Circumcision: can any rational thinker defend it ?

[kellyb]

the clitoral prepuce and labia are essential parts
Evidence?

[osmosis]

I have no problem with other doctors performing circumcisions, if that is what they feel to be correct. That is their decision.

From where I sit, it appears you're sidestepping the real issue, that is the right of a human not to be mutilated without consent or medical necessity.

You're saying, hey, if you want to cut pieces off your newborn infant for whatever reason, that's your decision. But does the infant get no say in the matter? The infant CANNOT protest or understand what is happening.

I just don't see how someone can support that, or even adopt a que sera sera attitude towards such an obvious breach of human rights.

[HawkeyeMD]

Did you watch the video of the circumcision being performed, apparently without pain relief?

If it was not a baby, but an adult, would it be "a huge moral issue" for you?

What if that pain was inflicted on you, but then you could be made to forget it, would you be up for that?

From my point of view infants make the perfect victims; they're small, can't speak and don't explicitly remember the pain that was inflicted upon them if it is done early enough in their existence.

I agree that the removal of foreskin is not a particularly big ethical issue in itself. The conditions under which it is removed are. Did you catch the earlier post that stated it looks like less than half of infant circumcisions in the US use anaesthetic?

Perhaps that was what Linda was talking about, if you did it, you would make sure the infant went through the minimum amount of suffering.

Easy there, cowboy. I agree with you, remember?

I don't need to watch the video or read the stats. I just finished both my pediatric and OB/GYN rotations. I've seen them done, live. (I happened to do both rotations at the same hospital and all of the doctors I observed used EMLA cream.)

Simple fact is, we do have to do some very unpleasant things to kids, and once you have gone through this training, it does change your viewpoint somewhat. That's not to say that I minimize the pain involved. That's a major issue I have with the procedure--why on earth do an unnecessary invasive procedure, and doing it without anaesthsia is simply unethical, as far as I'm concerned. However, the main issue I have with it is not with the pain itself, because that can be minimized. My main issue with it is the permanent alteration, for no good medical reason that I can see. There it sounds like we disagree. Are you saying you wouldn't have a problem with it if there was sufficient pain relief?

Don't get the idea that I'm not empathetic about the trauma. I am. I hate listening to kids scream, and I hate when we have to hurt them. We try not to. It's hard to explain this without resorting to the sort of emotional appeal I was arguing against earlier. It's just that I *have* seen circumcisions, and honestly, they are much less upsetting that some other things we have to do. I still cringe every time I see an attending trying to thread an IV into a premie's arm or leg. But let's be careful about calling the baby a 'victim'.

Once more--I *agree* with your position. I'm not sure why you're responding so personally to what I said.

[HawkeyeMD]

You're saying, hey, if you want to cut pieces off your newborn infant for whatever reason, that's your decision. But does the infant get no say in the matter? The infant CANNOT protest or understand what is happening.

No, that's a silly reductio ad absurdum rephrasing of what I'm saying. I'm saying I don't intend to perform them, at all, for any non-medical purpose. For much the reason you state--I feel that it is a decision that should only be made by someone who is old enough to understand what is being done and request it for themselves.

However, that is my opinion and I do not presume to speak for all medical professionals. I'm not even a full-fledged medical professional yet. Maybe some of them might know more than I do. Maybe all of them who do it are wrong. I just don't think I know everything. I'm willing to argue the point to my colleagues. What I'm not willing to do is to paint everything black and white. I don't think that parents or doctor or mohels or whoever wants it done are intrinsically evil.

[Ivor the Engineer]

Easy there, cowboy. I agree with you, remember?

I obviously didn’t express myself very well. Must try harder:(

I don't need to watch the video or read the stats. I just finished both my pediatric and OB/GYN rotations. I've seen them done, live. (I happened to do both rotations at the same hospital and all of the doctors I observed used EMLA cream.)

If what other people have said is still the case, it seems to be a very mixed situation across the US. This is the biggest issue for me. Except for emergency situations, I can think of virtually no reason to perform surgery without some kind of pain relief.

Simple fact is, we do have to do some very unpleasant things to kids, and once you have gone through this training, it does change your viewpoint somewhat. That's not to say that I minimize the pain involved. That's a major issue I have with the procedure--why on earth do an unnecessary invasive procedure, and doing it without anaesthsia is simply unethical, as far as I'm concerned. However, the main issue I have with it is not with the pain itself, because that can be minimized. My main issue with it is the permanent alteration, for no good medical reason that I can see. There it sounds like we disagree. Are you saying you wouldn't have a problem with it if there was sufficient pain relief?

No, I’m saying that without pain relief I see no difference between circumcision of infants and torture. Without pain relief, I wouldn’t care if it offered 100% protection against HIV.

However, if significant pain relief is used, then I can see a role for it, as the research in Africa has demonstrated. I can accept that most men in the situation they find themselves there would choose to be circumcised, as my earlier post with the report from the focus group in Zambia appeared to indicate. Thus I could accept Linda’s argument that the parent’s in that situation would likely be expressing what the child would want when it’s an adult.

In the developed world I still see significant ethical problems for doctors operating on healthy patients for no valid medical reason just because the parents request it.

I too can watch or make other people suffer if I know the actions being taken by others or myself are going to provide them with a significant benefit. I hope you understand what I mean when I say this.

Don't get the idea that I'm not empathetic about the trauma. I am. I hate listening to kids scream, and I hate when we have to hurt them. We try not to. It's hard to explain this without resorting to the sort of emotional appeal I was arguing against earlier. It's just that I *have* seen circumcisions, and honestly, they are much less upsetting that some other things we have to do. I still cringe every time I see an attending trying to thread an IV into a premie's arm or leg. But let's be careful about calling the baby a 'victim'.

I used the word victim because I was referring to the child in the video (or another in the same situation), where (I assumed) the child was healthy (i.e. the circumcision was not required), had been given no pain relief and was screaming as hard as it could when the doctor was operating.

As an aside, I showed my mother the video and she nearly passed out. It didn’t make me feel faint, just angry.

Once more--I *agree* with your position. I'm not sure why you're responding so personally to what I said.

Again, sorry if the way I phrased my reply sounded like I was having a go at you. I’m not. Actually, your situation interests me. I may be sending you a PM asking you a few questions… (Nice ones, I promise) :)

[kellyb]

EMLA cream isn't all that effective, is it?
I mean, it's better than nothing, but only by a very small percentage compared to a dorsal penile nerve block?

[BlackKat]

Evidence?

This is clearly a compelling delusion for you. Got any evidence that what you claim is actually true?

So... are we "deluded" for stating that the clitoris and labia are essential body parts which ought not to be removed? It really sounds like kellyb does not think they are essential even though the "Evidence?" was probably not intended that way.

Or is it that the "foreskin" is not necessary. Like I've said dozens of times already in this thread. I have no foreskin. My penis is perfect. You have a foreskin. Your penis is perfect. The best evidence anyone here can provide about circumcision is all anecdotes on both sides. The only purpose for the foreskin which has been clearly stated here is to lessen friction during intercourse. Have not had any chaffing myself, nor had a partner complain.

