Talk:Circumcision/Archive 49

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ADHD and RIC in the United States

In the 1990s, worldwide epidemiological data became available on the prevalence of ADHD. Everyone was amazing that ADHD seems to occur rarely outside of North America. And for 15 years, many ideas have been considered. Is ADHD a product of permissive Western culture? (Given the liberal social policies of Western Europe in comparison to North America, this appears to be a non-starter question.) Is ADHD a "social construct" invented by drug companies? (Perhaps the efforts to broaden diagnosis criteria to little girls who do not exhibit hyperactivity is.) And how do American health professionals talk with Europeans who don't believe ADHD exists? (Perhaps ADHD doesn't in Europe.)

ADHD is an American boys' disease. And what do Americans do to boys that Europeans and Asians do not do? One simple answer: They remove healthy tissue routinely for cosmetic reasons or on the off chance the procedure with reduce likelihood - but not prevent - a disease that could be cured with move conservative methods. And the kid will probably never get such a disease or need circumcision at all. Ever.

ADHD is marked by an abnormal cortisol reaction to stresses in everyday life, abnormal dopamine levels and glucose metabolism in the brain. Is it possible the the trauma of strapping down, ripping, crushing, pulling, tearing, crushing and finally cutting to prevent a host of diseases he probably won't get anyway, alters the autonomic and limbic fight-or-flight mechanism and that serious neurological damage is done even in the absence of memory of the event?

Second consideration: If circumcision actually reduces the chances of female-to-male HIV infection, why does the United States have a higher HIV infection rate than the United Kingdom, France, Italy, Germany, Japan and Canada? Could circumcision actually INCREASE the risk of HIV by removing Langerhans cells that provide a barrier to entry into the body? The science suggesting circumcision prevents HIV is extremely flawed. And promoting circumcision as an "arrow in the quiver" of the fight against HIV merely makes circumcised men believe they no longer need to use condoms.

Brit Pariah (talk) 03:39, 16 October 2008 (UTC)

We need stuff that is cited in reliable sources. Not to be curt, but this isn't a forum for discussion of the topic, or your own analysis. Blackworm (talk) 07:40, 16 October 2008 (UTC)

"Hygiene, and infectious and chronic conditions" section

I have reverted a number of additions to this section, as the material was problematic for a number of reasons. Here are a few of these:

  • "Kabya says that before considering circumcision physicians and parents should encourage boys to wash their hands frequently and to learn basic hygiene" - as written, this is completely incomprehensible.
  • Lengthy expansion of Fergusson to include detailed discussion of "problems". First. this adds a lot of bulk but relatively little information, and secondly, unless "problems" are defined, this is again incomprehensible.
  • Similar situation with Herzog and Alvarez - "complications" and "problems" are discussed without definition.
  • Fakjian, strangely, was removed from discussion.
  • "Like Fergusson, Van Howe found that circumcised penis's required more care in the first 3 months of life." Would need to be rephrased.
  • "To prevent adhesions forming after circumcision, parents should be instructed to retract and clean any skin covering the glans." First, this is the wrong section. Skin bridges are discussed in 'complications'. Second, it is prescriptive.
  • "The American Medical Association cite prevention of phimosis as a reason to circumcise." Do they?
  • "It is thought that only 1% of males aged 17 still have an unretractable foreskin." What does this have to do with circumcision?
  • "Some parents and physicians are not aware of the normal development of the foreskin." Unsourced, and difficult to see how it could be sourced. Also, it is difficult to see how this is related to circumcision.
  • "The foreskin is attached to the glans at birth and separates naturally over time and should never be forced." First, this isn't about circumcision. Second, it is prescriptive, and doesn't conform to WP:NPOV.
  • "However there still remains misconception that it requires action, be it ‘preputial stretching’, ‘freeing of adhesions’ or even circumcision." First, this is only tangentially related to circumcision. Second, it is hopelessly POV. If the viewpoint exists that action is required and another viewpoint exists that no action is required then one point of view cannot be stated as factual.
  • "Oster says that "phimosis is uncommon in schoolboys, and even rarer if the normal development of the prepuce is patiently awaited" - no direct relationship to circumcision.

