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 Topic: remember that study on the benefits of circumcision?

 (Read 3934 times)
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  • remember that study on the benefits of circumcision?
     OP - July 03, 2012, 04:00 PM


    I don't support a ban on circumcision. I'm open to being persuaded but I'm not persuaded yet. In part because to do so would push it underground and it would be better to have children receive it under good medical conditions. Having said that, rationally speaking I can make no defence of it as a general procedure.

    In the debate about circumcision much was made of the supposed health benefits of circumcision in relation to HIV following a study. Well, it turns out that the study was flawed, to say the least.

    +++++++++

    Quote

    Those who defend the practice of circumcision tend to fall into two camps. The first argue that to forbid it is to violate the religious freedom of the groups (mainly Jews and Muslims) who practice it. This is absurd. No one is saying that people should be forbidden from getting circumcised. What we are saying that circumcision should not be forced on anyone else. If any adult wants to get circumcised, they should be allowed to do so. But to allow parents to mutilate their babies to satisfy their own religious beliefs is simply wrong. You shouldn’t be allowed to establish your bona fides with god by mutilating your children.

    The other reason given in favor of circumcision is the supposed health benefit. The one that is most touted is supposedly enhanced defense against AIDS transmission. This was never a convincing argument since babies don’t have sex. Even if it were true, people could choose for themselves to be circumcised later in life when they become sexually active.

    But thanks to commenter Jeff Hess, I came across this article (via Andrew Sullivan) that debunks this whole idea of circumcision being an AIDS inhibitor, saying that is based entirely on bad science and that the supposed benefits are not only non-existent but the practice may actually increase the risk of AIDS transmission.


    http://freethoughtblogs.com/singham/2012/07/02/the-nonexistent-benefits-of-circumcision/



    "we can smell traitors and country haters"


    God is Love.
    Love is Blind. Stevie Wonder is blind. Therefore, Stevie Wonder is God.

  • Re: remember that study on the benefits of circumcision?
     Reply #1 - July 03, 2012, 04:01 PM


    The study referred to is explained in more detail here:

    ++++++++

    A fatal irony: Why the “circumcision solution” to the AIDS epidemic in Africa will increase transmission of HIV

    Step 1. How not to design or conduct an experiment

    A handful of circumcision advocates have recently begun haranguing the global health community to adopt widespread foreskin-removal as a way to fight AIDS. Their recommendations follow the publication of three [1] randomized controlled clinical trials (RCCTs) conducted in Africa between 2005 and 2007.

    These studies have generated a lot of media attention. In part this is because they supposedly show that circumcision reduces HIV transmission by a whopping 60%, a figure that wins the prize for “most misleading possible statistic” as we’ll see in a minute. Yet as one editorial [2] concluded: “The proven efficacy of MC [male circumcision] and its high cost-effectiveness in the face of a persistent heterosexual HIV epidemic argues overwhelmingly for its immediate and rapid adoption.”

    Well, hold your horses. The “randomized controlled clinical trials” upon which these recommendations are based (I use scare quotes deliberately) represent bad science at its most dangerous: we are talking about poorly conducted experiments with dubious results presented in an outrageously misleading fashion. These data are then harnessed to support public health recommendations on a massive scale whose implementation would almost certainly have the opposite of the claimed effect, with fatal consequences. As Gregory Boyle and George Hill explain in their exhaustive analysis of the RCCTs:

    While the “gold standard” for medical trials is the randomised, double-blind, placebo-controlled trial, the African trials suffered [a number of serious problems] including problematic randomisation and selection bias, inadequate blinding, lack of placebo-control (male circumcision could not be concealed), inadequate equipoise, experimenter bias, attrition (673 drop-outs in female-to-male trials), not investigating male circumcision as a vector for HIV transmission, not investigating non-sexual HIV transmission, as well as lead-time bias, supportive bias (circumcised men received additional counselling sessions), participant expectation bias, and time-out discrepancy (restraint from sexual activity only by circumcised men).