The medical studies on foreskins or lack thereof are all inconclusive (and should be because they sample a whopping 100 or 200 people in one hospital which does not guarantee any sort of accuracy.). The studies go both ways but with very small majorities in very small sample groups. Nobody here can show me a comprehensive study that shows men with foreskins are better off, nor can I show you a comprehensive study that shows men without foreskins are better off.

If someone performs a worldwide study with millions of participants from all over the globe which points one direction or the other... then maybe one of us will have "Evidence". Until then I'm pretty happy with our current "to each his or her own" practice of providing parents with all the pros and cons and letting them decide.

Maybe it would be better for everyone to wait until puberty to decide... but I personally am glad that a quick snip snip was performed on me as a baby when it was still an easy procedure over having my penis in a cast for a week at 13. An anecdote I know... but it's all we've got here.

[HawkeyeMD]

EMLA cream isn't all that effective, is it?
I mean, it's better than nothing, but only by a very small percentage compared to a dorsal penile nerve block?

No, it's not, based totally unscientifically on my own experimental methodology (meaning that I put it on the back of my hand). It does numb you, but I could still tell the difference between a needle and a dull touch (I didn't use that much and I didn't wait twenty minutes, though). I do know that a lot of residents or attendings have said that they don't use it for procedures like IVs and blood draws because they say it also dilates the capillaries in the area and can make it harder overall. I know a couple who use it for LPs. Not sure how effective it is there either.

I've never seen anyone use a nerve block on an infant. Frankly, I don't know a thing about them as regards this issue.

[HawkeyeMD]

I obviously didn’t express myself very well. Must try harder:(

Actually, your situation interests me. I may be sending you a PM asking you a few questions… (Nice ones, I promise) :)

No problem. ;) Have at it.

[kellyb]

So... are we "deluded" for stating that the clitoris and labia are essential body parts which ought not to be removed?
You said the clitoral prepuce was essential. I want to know where you're getting that idea from. Same thing for the labia, both major and minor. You obviously are holding this as some kind of fact in your mind while being either unable or unwilling to support it with evidence.
If your opinion is not based on evidence of any kind, what is it based on, other than wish?

It really sounds like kellyb does not think they are essential even though the "Evidence?" was probably not intended that way.
I have no reason to believe they're any more essential than the foreskin of the penis. And neither do you, apparently.

[Ivor the Engineer]

You said the clitoral prepuce was essential. I want to know where you're getting that idea from. Same thing for the labia, both major and minor. You obviously are holding this as some kind of fact in your mind while being either unable or unwilling to support it with evidence.
If your opinion is not based on evidence of any kind, what is it based on, other than wish?


I have no reason to believe they're any more essential than the foreskin of the penis. And neither do you, apparently.

There are women who have surgery because they are not happy with their labia. Take a read of this (http://www.beautysurg.com/learn/body_labia.html).

[kellyb]

There are women who have surgery because they are not happy with their labia. Take a read of this (http://www.beautysurg.com/learn/body_labia.html).

And the prepuce:

It's called a "hoodectomy". (http://www.geocities.com/hoodectomy/)

[BlackKat]

You said the clitoral prepuce was essential. I want to know where you're getting that idea from. Same thing for the labia, both major and minor. You obviously are holding this as some kind of fact in your mind while being either unable or unwilling to support it with evidence.
If your opinion is not based on evidence of any kind, what is it based on, other than wish?


I have no reason to believe they're any more essential than the foreskin of the penis. And neither do you, apparently.


Well... do I need to provide reference material as to what the various parts of the vulva do or are you just playing devil's advocate?

Do a google search for female anatomy will provide you with countless sources of information if you do not already know what the different parts are for. Most of us have known them since Sex Ed class or book or since our mom told us or from relations with our significant others.
Here ya go... you can even watch the movie (no it's not one of /those/ movies):
http://www.dermlectures.com/LecturesWMV.cfm?lectureID=78

The purposes of the foreskin, as we've learned in this thread, have been listed as follows:
1. To keep the penis glans warm and protected from cold weather
2. To aid in intercourse by providing an extra layer of lubrication and flexible skin
3. To aid in intercourse by providing more nerve endings

These have been countered repeatedly in this thread by the following points:
1. Wear pants when you go outside unless it's hot! (sorry nudists)
2. Men without foreskins have found that arousing the female prior to intercourse (foreplay) creates adequate levels of lubrication.
3. Men without foreskins have not been shown to require additional time or stimulation in order to achieve orgasms, and are just as likely or not likely to prematurely ejaculate (thus we think dull or repulsive thoughts during intercourse to prolong it)


As I understand it from a combination of Sex Ed, reading, girlfriends:
If I was female and had my clitoris and labia removed I would be losing my primary source of sexual satisfaction and constantly have issues with infections by bacteria and foreign matter. Having my clitoral hood removed would likely (but not necessarily) result in overstimulus of the clitoris to the point where it did not create pleasurable sensations. This is why trimming or removing the clitoral hood is not quite an exact compliment to male circumcision.

I am male and had my foreskin removed and I do not have a cold penis, nor is it chaffed, nor is it numb.

[kellyb]

Well... do I need to provide reference material as to what the various parts of the vulva do or are you just playing devil's advocate?
I seriously want to know if you have any evidence that bad things happen when the prepuce or labia are removed in part or in whole.
You said it was all "essential" and I'm challenging you to back your claim.


Having my clitoral hood removed would likely (but not necessarily) result in overstimulus of the clitoris to the point where it did not create pleasurable sensations.

Where are you getting that from?
(I don't have sound on my computer at the moment so I can't watch videos.)

[Jorghnassen]

OK, I didn't want to participate in this, but BlackKat: FGM is not comparable to male castration, as FGM doesn't remove the reproductive capabilities of women.

/just wanted to point that out.

[BlackKat]

OK, I didn't want to participate in this, but BlackKat: FGM is not comparable to male castration, as FGM doesn't remove the reproductive capabilities of women.

/just wanted to point that out.

Understood. But FGM is a helluva lot closer to castration than it is to circumcision.

[Darat]

Understood. But FGM is a helluva lot closer to castration than it is to circumcision.

Only some types. Type 1 (by the WHO classification) is very much equivalent to a male circumcision.

By the way anyone got some good statistics of the percentage of each type of FGM?

[BlackKat]

I seriously want to know if you have any evidence that bad things happen when the prepuce or labia are removed in part or in whole.
You said it was all "essential" and I'm challenging you to back your claim.




Where are you getting that from?
(I don't have sound on my computer at the moment so I can't watch videos.)

I thought I was pretty clear where I am getting that from. A combination of Sex Ed Class, Sex Ed books, females I have known, and the internet. But if you demand a precise source site, if you go to the site I linked the full text of the narrator is right below the video pane. It is not where I got the information from, but does coincide with what I already knew.

So I am a little confused by all these accusations of essentiality...
Are you saying that parts of the female genitals are not essential and that some forms of FGM are ok?
This is not a black and white issue. One thing can be WRONG while another separate thing can be INCONCLUSIVE. Nobody in this post ever claimed circumcision to be the BEST thing to do to a penis. Even those of us who said we like circumcisions have not said they should be done without forethought. Some people claimed it might be wise to in areas with high levels of HIV infections. But even those claims were offered with caveats.