Jakew (talk) 11:51, 13 October 2008 (UTC)

Thanks for keeping an eye on the article with attention to detail, Jakew. Based on what you say above, your reverts sound reasonable to me. Coppertwig (talk) 15:15, 13 October 2008 (UTC)
Yes the AMA do use phimosis as a reason to circumcise. I fail to see how the counter-argument to that is non-neutral. I'll add the reference if you want. What does it have to with circumcision? If you are going to prescribe circumcision for preventing the condition then the counter-argument(s) need to be listed. Also knowing how common the condition is, informs one as to whether the operation is worth it. The bit about "not being aware" is sourced, if you checked. The majority agree with Gairdner, oster , rickwood that circumcisions are performed needlessly due to pathologising what is the natural development of the foreskin.
Fakjian was put in the appropriate paragraph further down. Strange you used the word "discussion". As for as I could tell there is no discussion in this section.
"Some studies found that boys with foreskins had higher rates of various infections and inflammations of the penis than those who were circumcised." This is how the Ferguson and Herzog paragraph is currently phrased. There was no mention of meatal stenosis, which was a complication that occurred in more circumcised than uncircumcised boys- so deliberately misleading, if you ask me. Nor was it mentioned the fact that circumcised boys were more at risk in early infancy , but it was the reverse after infancy.
How would you amend the van howe paragraph? It seems perfectly fine to me.
Anyway, what is the purpose of having the medical analysis section if not to debate whether to circumcise? You mention "relevance for circumcision", the question could also be asked then what do all these conditions have to do with circumcision? Nothing, unless it is to debate whether one should circumcise to prevent the conditions. I have taken on some of your points and amended the section. Tremello22 (talk) 15:16, 13 October 2008 (UTC)
Tremello, please could you quote the passage from the AMA's statement in which they cite prevention of phimosis as a reason to circumcise? They do discuss prevention of phimosis, but I can't find anything about this being a reason to circumcise. If they do make such a statement, then we cannot use primary sources to make a counterargument; please see WP:MEDRS#Respect secondary sources.
The question "what does it have to do with circumcision" is of vital importance because, per WP:NOR, we must discuss what reliable sources say about the subject of the article.
As for "not being aware", it is difficult to see how it could be sourced as a statement of fact. Furthermore, you offer no source in support of your claim that the "majority" agree with Rickwood, etc. All we know is that, according to Rickwood and a few other authors, other physicians make diagnoses that are, in the opinion of Rickwood etc., inappropriate. It seems unlikely that the physicians making these diagnoses believe that they are incorrect. Presumably this happens often enough that Rickwood etc., consider the issue worth writing about, so either one physician is making an awful lot of diagnoses or there are lots of these physicians. Therefore, it seems that we have a situation in which there are two or more significant viewpoints.
Why was Fakjian moved? There's no logical basis for this. Fergusson et al., Herzog and Alvarez, and Fakjian are all epidemiological studies comparing the frequency of balanitis (etc) in circumcised and uncircumcised males (others include, as I recall, O'Farrell, Wilson, Taylor, Davidson, Richters, Parker, and Van Howe). They belong together.
"Some studies..." is a concise way of summarising these studies. This article is written in summary style. There is space in medical analysis of circumcision for in-depth discussion, but here we need to be brief. Of course there's no mention of meatal stenosis, since that is already discussed in the "complications" section.
Some comments on your latest changes:
  • "An inflammation of the penis and foreskin is called balanoposthitis, just the glans is called balanitis." No, just the glans is called the glans. :-)
  • "Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams." - or circumcision, as the source clearly states, and as this paragraph originally stated. Why delete the one thing most relevant to the article?
  • "They are also relatively rare despite cirumcision status: Kabya found that in uncicumcised boys, 9 out of 603 had balanoposthitis." Other studies, of course, found other rates. We could list them all, but since this article is about circumcision and not the incidence of balanoposthitis, what's the point?
  • "Consequently, there is debate as to whether neonatal cirumcision should be used to lower the the risk of getting the conditions.[ref:fakjian]" I don't see how the source supports the claim. Can you quote the relevant passage?
  • "Fergusson studied 500 boys and found that by 8 years, circumcised children had a rate of 11.1 problems..." same problem as before: too much detail, ill-defined 'problems', etc.
  • "Herzog and Alverez found the overall frequency of complications..." same problem as before
  • "Like Fergusson, Van Howe found that circumcised penis's required more care in the first 3 months of life. Unlike Fergusson and Alvarez, he found that circumcised boys are more likely to develop balanitis." - delete "like fergusson", change "penis's" (possessive) to "penes" (plural), delete "unlike fergusson and alvarez".
  • "The American Medical Association cite prevention of phimosis as a reason to circumcise." - see above
  • "The foreskin is attached to the glans at birth and separates naturally over time and should never be forced." - same issue as before.
  • "It is thought that only 1% of males aged 17 still have an unretractable foreskin." - same issue as before.
  • "However there still remains misconception that the unretractable foreskin in infancy is pathological and requires action, be it ‘preputial stretching’, ‘freeing of adhesions’ or even circumcision..." - and again. If relevant, it's fine to say that Rickwood has expressed this opinion. It cannot be endorsed without violating NPOV.
  • "Oster says that "phimosis is uncommon in schoolboys, and even rarer if the normal development of the prepuce is patiently awaited"" No doubt he does, but relevance to circumcision is not obvious.
  • "Metcalfe recommended that, "if physicians dissuade parents from having their infants circumcised, they must give those parents the information concerning hygiene and the slow natural separation of the foreskin from the glans."" Better.
  • "O' Farrel claims that circumcised men are more likely to wash." First, the authors (there were several) were O'Farrell et al.. Second, "states" or "reported" is more neutral than "claims", which implies doubt. (Discussion of O'Farrell needs reworking anyway.)