    That’s a whole laundry list of issues, so let me highlight a few of the more egregious. First, consider the “lack of placebo control.” What does that mean? Normally, when you’re trying to determine whether some medical intervention has a disease-fighting effect specific to its own (hypothesized) mechanisms—and over and above the placebo baseline—you have to have a control group. That group gets a dummy intervention, and nobody is supposed to know which participants were exposed to the actual treatment until after the results are in.

    After all, if someone knows (or thinks) that they’re getting a great big helping of medicine, they might act in various ways—whether consciously or unconsciously—that have the effect of generating positive health outcomes but which have nothing to do with the intervention itself. In the case of circumcision, however, there’s no way not to know if you’ve received the “medicine”—you have to go through a whole surgery and then you don’t have a foreskin anymore—so this basic condition of a true clinical trial is violated in the first instance.

    But that’s just the tip of the iceberg. As Boyle and Hill point out, the men who were circumcised got additional counseling about safe sex practices compared to the control group, and then they had to refrain from having sex altogether for the simple reason that their lacerated penises had to be wrapped in bandages until their wounds healed – leading to what Boyle and Hill refer to as “time-out discrepancy” in the quote above. By contrast, the non-circumcised men got to keep having sex during the full two month period during which the treatment group was in recovery mode. Then, mystery of mysteries, the trials were stopped early. These issues pose serious problems for the scientific credibility of the studies. Taken together with the other flaws, here is why:

    Let’s assume for a second that the circumcised men really did end up getting infected with HIV at a lower rate than the control-group men who were left intact—even though, as we will see in a moment, we have very little reason to believe that this is so. Why might that outcome have happened?

    If you answered, “Because those men knew they were in the treatment group in the first place, had less sex over the duration of the study (because they had bandaged, wounded penises for much of it), and had safer sex when they had it (because they received free condoms and special counseling from the doctors), thereby reducing their overall exposure to HIV compared to the control group by a wide margin” then you are on the right track.

    Step 2. How not to report results

    Now why should we doubt that the circumcised men actually did have a lower rate of HIV infections in the first place, poor experiment design notwithstanding, as I suggested in the paragraph above? After all, the 60% figure that’s being thrown around in media reports is a pretty big number, and it can’t be off by that much, even if the studies had some flaws, right? Not so fast. Do you know what the “60%” statistic is actually referring to? Boyle and Hill explain:

    What does the frequently cited “60% relative reduction” in HIV infections actually mean? Across all three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV-positive, so the absolute decrease in HIV infection was only 1.31%.

    That’s right: 60% is the relative reduction in infection rates, comparing two vanishingly small percentages: a clever bit of arithmetic that generates a big-seeming number, yet one which wildly misrepresents the results of the study. The absolute decrease in HIV infection between the treatment and control groups in these experiments was a mere 1.31%, which can hardly be considered clinically significant, especially given the numerous confounds that the studies failed to rule out.

    Step 3. How not to make public health recommendations

    So far we have been discussing problems with the experiments themselves—what’s called “internal validity” in technical terms. I really want you to read the Boyle and Hill paper here, because they go into painstaking detail about each of a long parade of flaws I can’t hope to cover in one blog post. I mean, there are a lot of flaws. Please read the paper. But let’s switch gears now and talk about the flip-side of things, or what’s called “external validity” – that is, problems with taking what you’ve (supposedly) found in a (relatively) controlled setting like an experiment and applying it to the chaotic mess that is the real world.

    Lawrence Green and his colleagues published an important article on just this topic as it relates to “the circumcision solution” in the American Journal of Preventative Medicine. “Effectiveness in real-world settings,” they sensibly point out, “rarely achieves the efficacy levels found in controlled trials, making predictions of subsequent cost-effectiveness and population-health benefits less reliable.”

    Some major issues with trying to roll-out circumcision in particular include the fact that the RCCT participants—who were not representative of the general population to begin with—had (1) continuous counseling and yearlong medical care, as well as (2) frequent monitoring for infection, and (3) surgeries performed in highly sanitary conditions by trained, Western doctors. All of which would be unlikely to replicate at a larger scale in the parts of the world suffering from the worst of the AIDS epidemic. And of course, circumcisions carried out in un-sanitary conditions (that is, the precise conditions that are likelier to hold in those very places) carry a huge risk of transmitting HIV at the interface of open wounds and dirty surgical instruments. So this is a serious point.