[BlackKat]

Only some types. Type 1 (by the WHO classification) is very much equivalent to a male circumcision.

By the way anyone got some good statistics of the percentage of each type of FGM?

Well Type 1 on the WHO site (http://www.who.int/mediacentre/factsheets/fs241/en/):
* Type I - excision of the prepuce, with or without excision of part or all of the clitoris;

Sounds rather broad...
If it's just the prepuce maybe... but the clitoris is a lot more sensitive than the glans. Exposing one does not equate to exposing the other.

And according to the same page:
The most common type of female genital mutilation is excision of the clitoris and the labia minora, accounting for up to 80% of all cases; the most extreme form is infibulation, which constitutes about 15% of all procedures.

[kellyb]

I thought I was pretty clear where I am getting that from. A combination of Sex Ed Class, Sex Ed books, females I have known, and the internet.

Ooooh...I see...
You're making it up. Okey dokey then. :)

Are you saying that parts of the female genitals are not essential and that some forms of FGM are ok?
No, but I don't think MGM is ok, either.
It also depends on how you define "essential", I guess, though.

By the way anyone got some good statistics of the percentage of each type of FGM?

This is a 2005 survey...the most recent I've been able to find:
http://www.unicef.org/publications/files/FGM-C_final_10_October.pdf

In the majority of countries that have included
questions regarding type of FGM/C, excision
of the prepuce (Type 1) is found to be the most
common. Only in Burkina Faso is excision of the
clitoris (Type 2) found to be most frequent.

[Skeptic Ginger]

I'm sort of thinking of the opposite response - that you accept the parents' decision by performing the procedure yourself. I know it sounds weird, but I think it forces you to take a harder look at the issue than you would by otherwise taking the easier route. I'm not really advocating that you do this, I'm just bringing it up for consideration. I have this same argument with my colleagues - not about circumcision, but about refusing treatment, for example, of active smokers. Disagreement is the rule there, too. :)

To accept their decision means that you help them carry it out to the best of your ability. If you discover that your strong feelings against that decision interfere with your ability to provide the best care, then it is reasonable to pass part (or all) of that care on to a colleague.

I just wanted to bring up a different perspective about what it means to interfere with the care of an individual.

LindaThis peds conference addresses this issue. Dr Marcuse, Seattle Children's Orthopedic Hospital, Chief of Staff has a brief segment which I admire in particular. I don't agree at all with refusing to treat patients who 'don't follow orders' which in some cases is what it amounts to. The doctor may rationalize it in a number of ways, and it isn't always the case, but often what it really amounts to is resentment of not being [believed, trusted, respected] (some combination of these issues.)

How Physicians View the Issue: Parents Who Refuse to Vaccinate a Child (http://www.uwtv.org/programs/displayevent.aspx?rID=5170)
This program focuses on a variety of issues related to parental rights regarding childhood vaccinations, including the origins of immunization hesitancy, and the medical community's response to the parent who refuses to vaccinate their child. Edgar Marcuse, professor at the University of Washington School of Medicine, discusses the nature and scope of immunization hesitancy and vaccine refusal in the United States. Dr. Marcuse identifies societal factors contributing to immunization hesitancy and discusses the tension between protecting the public's health and protecting the individual's right to choose. Joel Frader, professor at Northwestern University Feinberg School of Medicine, discusses the pediatricians' view of families who refuse vaccines and identifies the moral issues in responding to vaccine refusal. He also discusses options for physicians when parents refuse to vaccinate their children.I can't say I've never experienced resentment at not being believed but I can say I recognize it and I think I deal with it well considering how I may have dealt with it in the past and considering how people in these forums react when their view is not accepted by someone they are discussing an issue with.

And that is the segway to my next two posts.

[BlackKat]

Ooooh...I see...
You're making it up. Okey dokey then. :)

Not only is that 100% wrong but it is a 100% rude thing to say.

Obviously in the black and white world you perceive circumcision is as horrid as FGM.
Sorry. You're just not convincing me that I am suffering as much as some poor woman in Africa with a carved up vagina. Until you can do that I will maintain my position.

[kellyb]

Not only is that 100% wrong but it is a 100% rude thing to say.
My apologies for coming across rude. But seriously, you can't make claims and not provide evidence and expect to be taken seriously.

Obviously in the black and white world you perceive circumcision is as horrid as FGM.
I consider male circumcision quite comparable to removal of the clitoral prepuce.

Sorry. You're just not convincing me that I am suffering as much as some poor woman in Africa with a carved up vagina. Until you can do that I will maintain my position.
Of course you will. It would be very upsetting for you to acknowledge the similarities. When people hold irrational beliefs, there's usually a deep psychological need there.

[Skeptic Ginger]

Nice dodge. It is not an appeal to emotion; it’s an appeal to logical (i.e. consistent) reasoning. Something you think you’re rather good at. All you’ve said above is that you're just following orders. That’s not very logical, Skeptigirl.You can try, Ivor, but I'm not taking your bait. No one is "just following orders". If your physician or other health care provider isn't concerned with standards of care, I'd find another provider. And more than one person in this thread is now resorting to such insults which I interpret as getting frustrated their arguments fail to sway my position.

Medical standards and professional organizations' position statements are an important resource for any provider. Perhaps you are not aware of efforts in the medical profession to standardize care and promote evidence based decisions. There is a wealth of research which any number of patients are not afforded the advantage of because the pace at which research is now acquired makes it is impossible to keep up on an individual basis alone. With justification, and hopefully supporting evidence, one can certainly choose not to follow a standard, but it needs to be done with great care.

Just to reiterate my position which is continually being distorted and demonized here,

I agree with the position of the AAP and the AAFP, which also means I agree with what they believe is the appropriate standard of care.That position recognizes parents do not all assign the same weight to various components used to make their choice to circumcise their infant.The evidence based medical decision to circumcise (in low HIV prevalence countries) is equivocal.**I recognize not everyone in this thread agrees with that statement. But that comes as no surprise when you consider people here just like any parent have their own priorities which they are using to weigh the components of the decision.

Different values are assigned to such things as:
Religion and beliefs about right and wrong.The child's self esteem in the grade school locker room.Health.The child's right to choose.The child's right to 'body integrity'.Risk perception.Beliefs about the affects on sexual pleasure.

I may be leaving some out, but the point is the decision can vary depending on which of these factors are the most important to you and on how you view each of these. I don't believe the components of this decision which are most important to me should be used to decide what is someone else's decision to make. Nor does it bother me everyone isn't making the same decision.

Let’s try again.

Is it your view that an infant does _not_ have the right to body integrity? I.e., that the parent’s rights to choose trump the child’s rights to not have an unnecessary medical procedure, based on the available* evidence, that will permanently alter their body.

Yes or No will do, but I’d prefer a reasoned, consistent argument, if you think one is possible for your position.The answer is, no, not in this case.

Suppose the circumcision was medically necessary. The child has a kidney & urinary tract malformation and UTIs carry life threatening risk. What happens to your argument about right to body integrity? (I assume the people objecting to circumcision here would say, that's different.)