Jakew (talk) 17:10, 13 October 2008 (UTC)

AMA statement: "Properly performed circumcision protects against the development of phimosis" It seems the ref (5) links to the AAP statement where they list phimosis under penile problems. The implication is that phimosis is obviously a condition of the uncircumcised penis and it is a problem. How serious is the problem, is the question. And is it worth performing neonatal circumcision to prevent it? The most important question is: what is phimosis? There appears to be a disagreement (according to you) about whether it is phimosis or just a normal stage of prepuce development. Incidently they quote Oster as their reference.
I realise we need to be brief. This was just a start because I just recognised that it seemed a little one-sided. I don't expect this to be the final edit.
"The question "what does it have to do with circumcision" is of vital importance because, per WP:NOR, we must discuss what reliable sources say about the subject of the article." Well phimosis was already mentioned in the previous version, which was "Forcible retraction of the foreskin in boys can lead to infection[107] and acquired phimosis. Furthermore, developmentally non-retractile foreskin may be misdiagnosed as phimosis and lead to unnecessary circumcision.[160]" So what do you suggest then? That is not really treating the subject of phimosis in a balanced way is it? To the average reader it looks like "arguments FOR cirucmision". The title of the section is "medical analysis of circumcision" Not "arguments FOR circumcision"
We could list them all, but since this article is about circumcision and not the incidence of balanoposthitis, what's the point? You have lost me there. The subject of this section of the article is what? It is "Medical analysis of circumcision", is it not? So according to your way of thinking, if you tell someone that circumcision will prevent a disease then: a)it isn't important how serious that disease is, b)how common it is or c)how much circumcision protects you from that disease, if at all? I would propose we use a range to find the incidence. You could have added that, could you not?
Why was fakjian removed , a better question is why those studies? It wasn't really removed anyway i just used it to suggest there is debate over whether circumcision should be used to prevent circumcision. The title of the fakjian study is "An argument for circumcision. Prevention of balanitis in the adult". "Argument" implies that there is debate. Also, What criteria should be used for picking which studies go into the main article? Van Howe found different conclusions, but was not included. It is called balance and reflecting the true picture instead of trying to push your point of view.
Also instead of writing out minor mistakes such as not putting et al or not phrasing something well, wouldn't it be easier if you just amended it yourself? It doesn't really add to your list of other arguments does it? So unless it is important then I wouldn't bother bringing it up. Tremello22 (talk) 21:25, 13 October 2008 (UTC)
Ok, Tremello, we're obviously reading the same part of the AMA's statement. However, for some reason, you're reading the statement you quote as a reason to circumcise. That doesn't make a lot of sense to me. There's a difference between saying that something has an effect (even a desirable effect) and saying that it should therefore be done. To illustrate using an extreme example, a statement that a "properly performed leg amputation protects against the development of athlete's foot", while true, doesn't seem to be "citing athlete's foot as a reason to perform leg amputation".
You ask a number of questions ("How serious is the problem", etc) that may be important, and if so, they will have been discussed in reliable sources in the context of the subject of this article. So instead of performing original research by citing sources that don't even discuss circumcision, the obvious thing to do is to cite secondary sources that discuss these issues in the context of circumcision.
I'm afraid I don't quite understand what you perceive as the problem with the previous version. The two sentences which you quote are not perfect, I agree, but I would note that a) the sentences are short, and b) both sources cited make these remarks in the context of circumcision.
Regarding the incidence of balanoposthitis, I'm not suggesting that these issues are unimportant, but — again — if it's important, then sources can be found that discuss this information in the context of circumcision. It's questionable whether such information should be added to the article even then, though, because a large number of statements have been made about circumcision and we have limited space available, and must remain focused. I don't think that adding a range would be productive because, as I said, the subject of the article is circumcision, not the incidence of balanoposthitis. (I would encourage adding this information to the appropriate article, however.)
Re the title of Fakjian's study, "argument" may imply that there is debate over circumcision itself, but it doesn't imply that there is debate over a specific condition. The fact that this source is used to support a point that it doesn't make is disturbing, especially so given that the point it did make has been deleted.
You ask what criteria should be used to include sources in this article. That's a very valid point. Failing to include Van Howe might suggest that every study found reduced rates of penile inflammation in circumcised males. On the other hand, including Van Howe's study as well alongside too few of the other studies might suggest that results have been more mixed than they have been. If lots of space were available, the solution would be obvious: include all of the studies. In the absence of that, we can either cite a representative selection or, ideally, find and use reliable secondary sources instead. I would be grateful, incidentally, if you would adhere to WP:CIVIL and avoid accusations of POV pushing. Jakew (talk) 22:25, 13 October 2008 (UTC)
Reply to Tremello: If an editor chooses to mention a mistake on the talk page rather than editing the article, I think that's fine: I can think of a number of reasons why one might consider that preferable under some circumstances. For substantial changes, I would prefer that editors follow the request in the template at the top of this talk page, which says "Please ... discuss substantial changes here before making them." Coppertwig (talk) 00:08, 14 October 2008 (UTC)
The point is coppertwig, I obviously knew that it was fergusson et al. And if something is phrased badly then I am not going to object to it being improved, am I? So there was no point in bringing another argument up when it is irrelevant and there are other more important things to discuss. We might as well concentrate on the things we are disagreeing with. Tremello22 (talk) 11:04, 14 October 2008 (UTC)

