regarding whether routine infant circumcision is recommended we have the AMA's summary of the policies of "virtually all" other organisations, and regarding whether circumcision is protective against HIV we have the CDC and WHO. These seem to balance each other nicely, and I really can't see why your addition is needed. In fact, it seems inconsistent with NPOV to include (as Jayjg pointed out) non-representative policies and/or out-of-context quotations. Jakew (talk) 20:24, 30 May 2011 (UTC)

The last paragraph in the lead is the problem. It relates to recent HIV findings in the news, implies they are really important, and that there will be some recommendation to circ. by the CDC, or that the AMA statement is old/uninformed. I agree that we shouldn't be redundant saying don't recommend. But with the HIV studies, so far, two similar organizations (med professionals) have studied the same HIV facts and arrived at their association conclusions. Those statements are stronger than the AMA statement, so per wiki we're required to present that information. But we also need the global scope provided by the AMA quote. I guess we combine statements into one stronger one which can be dated 2010 with both cites? Properly, we should add HIV to the Schoen sentence. Would you prefer that approach?

There is no excuse for a grossly misleading paragraph lacking key neutral information, which is what we currently have.Earthsales5 (talk) 23:32, 30 May 2011 (UTC)

So, if I understand you correctly, you're picking these statements and these specific quotes because you want to contradict the view of the World Health Organization regarding circumcision and AIDS prevention? Jayjg ^(talk) 02:17, 31 May 2011 (UTC)

I join in the conversation quickly. There are no contractions between the statements of RACP and RDMA and the recommendations of WHO and UNAIDS.

For developed countries, WHO and UNAIDS have said that :

"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."

"Countries with other HIV epidemic situations should carefully consider the potential impact that promoting male circumcision and expanding safe circumcision services will have on their HIV epidemic."

Currently three countries have studied the question : France, Australia and Netherlands. (for France: "Report on Male Circumcision: an Arguable Method of Reducing the Risks of HIV Transmission", French National AIDS Council, 2007).

And conclusions are similar: that is applicable in Sub-Saharan Africa is not in developed countries.The health situation in Lesotho is not the same as in Italy. Regards.--Galateo46 (talk) 13:38, 31 May 2011 (UTC)

Exactly Galateo. So, why does the paragraph (HIV in lead) imply there will be a change in policy? Why does the paragraph imply "significant" though of limited public benefit in the West due to low incidence?Earthsales5 (talk) 15:20, 31 May 2011 (UTC)

The paragraph doesn't imply that there will be a change in policy. Furthermore, according to the WHO and other organisations, the potential impact of circumcision programmes is expected to be significant in the geographical regions where it is being promoted. Please remember that Wikipedia is a global project: we don't write it as though developed Western nations were all that mattered. Jakew (talk) 15:41, 31 May 2011 (UTC)

How's this fix. I got rid of the CDC speculation line in paren but left the reference, moved HIV up, and added RACP and RDMA affirmations to the now ending paragraph. Answering jayg, the RDMA is a quality group of professionals producing quality work.Earthsales5 (talk) 15:55, 31 May 2011 (UTC)

@Jakew, WHO and UNAIDS have said that :

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.

And look at the map of the prevalence of AIDS.

Conclusion: with the exception of some small Latin American countries, all countries have a prevalence of AIDS than 3% are in Africa. Wikipedia is a global project and the world is not just Africa. The health situation in Lesotho is not the same as in Italy, Japan, India, China or Brasil. Regards. --Galateo46 (talk) 16:44, 31 May 2011 (UTC)

I'm quite sure that if people in these countries were unimportant then sources wouldn't pay them any attention, Galateo46. Jakew (talk) 17:56, 31 May 2011 (UTC)

I agree with you, the introduction should be noted that the WHO recommendation is for countries with high prevalence in Africa.--Galateo46 (talk) 18:48, 31 May 2011 (UTC)

We don't currently mention in the lead that the WHO actually recommend circumcision (we say that they note that it reduces the risk of HIV, which isn't the same thing). Are you suggesting that we should explicitly note that they do? Jakew (talk) 11:35, 1 June 2011 (UTC)

Earthsales5, you still haven't explained why the lede should contain material from these small-country medical association statements. Please frame your response in terms of WP:UNDUE, which you should read first. Jayjg ^(talk) 03:07, 1 June 2011 (UTC)

Please Jakew and Jayjg, first, read: WP:BITE WP:AGF

Second, read carefully WP:NOTYOURS :

Some contributors feel possessive about material they have contributed to Wikipedia. A few editors will even defend such material against all others. It is quite reasonable to take an interest in an article that you maintain on your watchlist— perhaps you are an expert or perhaps you just care about the topic. But if this watchfulness starts to become possessiveness, then you may be overdoing it. Believing that an article has an owner of this sort is a common mistake people make on Wikipedia.

So, WHO has never indicated that circumcision reduces significantly the transmission of HIV worldwide. In fact, in its recommendations that the WHO says circumcision reduces significantly the risk in countries where prevalence exceeds 3% and where HIV is spread predominantly through heterosexual transmission and where relatively few men are circumcised.