Now suppose the kidney defect is milder. Now the risk is less but a UTI in this child is still going to be riskier and/or more serious than a UTI in a healthy child. The evidence is that UTIs are potentially serious in any child but now you take the child with no anatomical issue making their UTI risk greater than any other child. So you have a continuum of medical risk/benefit where each person is drawing the line between circumcision being justified with the benefit greater than the risk, and circumcision being unjustified.

So what is the justification for where you draw that line? According to the medical evidence is there is a small medical benefit of UTI risk reduction with a circumcision.

Throw in another scenario. Suppose you have parents who have a healthy newborn but lost a previous child to an antibiotic resistant infection. Their priority is to take any action which decreases the risk of infection. Hearing there is evidence circumcisions decrease the risk of infection by a very small amount, they don't hear another word in the discussion. They opt for the circumcision. The previous child died from luck of the draw, not from any genetic contribution to risk. The parents, from previous experiences weigh the minor benefit of UTI risk reduction as extremely important. That is the only thing that differs here.

You say yourself, there is a threshold of risk reduction which you concede would make circumcision acceptable:It seems I can change my position on circumcision for increased resistance to HIV infection in Africa, but you can’t do the same for unnecessary (based on the evidence) circumcisions in the US.Who gets to draw that line, Ivor? Where do you draw it for UTI risk reduction? The kid with the major GU malformation, the moderate malformation, or no malformation but medical evidence still puts UTIs as potentially serious in any child?

Do the parents whose risk perception of infection is greater than your's get to use their value or yours or mine for that matter? These parents don't necessarily have false beliefs such as a parent refusing to vaccinate. These parents simply have had an experience which altered their value of infection prevention.

However, I doubt you’ll answer because the cognitive dissonance I think you have on this issue will make you dismiss my question as stupid or emotional.You really doubt I'll answer? You've got to be kidding. :rolleyes:

I have no cognitive dissonance here, Ivor. And I don't think the definition of cognitive dissonance even applies, unless there is a second definition I'm unaware of. I think you are looking for a word that describes a decision when there is more than one moral issue to compare. The parent's rights vs the child's rights, that isn't cognitive dissonance. CD is when you believe two things which are incompatible, such as believing in scientific evidence and believing in gods. Ah well, I suppose no one can be sceptical all the time about all issues.More insults because you are frustrated you have failed to convince me?

*The available evidence includes an individual assessment by a professional of the child’s body. Seems a lot of people in the US currently tend to weight that bit of evidence rather lightly when it disagrees with their wishes.I don't get what you mean here but if it has to do with more sarcasm and insults, that isn't very productive.

[BlackKat]

My apologies for coming across rude. But seriously, you can't make claims and not provide evidence and expect to be taken seriously.

Well I think I provided you with my evidence. I learned what the body parts do in Health and Sex Ed classes and from such Sex Ed books as were prevalent in the 1970s and early 1980s. I refined this knowledge by phyiscal relations with the opposite sex, testimonial though it may be. And before I posted I verified my facts as best as possible on the interweb (where there is as much fiction as fact) and provided you with one of the links I had visited.


I consider male circumcision quite comparable to removal of the clitoral prepuce.

And it could be argued to be comparable, except the revealed glans is just not analogous enough to the revealed clitoris. But my point to that has always been that removal of the clitoral hood is but one small aspect of FGM. And (with the exception of piercings which are if not infected essentially harmless) it does seem far less severe than removing the clitoris. But having an exposed clitoris can be extremely detrimental to sexual enjoyment.



Of course you will. It would be very upsetting for you to acknowledge the similarities. When people hold irrational beliefs, there's usually a deep psychological need there.

There are many more differences than similarities. I find nothing rational in believing penises are aestheticly better looking without a foreskin. You can not tie rational into aesthetic beliefs. People do not enjoy a painting or a penis or a song because it is rational to do so. They enjoy them because of the emotions those things evoke.

We can apply rational thinking to whether the emotions a circumcized penis evoke outweigh or not an infant's rights to body integrity versus a parent's right to request cosmetic body modifications. We must weigh a variety of factors when doing so, and one is "will these body modifications have a negative, positive, or no appreciable effect on this child". If the answer is positive or no appreciable effect then there is no reason to be opposed to them even if you do not promote them. If the answer is negative then there is reason to be opposed to them.

I thought it was fairly clear the FGM had enough evidence to say it was a negative modification. Maybe not for everyone, but I have seen enough evidence to convince me.
I just do not see any conclusive evidence showing negative effects to male circumcision, and I have seen some (a small amount) showing positive effects.

It definitely is something that merits more study. A large scale research project seems to be in order. I am pretty dismayed to see that both the pro-circumcision and anti-circumcision papers out there have such miniscule samples to use for making conclusions.

Really I don't see a single thing wrong with parents who choose to or who choose not to circumcise their children. So long as the circumcision is performed in a humane and medically sound manner and the baby does not suffer unduly. The same could be said of other debated neonatal procedures. for instance umbilical cord cutting vs. delayed cutting. If those parents are happy with a baby with a foreskin and are willing to risk the added infections and the way the penis looks, then they should not circumcise their child.
"To each their own" is a fitting statement for this. And that child is their own, entitling them to make decisions for the child until they are an adult so long as those decisions do not threaten the health or happiness of the child.

[Morrigan]

In other words, parents ought to have the right to remove useful but non-essential body parts of infants if they arbitrarily think it looks prettier.

Interesting.

[Z]

In other words, parents ought to have the right to remove useful but non-essential body parts of infants if they arbitrarily think it looks prettier.

Interesting.

Prove that the foreskin is 'useful'. Or, should I say, prove that the benefits of having a foreskin outweigh the benefits of not having one. So far, the benefits of having one appear minimal at best, while the benefits of not having one are somewhat greater (at least in our society).

Personally, I agree that parents ought to have the right (and, in fact, they DO have the right) to have surgery done on their children to improve their appearance. But then, I'm something of an extremist in this area, and my commentaries should be treated accordingly.

[Skeptic Ginger]

If, after reading the last few posts I have made, you seriously think you can justify saying that I would not respect the values of parents...I don't think there is any point in continuing this discussion. That is far more judgmental than anything I have even implied and is, frankly, insulting.And, I think becoming angry at a person who has a different perception of your 'planned response' to a parent opting for circumcision than you have of your response is the more insulting thing in this exchange so far.

We have a different perception of what your planned response means to the parent. You see it as respecting the parent's decision by offering them another physician to perform the circ. I perceive it as telling the parents you disapprove of their decision, and I don't equate that with respecting their opinion.

I realize you don't like the way I perceive your planned response. But if you choose to take that as an insult, I think you are short changing yourself.

I was willing to let the whole "alternate philosophies" idea slide, even though I very much disagree with any such notion. Nurses do not have a monopoly on 'teaching' and 'assisting' and 'helping'.You are interpreting my discussion about an educational philosophy and its subtle effect on subsequent patient provider interactions and approaches on some level of concrete thinking. That may be why you disagree and it certainly seems to be making you confuse a discussion of 'patient approach' with 'provider's skills'. Skills have absolutely nothing to do with what I am talking about. I'll try once more but then think it best to drop it. Perhaps I am communicating the concept poorly, but regardless, we're just talking past each other.