Arbitrary section break

Yet more edits to this section have brought more problems:

  1. The section is now far too long, containing (as I judge by eye) more text than any other section about medical aspects of circumcision.
  2. A huge amount of text has been added: "Escala and Rickwood recommend against a policy of routine infant circumcision to avoid these complaints, saying that "the condition affects no more than 4% of boys, is commonest during pre-school years (but rare prior to toilent training) and is usually associated with a prepuce which is partly or completely non-retractable. It does not cause phimosis and no single pathogen is involved. Most boys suffer a single episode and circumcision is indicated only for those with recurrent, troublesome attacks." Surely one sentence would be enough?
  3. The text discussing O'Farrell has been expanded from "In a study of 225 men, O'Farrell et al. found that circumcised men were less likely to be diagnosed with balanitis than uncircumcised men." to "In a study of 225 men attending a sexually transmitted infections (STI) clinic, O'Farrell et al. found that less circumcised men were diagnosed with balanitis than uncircumcised men (5% and 42%, P=0.036)." Unfortunately, this not only increases the word count, but is wrong. The correct figures are provided in the full text of the study, and are given in the quote in the ref tag. These figures (5 and 42%) are associations with washing, not circumcision.
  4. In addition to Van Howe's 1997 study, we also quote his 2007 study, which was a follow-up including the earlier observations. It would be more logical to cite just the follow-up, and in a single sentence, rather than dedicating four sentences to Van Howe and one sentence each to the other studies.
  5. The AMA's statement ("The American Medical Association state that circumcision, properly performed, protects against the development of phimosis.") has been removed, and has been replaced by Van Howe. Why replace a secondary source with a primary? This makes no sense whatsoever.
  6. After Rickwood, the text "A later study by Rickwood and Shankhar echoed these findings saying that "The incidence of pathological phimosis in boys was 0.4 cases/1000 boys per year, or 0.6% of boys affected by their 15th birthday, a value lower than previous estimates and exceeded more than eight-fold by the proportion of English boys currently circumcised for 'phimosis'." has been added. Why? This point has been made already.
  7. Metcalfe has been expanded at length, with unnecessary citations to Metcalfe's sources. We don't need to cite the sources cited by our sources. Additionally, the point of the expansion is unclear. The first two sentences say almost the same thing as the last.
  8. More lengthy additions: "In a study to determine the most cost-effective treatment for phimosis, Van Howe concluded that using cream was 75% more cost effective than circumcision at treating pathological phimosis. Also adding that "The argument that circumcision is a minor surgical procedure without complications is not only erroneous, but also irrelevant. It is ethically as well as economically questionable to operate on a child to treat a physiological process."" This argument isn't about cost-effective treatment of phimosis. It's about circumcision. At most, cut back to a single sentence: "Van Howe stated that using cream was 75% more cost effective than circumcision at treating pathological phimosis."