We must be faithful to the recommendations of WHO and do not interpret (WP:UNDUE). So I propose this addition (in red) :

The World Health Organization (WHO; 2007), the Joint United Nations Programme on HIV/AIDS (UNAIDS; 2007) state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex in countries where prevalence exceeds 3% and where HIV is spread predominantly through heterosexual transmission, but also state that circumcision only provides partial protection and should be considered only in conjunction with other proven prevention measures.

For the CDC, the introduction mentions that. "Centers for Disease Control and Prevention (CDC; 2008) state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex". It is not true. In fact, the CDC says (1 and 2) :

"Male circumcision has been associated with a lower risk for HIV infection in international observational studies and in three randomized controlled clinical trials. It is possible, but not yet adequately assessed, that male circumcision could reduce male-to-female transmission of HIV, although probably to a lesser extent than female-to-male transmission. Male circumcision has also been associated with a number of other health benefits. Although there are risks to male circumcision, serious complications are rare. Accordingly, male circumcision, together with other prevention interventions, could play an important role in HIV prevention in settings similar to those of the clinical trial."

And :

"It is important to note that the recommendations are still in development and CDC has made no determination at this time about the final content".

The CDC has made ​​no statement. So to avoid any speculation, it should not be mentioned in the introduction.

Regards--Galateo46 (talk) 13:30, 1 June 2011 (UTC)

Galateo, it is not correct to say that the WHO state that circumcision reduces the risk in these countries. They give no indication that the protective effect depends upon geographical location. What they state is that circumcision reduces the risk, and, therefore, they recommend it in certain countries with high prevalence of HIV and low prevalence of circumcision.

Regarding the CDC, I do not understand why you've added emphasis to "It is possible, but not yet adequately assessed", since this sentence is about male-to-female transmission, whereas the sentence in the article is about female-to-male transmission. The sentence in the article is accurate, and the parenthetical comment also notes that the CDC have not issued final recommendations. Jakew (talk) 15:09, 1 June 2011 (UTC)

WHO/UNAIDS state public benefit will be limited to areas where the infection rate exceeds 3%, which overlaps geographical locations. Generally, no public benefit outside Africa. I agree that the sentence must be qualified as proposed by Galateo.Earthsales5 (talk) 18:02, 1 June 2011 (UTC)

That's not what they actually say, Earthsales5. Jakew (talk) 18:51, 1 June 2011 (UTC)

jayg, Medicine is global now, with care in the US as good as in Australia ect., and vice verse, obviously. With the RACP and RDMA we benefit from committee groups of a world class group of scientists and doctors. World class, so wiki benefits. The RACP and RDMA statements are relatively independent of the social culture and politics (procedure profit) of circumcision in the US.Earthsales5 (talk)

I'm sure that the RACP, etc., are highly competent, but that isn't by itself a good argument for quoting them in the lead. Jakew (talk) 18:51, 1 June 2011 (UTC)

The AMA link page is gone. We should replace it with the RACP and RDMA medical association statements. OR, how about a short compliation of statement from the major globla associations?Earthsales5 (talk) 17:44, 1 June 2011 (UTC)

That's irrational: whether the statement currently appears on their website has no bearing on its value as a secondary source regarding the policy statements of other organisations. Jakew (talk) 18:51, 1 June 2011 (UTC)

Oh, cool. That saves lots of round and round discussion to get almost nowhere.Earthsales5 (talk) 14:53, 2 June 2011 (UTC)

Schoen paragraph

Is about circumcision activism, pro and con. We need to start the paragraph out with something like:

• Schoen, an advocate of circumcision, argues that it provides important health advantages which outweigh the risks, has no substantial effects on sexual function, has a low complication rate when carried out by an experienced physician, and is best performed during the neonatal period. Milos and Fayre, opponents of circumcision, argue well you get the picture.Earthsales5 (talk) 17:27, 31 May 2011 (UTC)

Prior to May 22, the article read: "Arguments that have been raised in favour of circumcision include that it...". I don't understand why you changed it in the first place. Jakew (talk) 18:00, 31 May 2011 (UTC)

I made it worse, and will change to advocate/opponent.Earthsales5 (talk) 17:14, 1 June 2011 (UTC)

This is 20 years old and does not belong in the article per WP:MEDMOS. Doc James (talk · contribs · email) 22:45, 1 June 2011 (UTC)

Introduction

The citation for the third paragraph goes to a non-existing link, so there's a question as to whether the report cited even exists. According to the AMA's website, the page does not exist. In addition it seems to me that this information, if in fact it ever existed, is rather old to be cited at the very top of the article (1999) Research on this topic, as well as medical opinions, have changed since then, so this position may be out-of-date. The medical sources cited in the rest of the intro are within the last five years. Obamancrush (talk) 14:06, 1 June 2011 (UTC)

This is the current position of the AMA and AAP published on September 1, 2005 http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686 .--Quabosman (talk) 15:36, 1 June 2011 (UTC)

See my proposal above to use the RACP and RMDA affirmations of similar policy dated 2010.Earthsales5 (talk) 17:11, 1 June 2011 (UTC)

Rewrite of introduction

Let just put the current position of the scientific literature in the lead. Ie circumcision works in Africa but there is little no evidence of benefit elsewhere. Moved the discussion of specific countries positions to there section. The only one that is notable in the lead is the WHO. Doc James (talk · contribs · email) 22:47, 1 June 2011 (UTC)