Take a look at wiki's Nursing Model (http://en.wikipedia.org/wiki/Nursing_Theories) and Medical Model (http://en.wikipedia.org/wiki/Medical_model) pages. They aren't the best descriptions but at least you can see that there is a distinctly different approach to the patient. I have one foot in each field. I have observed patient provider interactions for 30 years now. Not that it is the only way to understand, but if you spent a year in nursing school you might have a better understanding of the different philosophy that one comes out of their respective educations with.

Take the discussion about physicians refusing to take patients who refuse certain medical advice. That would be unheard of in nursing. Not because nurses are not autonomous and don't have the luxury, but because the role in nursing is to accept the patient and work with that. A patient refuses meds or to be compliant with a diabetic regimen, it is a nursing function to assess what the barriers are and find ways to accommodate. My role as a nurse would be to solve that problem, not reject the patient for it. Obviously not many physicians are rejecting patients, but the educational philosophy of the physician in charge allows it. The educational philosophy of nursing would not.

Your perception of what constitutes respect for the parent's decision and my perception of what constitutes respect are philosophically at odds. Perhaps we are merely arguing semantics. Respect in this case to me means, giving the parents the choice without bias. I believe you are defining it as, giving the parents the choice by accommodating it but with bias.

If you honestly think that you can do any of that without conveying an opinion, without 'deciding', 'recommending' or 'knowing an answer', you are kidding yourself at best. 'Unbiased' does not mean the same thing as 'unknowledgable'.You are confusing 'facts' with 'values'. A medical opinion is based on facts. I am going to tell a patient, for example, what the risks and benefits are for a procedure or medication, and they are going to decide whether to go ahead. That's simply informed consent. Many if not most medical recommendations are guided by the evidence.

There's a difference in telling the patient that some men believe circumcision has affected their sexual pleasure and telling the patient that it is morally wrong to circumcise their infant. If I were advising parents today, I would find the latest statistics so that I could say, many parents are choosing not to circumcise, so they needed worry about their child being different. If the parent said it was important Jr look like daddy, I might be ready with studies on whether that impacts kids or some suggestion on how to approach that issue. There are countless ways to properly influence parent's decisions which do not involve rejecting their values or giving biased or even selective information.

The information you give the parent is in response to their decision making steps rather than cherry picked. If you left out the information about the medical benefits or downplayed them inappropriately, that would be unethical and you would not be presenting information in an unbiased way. You'd be denying the parents the right to decide by cherry picking facts in order to persuade.

Your viewpoint is clear. You think circumcision is a good thing. Fine. You will have to accept the fact that there are other medical professionals who disagree with you. And the reason that people keep responding to the idea that you are espousing the concept of circumcising American boys for the purpose of avoiding HIV infection is that you keep responding this way to those of us who are making the point that it does not apply in non-Third-World nations with posts like these.I agree with the AAP and the AAFP position statements. Twisting that into a completely false claim that I must think circs are a good thing is an indication you're frustrated that you have not made your case. I don't care if I make my case to you. I'm confident that my position is supportable and I'm not invested in convincing any particular individuals. I find discussions like these actually help me refine my thoughts on the subject being discussed.

I remember a previous thread where you took on a rather obvious troll about the parallel nature of the professions of medicine and nursing, and I also recall posting in your support. I am now inclined to reassess my support, because you are now sounding very much like the bad caricature of a nurse who wishes she were a doctor. And I would prefer not to think that of anybody, because I prefer not to think that such a creature exists.Now this, is absurd. Especially if you read even a quarter of the posts I wrote in that thread. Anyone who had would have no question how highly I regard the nursing profession, and how completely satisfied I am with my career. Nor should there be any doubt whatsoever if you read my posts in that thread, I do not view the nursing and medical professions as subordinate to either. Both are separate professions with equally important roles in health care. I could make an equally offensive statement that you are a med student miffed that a 'mere' nurse should dare challenge your superior position. But I would hope med school isn't still teaching that tripe.

Let me state for the record that, although I am only a fourth-year medical student, I am not a kid. I'm 39 years old and had a couple of careers prior to returning to school to become a doctor. I have the utmost respect for my patients and for those who make decisions for them. That is why I feel I should give them the benefit of the knowledge I have worked so hard to acquire. To suggest acquiescing to anything else in the name of "values" is to condescend to them. I have made it clear that I would never try to prevent a parent who, having heard my opinion, still wanted the procedure, from having it done.

Exactly where do you find an attack on a patient's parents values in that?I think I have addressed this in this post and in my above post to Ivor. What I put in my reply to him I almost put in this post instead. So if you're sick of this exchange, at least read that post before wandering off.

[Skeptic Ginger]

Evidence?I hope you are trying to claim the foreskin is more rather than the clitoris is less here.

Otherwise I might need to offer you some sympathy for what you've missed.

[Skeptic Ginger]

In other words, parents ought to have the right to remove useful but non-essential body parts of infants if they arbitrarily think it looks prettier.

Interesting.What if it is a cultural belief of aesthetics? Not something essential like in the FGM arguments it's cultural, but say ritual scarring (http://en.wikipedia.org/wiki/Scarification) some cultures perform?

[kellyb]

I hope you are trying to claim the foreskin is more rather than the clitoris is less here.

Otherwise I might need to offer you some sympathy for what you've missed.

Do you know what the prepuce is, Skeptigirl?
Can you perhaps show me the logic behind the argument that the clitoral prepuce is an "essential part" whereas the foreskin of the penis is not?

I keep asking for evidence from BlackKat and Z, but they are staunchly refusing to provide it.

[kellyb]

Well I think I provided you with my evidence. I learned what the body parts do in Health and Sex Ed classes and from such Sex Ed books as were prevalent in the 1970s and early 1980s. I refined this knowledge by phyiscal relations with the opposite sex, testimonial though it may be. And before I posted I verified my facts as best as possible on the interweb (where there is as much fiction as fact) and provided you with one of the links I had visited.
No, that's not evidence. That's you claiming to know what you're talking about. There's a difference there.

And it could be argued to be comparable, except the revealed glans is just not analogous enough to the revealed clitoris.
You keep saying that, but when I challenge you to prove it, you just keep on with the "I know what I'm talking about!" thing.

And that's an extremely uncompelling argument.

But my point to that has always been that removal of the clitoral hood is but one small aspect of FGM.
It's actually pretty darn common, but you're refusing to acknowledge that, because it makes you uncomfortable or something...

And (with the exception of piercings which are if not infected essentially harmless) it does seem far less severe than removing the clitoris.
Agreed.

But having an exposed clitoris can be extremely detrimental to sexual enjoyment.
"Extremely detrimental", huh? And you know this because...you know what you're talking about and don't need to provide evidence to back your claims, because you know what you're talking about?
Got it.