    What should we conclude? Green et al. get it right: “Before circumcising millions of men in regions with high prevalences of HIV infection, it is important to consider alternatives. A comparison of male circumcision to condom use concluded that supplying free condoms is 95 times more cost effective.”

    And not only more cost effective, but also more effective—period—in slowing the spread of HIV. Condoms are cheap, easy to distribute, do not require the surgical removal of healthy genital tissue, and—yes—are much, much, much, much more effective at preventing infections. Compare. Condoms: 80% minimum reduction in HIV infection [3]. Circumcision: clinically insignificant absolute reduction, according to the most optimistic presentation of data from three deeply flawed studies. There is no contest.

    Step 4. This is serious business

    The worst part about all of this is not just that the science behind “the circumcision solution” is so shaky, but that the actual implementation of these recommendations—so vociferously pushed-for by the circumcision advocates doing this research — would very likely lead to more HIV infections, not less. The big idea here is “risk compensation” – the subject of an excellent paper by Robert Van Howe and Michelle Storms.

    Risk compensation occurs when people believe they have been provided additional protection (wearing safety belts) [such that] they will engage in higher risk behavior (driving faster). As a consequence of the increase in higher risk behavior, the number of targeted events (traffic fatalities) either remains unchanged or [actually] increases.

    They argue:

    Risk compensation will accompany the circumcision solution in Africa. Circumcision has been promoted as a natural condom, and African men have reported having undergone circumcision in order not to have to continually use condoms. Such a message has been adopted by public health researchers. A recent South African study assessing determinants of demand for circumcision listed “It means that men don’t have [to] use a condom” as a circumcision advantage in the materials they presented to the men they surveyed. [Yet] if circumcision results in lower condom use, the number of HIV infections will increase. [Citations can be found in the original paper.]

    In Uganda, as Boyle and Hill uncovered, the Kampala Monitor reported men as saying, “I have heard that if you get circumcised, you cannot catch HIV/AIDS. I don’t have to use a condom.” Commenting on this problem, a Brazilian Health Ministry official stated: “[T]he WHO [World Health Organization] and UN HIV/AIDS program … gives a message of false protection because men might think that being circumcised means that they can have sex without condoms without any risk, which is untrue.”

    Van Howe and Storms spell this all out:

    How rational is it to tell men that they must be circumcised to prevent HIV, but after circumcision they still need to use a condom to be protected from sexually transmitted HIV? Condoms provide near complete protection, so why would additional protection be needed? It is not hard to see that circumcision is either inadequate (otherwise there would be no need for the continued use of condoms) or redundant (as condoms provide nearly complete protection).

    The argument that men don’t want to use condoms needs to be addressed with more attractive condom options and further education: [they need to be told] that sex without a condom and without a foreskin is potentially fatal, while sex with a condom and a foreskin is safe. No nuance is needed. Offering less effective alternatives can only lead to higher rates of infection.

     Their conclusion?

    Rather than wasting resources on circumcision, which is less effective, more expensive, and more invasive, focusing on iatrogenic sources and secondary prevention should be the priority, since it provides the most impact for the resources expended.

    That is my conclusion as well. In this article I have focused on just the science behind—and claimed public health benefits of—“the circumcision solution” and shown how truly weak they are. I’ve completely ignored the attendant ethical issues, though I discuss these here and here.

    The studies we’ve looked at, claiming to show a benefit of circumcision in reducing transmission of HIV, are paragons of bad design and poor execution; and any real-world roll-out of their procedures would be very difficult to achieve safely and effectively. The likeliest outcome is that HIV infections would actually increase—both through the circumcision surgeries themselves performed in unsanitary conditions, and through the mechanism of risk compensation and other complicating factors of real life. The “circumcision solution” is no solution at all. It is a waste of resources and a potentially fatal threat to public health.

     

    WORKS REFERENCED (RECOMMENDED READING):

    Boyle, G. J. and Hill, G. (2011). Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. Journal of Law and Medicine. Available as a PDF here.