Jakew (talk) 14:28, 14 October 2008 (UTC)

I think you are over-reacting to this edit. If there are any problems, they are minor. And can be solved with a bit of tweaking.
You mention the citation of later studies as if that makes a difference - it doesn't, I could say the same about citing all the studies showing that uncircumcised were more likely to get balanitis.
I feel that the previous metcalfe quote didn't properly represent his opinion.
You are right about O farell , that was a mistake. That can be changed back.
re. van howe - it doesn't say that the final 2 sentences are about cost-effective treatment. It is about whether circumcision should be used to cure phimosis. If you feel that bit should go elsewhere in the section, then move it, simple. Why at most? You would prefer it got cut out all together? May I ask why?
The AMA statement references the AAP and so it is a secondary source citing a secondary source. It is also nearly 10 years old. It doesn't give any information to the reader about why it prevents phimosis, nor does define what it means by phimosis, or say what primary sources it uses to come to that conclusion. Therefore it seeemed a bit arbitrary to me.
I will do my best to cut it down a bit anyway, but not so much that it leaves out important inforamtion. Tremello22 (talk) 15:29, 14 October 2008 (UTC)
I oppose lengthening the article. As I said above, I request that editors follow the request at the top of this talk page, and discuss substantial changes here on the talk page before editing them in. For example, grammatical errors should be fixed by discussion here on the talk page before adding the material. For some Wikipedia articles, adding material with grammatical errors may be OK and preferable to not adding the material at all; but this is (was?) a heavily-edited, polished article, so substantial changes should not be made before ironing out problems on the talk page and getting rough consensus. Coppertwig (talk) 15:33, 14 October 2008 (UTC)
I support lengthening the article to clarify misleading points. The alternative is to remove the information completely. Let's not also forget the wiki crede Be Bold. Garycompugeek (talk) 20:16, 14 October 2008 (UTC)
Tremello, regarding citation of later studies, data presented in Van Howe's 2007 paper is a superset of that presented in his 1997 paper, as he states at least twice in the text of his (later) paper. The difference is that the first paper included observations by Van Howe made between 1 June 1995 and 30 April 1997, whereas the later paper included his observations upto 31 May 2001. There is no logical reason to report on the 1995-1997 period twice, which is in effect the result of reporting on both papers; it makes far more sense to include the latter paper — the observations from 1995-2001.
Re Metcalfe, I would suggest deleting the last sentence, then. The important thing is to be concise.
Re treatment of phimosis, that isn't what this article is about, and we need to avoid giving too much weight to one particular viewpoint. In an in-depth article such as medical analysis of circumcision or phimosis, detailed discussion is appropriate. In this article, all that really needs to be said (with appropriate sourcing, of course) is that "circumcision is sometimes used to treat phimosis, but that this is controversial". That's 12 words, which is a lot more concise than 68.
Re the AMA statement, it is thus in effect a tertiary source, which is appropriate for inclusion, but if you prefer we can cite the AAP directly. Deleting the AMA statement and replacing it with a single primary source asserting the opposite seems rather questionable in terms of WP:NPOV. Jakew (talk) 16:50, 14 October 2008 (UTC)
Gary, I have already shortened the section. I don't know if jakew is satisfied with that, or not. Tremello22 (talk) 20:26, 16 October 2008 (UTC)
I appreciate your efforts, Tremello. I've made a number of tweaks to address the remaining issues.
Please note that I've replaced Van Howe's phimosis statement with the AMA's statement, since it's preferable to cite a secondary source. If we cited one primary source we'd need to cite others as well, and that would add a lot of material. Jakew (talk) 23:44, 16 October 2008 (UTC)