There are many more differences than similarities.
Actually you're wrong. LOTS of similarities going on, as I'm about to demonstrate:
I find nothing rational in believing penises are aestheticly better looking without a foreskin. You can not tie rational into aesthetic beliefs. People do not enjoy a painting or a penis or a song because it is rational to do so. They enjoy them because of the emotions those things evoke.


http://www.irinnews.org/InDepthMain.aspx?InDepthId=15&ReportId=62462
Other communities consider female genitalia to be ugly, offensive or dirty, and thus the removal of the external genitalia makes a woman more hygienic and aesthetically pleasing.


"To each their own" is a fitting statement for this. And that child is their own,
But it only works like that for boys, though, right?
If the baby is a girl, her genitalia do not belong to her parents for them to remove parts arbitrarily based on aesthetics?

[Skeptic Ginger]

Do you know what the prepuce is, Skeptigirl?
Can you perhaps show me the logic behind the argument that the clitoral prepuce is an "essential part" whereas the foreskin of the penis is not?

I keep asking for evidence from BlackKat and Z, but they are staunchly refusing to provide it.OK, sorry, reread your post, I read it wrong. Seems easy to do. I wonder how often we all are doing it?

[BlackKat]

No, that's not evidence. That's you claiming to know what you're talking about. There's a difference there.

You keep saying that, but when I challenge you to prove it, you just keep on with the "I know what I'm talking about!" thing.

And that's an extremely uncompelling argument.

Like I said. Knowledge was confirmed as best it can be by the internet. And I provided you with a link. It's inane to argue this anyhow since you also know the exact same thing I know. If you don't believe I know what I'm talking about with circumcision then say THAT. You're trying to argue a completely separate point just to try to cast aspersion about some other point.


It's actually pretty darn common, but you're refusing to acknowledge that, because it makes you uncomfortable or something...
Never said it was uncommon. I said it was one of about 10 different FGM practices, and that is was rarely done in exclusion. You keep saying Type I is the most common. Type I is the excision of the clitoris and/or the labia.


"Extremely detrimental", huh? And you know this because...you know what you're talking about and don't need to provide evidence to back your claims, because you know what you're talking about?
Got it.
Again you know this is true but you are arguing not because you don't think I'm right because you are trying to cast aspersions on my statement that the foreskin is not important.



http://www.irinnews.org/InDepthMain.aspx?InDepthId=15&ReportId=62462

From that article:
"The function of this practice, whether mild or severe, is ultimately to reduce a woman's sexual desire, and so ensure her virginity until marriage. The more extensive procedure, involving stitching of the vagina, has the same aim, but reducing the size of the vagina is also intended to increase the husband's enjoyment of the sexual act."

That does not sound like aesthetics to me. Now keep reading below that in the article and it lists the short and long term effects of FGM. Guess what? Men who are circumcised do not suffer those effects.


But it only works like that for boys, though, right?
If the baby is a girl, her genitalia do not belong to her parents for them to remove parts arbitrarily based on aesthetics?

No if the parents wanted to perform on a female or male infant ritual scarring, most forms of piercing, tattooing... it's also their choice so long as it is done in as sterile and painless way as is medically viable. And so long as these things will not negatively impact the child's future.

You're trying to make equivalent two completely separate, and distinctly different, procedures and it is not working. That's like saying red is blue because they're both colors. Try arguing just about the merits or detriments of circumcision rather than trying to make circumcision into something that it's not.

[Ivor the Engineer]

You can try, Ivor, but I'm not taking your bait. No one is "just following orders". If your physician or other health care provider isn't concerned with standards of care, I'd find another provider. And more than one person in this thread is now resorting to such insults which I interpret as getting frustrated their arguments fail to sway my position.

Now come on skeptigirl, they weren't insults, just provocatitve statements:D

Medical standards and professional organizations' position statements are an important resource for any provider. Perhaps you are not aware of efforts in the medical profession to standardize care and promote evidence based decisions. There is a wealth of research which any number of patients are not afforded the advantage of because the pace at which research is now acquired makes it is impossible to keep up on an individual basis alone. With justification, and hopefully supporting evidence, one can certainly choose not to follow a standard, but it needs to be done with great care.

Circumcision of a healthy infant is not an evidence based decision. It’s a whim.

Just to reiterate my position which is continually being distorted and demonized here,

I agree with the position of the AAP and the AAFP, which also means I agree with what they believe is the appropriate standard of care.That position recognizes parents do not all assign the same weight to various components used to make their choice to circumcise their infant.The evidence based medical decision to circumcise (in low HIV prevalence countries) is equivocal.**I recognize not everyone in this thread agrees with that statement. But that comes as no surprise when you consider people here just like any parent have their own priorities which they are using to weigh the components of the decision.

Different values are assigned to such things as:
Religion and beliefs about right and wrong.The child's self esteem in the grade school locker room.Health.The child's right to choose.The child's right to 'body integrity'.Risk perception.Beliefs about the affects on sexual pleasure.

I may be leaving some out, but the point is the decision can vary depending on which of these factors are the most important to you and on how you view each of these. I don't believe the components of this decision which are most important to me should be used to decide what is someone else's decision to make. Nor does it bother me everyone isn't making the same decision.

What about putting yourself in the position of each person being affected by the decision. Can you put yourself in the position of the infant? Using your adult reasoning and knowledge that this procedure is not required and is going to hurt you (to a greater or lesser extent), would choose to have it performed on you?

The answer is, no, not in this case.

Thanks for your answer. The caveat of ‘not in this case’ implies there are situations where you think a child does have the right to body integrity. Could you give some examples where you think this right for the child should be supported over parent’s wishes?

Suppose the circumcision was medically necessary. The child has a kidney & urinary tract malformation and UTIs carry life threatening risk. What happens to your argument about right to body integrity? (I assume the people objecting to circumcision here would say, that's different.)

My reasoning (putting myself in each individual’s position) leads me to the conclusion that the procedure should be performed.

Now suppose the kidney defect is milder. Now the risk is less but a UTI in this child is still going to be riskier and/or more serious than a UTI in a healthy child. The evidence is that UTIs are potentially serious in any child but now you take the child with no anatomical issue making their UTI risk greater than any other child. So you have a continuum of medical risk/benefit where each person is drawing the line between circumcision being justified with the benefit greater than the risk, and circumcision being unjustified.

So what is the justification for where you draw that line? According to the medical evidence is there is a small medical benefit of UTI risk reduction with a circumcision.

Yes, pro-infant circumcision people do go on and on and on about the fact that circumcised boys have a lower incidence of UTI’s. If they also then take action to avoid all other similar magnitude risks for their child then at least they are being consistent. I bet they don’t though.

Again, put yourself in the position of the child. You know that studies have shown that being circumcised has a small benefit for contracting a UTI. You know that the risk is extremely small of you contracting a UTI in the first place. You know that circumcision is not 100% effective for preventing UTI. You know that a UTI can be treated with antibiotics successfully in the vast majority of cases. I think anyone who chose to have an irreversible medical procedure for that level of benefit would need serious psychological treatment (such as for OCD hand-washing) for their perception of risk, don’t you?