    Green et al. (2010). Male circumcision and HIV prevention: Insufficient evidence and neglected external validity. American Journal of Preventative Medicine. Available as a PDF here.

    Van Howe, R. S. and Storms, M. (2011). How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa. Available as a PDF here.

    ADDITIONAL RESOURCES:

    Darby, R. and Van Howe, R. (2011). Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. Australian and New Zealand Journal of Public Health. Available here.

    Green, L., McAllister, R., Peterson, K., and Travis, J. (2008). Male circumcision is not the HIV “vaccine” we have been waiting for. Future Medicine. Available as a PDF here. A short, readable editorial.

    I also recommend Zabus, Chantal (Ed.) (2008). Fearful symmetries: Essays and testimonies around excision and circumcision. Available from Amazon.com here.

    And these blog posts by me:

    Circumcision is immoral, should be banned.

    Tattoos vs. circumcision.

    [1] Auvert B, Taljaard D, Lagarde E et al, “Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial” (2005) 2(11) PLoS Med e298; Bailey RC, Moses S, Parker CB et al, “Male Circumcision for HIV Prevention in Young Men in Kisumu, Kenya: A Randomised Controlled Trial” (2007) 369(9562) Lancet 643; Gray RH, Kigozi G, Serwadda D et al, “Male Circumcision for HIV Prevention in Men in Rakai, Uganda: A Randomised Trial” (2007) 369(9562) Lancet 657.

    [2] Halperin DT, Wamai RG, Weiss HA, et al. Male circumcision is an effıcacious, lasting and cost-effective strategy for combating HIV in high-prevalence heterosexual epidemics: the time has come to stop debating the basic science. Future HIV Ther 2008;2(5):399 – 405.

    [3] Weller SC and Davis-Beaty K, “Condom Effectiveness in Reducing Heterosexual HIV Transmission” (2002) 1 Cochrane Database of Systematic Reviews Art No CD003255.


    http://blog.practicalethics.ox.ac.uk/2012/05/when-bad-science-kills-or-how-to-spread-aids/

    "we can smell traitors and country haters"


    God is Love.
    Love is Blind. Stevie Wonder is blind. Therefore, Stevie Wonder is God.

  • Re: remember that study on the benefits of circumcision?
     Reply #2 - July 03, 2012, 04:04 PM

    Oh yes that has been debunked for ages in academic and medical circles. Somehow it just hasn't trickled down into public consciousness yet for some reason.


    "Male circumcision is not the HIV ‘vaccine’ we have been waiting for!"
    Authors: Lawrence W Green, Ryan G McAllister, Kent W Peterson & John W Travis
    Future HIV Therapy. May 2008, Vol. 2, No. 3, Pages 193-199 , DOI 10.2217/17469600.2.3.193
    (doi:10.2217/17469600.2.3.193)



    "Myths about Circumcision You Likely Believe"
    (with citations)
    Published on September 11, 2011
    Author: Darcia Narvaez, Ph.D.



    (pdf) "Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns"
    Authors: Gregory J Boyle and George Hill



    "How the circumcision solution in Africa will increase HIV infections"
    Authors: Robert S. Van Howe, Michelle R. Storms

    Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Marquette, MI, USA

    Journal of Public Health in Africa 2011; 2:e4 doi:10.4081/jphia.2011.e4


    "Blessed are they who can laugh at themselves, for they shall never cease to be amused."
  • Re: remember that study on the benefits of circumcision?
     Reply #3 - July 03, 2012, 04:09 PM


    Ah, thanks allat - ahead of me as usual Afro

    "we can smell traitors and country haters"


    God is Love.
    Love is Blind. Stevie Wonder is blind. Therefore, Stevie Wonder is God.

  • Re: remember that study on the benefits of circumcision?
     Reply #4 - July 03, 2012, 04:28 PM



    Fuck that article. I have a circumcised dick and I refuse to believe that there are no "benefits".  whistling2
  • Re: remember that study on the benefits of circumcision?
     Reply #5 - July 03, 2012, 04:33 PM

    In part because to do so would push it underground and it would be better to have children receive it under good medical conditions.