Throw in another scenario. Suppose you have parents who have a healthy newborn but lost a previous child to an antibiotic resistant infection. Their priority is to take any action which decreases the risk of infection. Hearing there is evidence circumcisions decrease the risk of infection by a very small amount, they don't hear another word in the discussion. They opt for the circumcision. The previous child died from luck of the draw, not from any genetic contribution to risk. The parents, from previous experiences weigh the minor benefit of UTI risk reduction as extremely important. That is the only thing that differs here.

You say yourself, there is a threshold of risk reduction which you concede would make circumcision acceptable:Who gets to draw that line, Ivor? Where do you draw it for UTI risk reduction? The kid with the major GU malformation, the moderate malformation, or no malformation but medical evidence still puts UTIs as potentially serious in any child?

Do the parents whose risk perception of infection is greater than your's get to use their value or yours or mine for that matter? These parents don't necessarily have false beliefs such as a parent refusing to vaccinate. These parents simply have had an experience which altered their value of infection prevention.

Stop with the parents! They and the physician should be advocating for the child, i.e. putting themselves in the position of the child.

You really doubt I'll answer? You've got to be kidding. :rolleyes:

Actually, I had only an incy-wincy bit of doubt. That’s why I put that (and other provocative statements) in. I know, I’m a pri*k:D

I have no cognitive dissonance here, Ivor. And I don't think the definition of cognitive dissonance even applies, unless there is a second definition I'm unaware of. I think you are looking for a word that describes a decision when there is more than one moral issue to compare. The parent's rights vs the child's rights, that isn't cognitive dissonance. CD is when you believe two things which are incompatible, such as believing in scientific evidence and believing in gods. More insults because you are frustrated you have failed to convince me?

The CD comes from you supporting the child’s rights in one situation and parent’s rights in another when they equivalent situations.

I don't get what you mean here but if it has to do with more sarcasm and insults, that isn't very productive.

No sarcasm or insult intended, just trying to clarify that the one piece of evidence that does not seem to get mentioned much (in this kind of debate) is what the assessment of an individual child’s condition is.

[Z]

The child ultimately doesn't care, if the circumcision is done right. The pain - if any - is fleeting, and in the long term, the child doesn't remember the pain and doesn't suffer any side-effects. So that empathy plea isn't going to work, either.

If it was such a traumatic and life-damaging experience, it wouldn't be so common in the U.S. Men wouldn't be insisting such a painful and useless procedure be done on their male children - we're not inherently cruel, you know. And that goes for men from all walks of life (excepting the fundies of any given group), including men raised atheist. So you can't even claim that they were obeying their religious precepts over their latent memories of pain and fear.

What the infant feels is a non-issue.

[fls]

Mmmm...interesting. :cool:

It's food for thought, but I have to disagree, ultimately, with the idea that "to accept their decision means that you help them carry it out to the best of your ability." I can accept their decision because ultimately, I don't think circumcision is particularly harmful. (I brought this up again with my husband last night and he agreed it's not something that's ever bothered him one way or another. That's the thing--I don't see it as a huge moral issue, I just see it as medically unnecessary, which is not the same thing as actively harmful.) But that doesn't mean I have to agree with the decision. Personally, I think if I don't agree with it, I shouldn't do it. As you say, reasonable people may come to different conclusions. ;)

I could postulate a decision that I would disagree with so vehemently that I would not even consider being involved with it, or even one so against what I see as the patient's best interests that I would be willing to take legal action to prevent its being acted on. (The ethics committee/legal department has had two of those since I've been in school--no one likes that.) But this just isn't that decision.

Somewhere backalong you said something about no behavior (pardon the American spelling) having been changed if I passed on the decision. Not quite true. I mean, mine has been, right? :D

I think that your behaviour is immaterial, except maybe to serve to emphasize your disagreement with the parents' choice. And this may be a good thing. I think ethical concerns can and should be a part of some discussions. But I am more interested in whether others understand and have given due consideration to the issues, than I am about whether we ultimately agree, because otherwise I worry that I am attempting to impose my own beliefs onto someone else. When you make a point of saying that you won't perform circumcisions for non-medical reasons, it could be taken as though you are allowing your beliefs to take priority over the beliefs of your patient's surrogate decision makers. What saves you is that the circumstances won't actually result in a denial of service, so it really just serves to somewhat quantify the strength of your disagreement. I just think it should be made clear that what we are talking about is whether it is appropriate for you specifically and for physicians generally to make their judgment on this issue part of the discussion.

I don't have an answer, I just don't think it should be left up to individual physicians to take it upon themselves.

Linda

[Katana]

I think that your behaviour is immaterial, except maybe to serve to emphasize your disagreement with the parents' choice. And this may be a good thing. I think ethical concerns can and should be a part of some discussions. But I am more interested in whether others understand and have given due consideration to the issues, than I am about whether we ultimately agree, because otherwise I worry that I am attempting to impose my own beliefs onto someone else. When you make a point of saying that you won't perform circumcisions for non-medical reasons, it could be taken as though you are allowing your beliefs to take priority over the beliefs of your patient's surrogate decision makers. What saves you is that the circumstances won't actually result in a denial of service, so it really just serves to somewhat quantify the strength of your disagreement. I just think it should be made clear that what we are talking about is whether it is appropriate for you specifically and for physicians generally to make their judgment on this issue part of the discussion.

I don't have an answer, I just don't think it should be left up to individual physicians to take it upon themselves.

Linda


So you see no role for your own judgment in the care of your patients?

[kellyb]

Never said it was uncommon. I said it was one of about 10 different FGM practices, and that is was rarely done in exclusion. You keep saying Type I is the most common. Type I is the excision of the clitoris and/or the labia.

Again: (the most recent survey done! )
http://www.unicef.org/publications/files/FGM-C_final_10_October.pdf

In the majority of countries that have included
questions regarding type of FGM/C, excision
of the prepuce (Type 1) is found to be the most
common. Only in Burkina Faso is excision of the
clitoris (Type 2) found to be most frequent.

Again you know this is true but you are arguing not because you don't think I'm right because you are trying to cast aspersions on my statement that the foreskin is not important.
I'm saying there's no reason to believe they are not THE SAME. Removing the clitoral prepuce or the penis's foreskin...it is extremely similar. There is no evidence that one is "worse" than the other.

That does not sound like aesthetics to me. Now keep reading below that in the article and it lists the short and long term effects of FGM. Guess what? Men who are circumcised do not suffer those effects.
You can not compare the medical complications that happen in the two thirds world with the complications that happen in industrialized nations. Male circumcision "over there" often results in all kinds of horrible things we don't see over here.

No if the parents wanted to perform on a female or male infant ritual scarring, most forms of piercing, tattooing... it's also their choice so long as it is done in as sterile and painless way as is medically viable. And so long as these things will not negatively impact the child's future.
You've provided no evidence that removing the clitoral prepuce from an infant girl does anything "bad" that removing the penile foreskin from an infant male does not. Yes, logically, it's removing nerves and will result in desensitization from friction. But guess what? That happens in boys, too.

You're trying to make equivalent two completely separate, and distinctly different, procedures and it is not working. That's like saying red is blue because they're both colors.

It's more like arguing the the differences between "blanco" and "white".