    I agree, and I feel the same about female circumcision (not to start up that argument again Roll Eyes ). However, I feel education could probably eliminate all but the religiously motivated circumcisions.

    There is a group on facebook called Intactivists. Their page has a lot of resources if anyone is interested in reading more. I found these survey results interesting.

    I hear the rains, I see the fire, I feel the flame. It doesn't change the faces I want to blame for the shame I'm feeling.
    But the winds of change will blow again. And we're the lucky ones who travel on towards the sun.

    Can you hear it calling you?
  • Re: remember that study on the benefits of circumcision?
     Reply #6 - July 03, 2012, 04:36 PM

    I don't support a ban on circumcision. I'm open to being persuaded but I'm not persuaded yet. In part because to do so would push it underground and it would be better to have children receive it under good medical conditions. Having said that, rationally speaking I can make no defence of it as a general procedure.

    I could say the same about FGM.

    I'm strongly in favour of a ban, with exceptions made for circumcisions that are consensual and/or medically required. It's a human rights issue for me, plain and simple. No one should be allowed to permanently alter the body of another human being for no good reason.
  • Re: remember that study on the benefits of circumcision?
     Reply #7 - July 03, 2012, 05:38 PM

    You're right Godot, you could say the same thing. My reasoning is that the practise is so entrenched that it would definitely turn underground and result in lower clinical standards leading to less due care being taken in the procedure.

    However I'm very glad that the debate is taking place, because I think its important that the assumptions of a religious prerogative over the physical body of children is challenged. Minds can be changed, at least you have to aim to do so.

    "we can smell traitors and country haters"


    God is Love.
    Love is Blind. Stevie Wonder is blind. Therefore, Stevie Wonder is God.

  • Re: remember that study on the benefits of circumcision?
     Reply #8 - July 03, 2012, 06:04 PM

    You're right Godot, you could say the same thing. My reasoning is that the practise is so entrenched that it would definitely turn underground and result in lower clinical standards leading to less due care being taken in the procedure.

    I can see this happening too, which is why I'd be in favour of jailing anyone who requests or performs a circumcision for someone unnecessarily and without consent. We have to realise that just because a practice is widespread, that doesn't make it acceptable. We're talking about forcibly mutilating a person's genitals. That's child abuse. It's a violent and coercive procedure that needs to be stamped out. The only time a circumcision should be permitted is when there's consent, or a legitimate medical reason. Anything else is a human rights violation, and needs to be criminalised.

    However I'm very glad that the debate is taking place, because I think its important that the assumptions of a religious prerogative over the physical body of children is challenged. Minds can be changed, at least you have to aim to do so.

    I agree. It's about time we challenged this. I'm sick of people acting like it isn't a big deal.
  • Re: remember that study on the benefits of circumcision?
     Reply #9 - July 03, 2012, 06:18 PM


    Its not going to happen in the foreseeable future. Any restriction will ultimately be brought about by social and political consensus on the issue - which is why the discussion and debate being held is important.


    "we can smell traitors and country haters"


    God is Love.
    Love is Blind. Stevie Wonder is blind. Therefore, Stevie Wonder is God.

  • Re: remember that study on the benefits of circumcision?
     Reply #10 - July 03, 2012, 06:28 PM

    Its not going to happen in the foreseeable future. Any restriction will ultimately be brought about by social and political consensus on the issue - which is why the discussion and debate being held is important.

    You're right, of course. It's just a shame we're always having to wait for everyone else to catch up before things can change. Roll Eyes
  • Re: remember that study on the benefits of circumcision?
     Reply #11 - July 03, 2012, 06:32 PM

    I could say the same about FGM.

    I'm strongly in favour of a ban, with exceptions made for circumcisions that are consensual and/or medically required. It's a human rights issue for me, plain and simple. No one should be allowed to permanently alter the body of another human being for no good reason.

    +1

    I couldn't say it better myself. Without consent, it should be banned.

    Life is what happens to you while you're staring at your smartphone.

    Eternal Sunshine of the Religionless Mind
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