Try arguing just about the merits or detriments of circumcision rather than trying to make circumcision into something that it's not.
The merits of the milder forms of FGM are largely unknown because the practice is viewed as barbaric. We do have evidence that it decreases HIV, though. (that was discovered accidentally when researchers were attempting to prove the opposite). Logically, ulcerative genital sores from various STDs could be reduced by some forms, too.
So there are some parallels there with the benefits of male circumcision.
The "down sides" would be similar, as well. (desensitization, primarily).

What the infant feels is a non-issue.
I have no idea how to respond to that other than to say I totally disagree.

[Ivor the Engineer]

So you see no role for your own judgment in the care of your patients?

Safety in numbers, remember?

[Morrigan]

Prove that the foreskin is 'useful'. Or, should I say, prove that the benefits of having a foreskin outweigh the benefits of not having one. So far, the benefits of having one appear minimal at best, while the benefits of not having one are somewhat greater (at least in our society).

Excuse me, but this thread has failed to convince me that the benefits are "greater". You're talking completely subjective bollocks here.
As for the foreskin being "useful" - um, it has been said over and over again what the uses of the foreskin are. Just because -you- don't agree these uses are significant doesn't mean they aren't, or don't exist.


Personally, I agree that parents ought to have the right (and, in fact, they DO have the right) to have surgery done on their children to improve their appearance. But then, I'm something of an extremist in this area, and my commentaries should be treated accordingly.
So if, in my "culture", earlobes are ugly, I can cut off my children's earlobes to make them look prettier, and hey, they won't suffer from potential pierced earlobe infection, so it's all good... right?
Same argument with the removal of the clitoral hood, actually. Or any other form of FMG, for that matter. Who are we to put the female's sexual pleasure over her acceptance into her community as someone with beautiful, healthy-looking, excised genitals, after all? Those women don't miss their intact genitals, in fact, they even make sure their daughters get the same treatment.

[Ivor the Engineer]

What the infant feels is a non-issue.

Wow! That's all the way up to Level 1, Pre-conventional morality (Right and wrong determined by rewards/punishment). Were you in the armed forces?

Most of the arguments here (including some of my own) are Level 2, Conventional morality (Views of others matter. Avoidance of blame; seeking approval).

Anyone care to try an argument based on Level 3, Post-conventional morality (Abstract notions of justice. Rights of others can override obedience to laws/rules)?

[HawkeyeMD]

When you make a point of saying that you won't perform circumcisions for non-medical reasons, it could be taken as though you are allowing your beliefs to take priority over the beliefs of your patient's surrogate decision makers. What saves you is that the circumstances won't actually result in a denial of service, so it really just serves to somewhat quantify the strength of your disagreement. I just think it should be made clear that what we are talking about is whether it is appropriate for you specifically and for physicians generally to make their judgment on this issue part of the discussion.

I don't have an answer, I just don't think it should be left up to individual physicians to take it upon themselves.

Linda

But you seem to be assuming that my 'belief' has something to do with something other than the medical necessity or value of the procedure. If another kind of 'belief' is involved, then the parents are free to seek out another provider.

I don't understand what you mean by "left up to individual physicians to take it upon themselves." I've said several times that I would never try and stop parents who really wanted it done, for whatever reason. But there's no way I have to do something just because someone wants it. What if it's a parent of a child who absolutely wants their kid's cold to be treated with antibiotics, because they "know it will help"? Is their 'belief' supposed to trump my training and knowledge that antibiotics don't help colds, that they're overprescribed, and that they confer a risk of side effects including anaphylaxis?

And is the fact that the parent can probably talk some other overworked doctor into writing the script supposed to convince me to just go ahead and give it anyway, because that's what their belief is and my judgment shouldn't trump theirs?

[HawkeyeMD]

So you see no role for your own judgment in the care of your patients?

I'm puzzled by this idea as well.

[Z]

Wow! That's all the way up to Level 1, Pre-conventional morality (Right and wrong determined by rewards/punishment). Were you in the armed forces?

Yes, as a matter of fact, for a decade.

Most of the arguments here (including some of my own) are Level 2, Conventional morality (Views of others matter. Avoidance of blame; seeking approval).

Yeah, I tend to reject that nonsense. Views of others: irrelevant. Acceptance of blame. Dismissal of approval.

Anyone care to try an argument based on Level 3, Post-conventional morality (Abstract notions of justice. Rights of others can override obedience to laws/rules)?

Pure crap... metaphorically speaking, of course.

Since the infant does not remember the pain, their pain is in this case irrelevant. Their pain is not life-threatening, nor disruptive to their growth and development, nor is it going to cause an issue in later life. Hence, it can be dismissed.

And Morri, the claimed uses of the foreskin are completely unconvincing. Having never had one, I've never had any problems from not having one; and I value my personal experience in this matter over these far-reaching attempts to justify keeping the foreskin.

As for the earlobes issue, sure. Earlobes are unnecessary. If your culture finds their removal to be more attractive, great.

As to the issue of the prepuce, I will say that IF its removal results in similar non-issues to the removal of the foreskin, then that's fine, too. However, I am aware that the clitoris is a far more sensitive member than the glans penis, and that removal of the clitoral prepuce can actually deter from the enjoyment of sex. Since removal of the foreskin does not deter from the enjoyment of sex - personal experience, again - it is not equivalent.

Personally, I think unless you've been circumcised, you have no place discussing circumcision.

:D

[Ivor the Engineer]

...Since the infant does not remember the pain, their pain is in this case irrelevant. Their pain is not life-threatening, nor disruptive to their growth and development, nor is it going to cause an issue in later life. Hence, it can be dismissed...

So if it was possible to erase adults' memories of specific events, you wouldn't mind if those events involved inflicting pain on the individual?

Do you find date rape (victim drugged, can't remember what happened, wakes up in bed) more acceptable than rape performed at knife-point?

[Z]

So if it was possible to erase adults' memories of specific events, you wouldn't mind if those events involved inflicting pain on the individual?

As long as those events resulted in a positive effect for the individual, no. Hence, anesthesia for surgery.

Do you find date rape (victim drugged, can't remember what happened, wakes up in bed) more acceptable than rape performed at knife-point?

I find no form of rape acceptable, because rape does not result in a positive effect for the victim. Nor do I find drugging a person against their will acceptable.

How soon before you ask me if I've stopped beating my wife and raping my children? You anti-circers are big on making sweeping emotional pleas, aren't you?

Circumcision does result in positive effects for the individual, and the pain is forgotten if done in infancy. That pain is, therefore, irrelevant.

[kellyb]

So if it was possible to erase adults' memories of specific events, you wouldn't mind if those events involved inflicting pain on the individual?

As long as those events resulted in a positive effect for the individual, no.

This is a very interesting insight into the mind of the circumcising parent.

I'm really thinking at this point that we need more laws in place to protect small children and others without a voice from needless suffering.

[Tsukasa Buddha]

Since the infant does not remember the pain, their pain is in this case irrelevant. Their pain is not life-threatening, nor disruptive to their growth and development, nor is it going to cause an issue in later life. Hence, it can be dismissed.

:eek: What the ****. Suffering is only relevant if the subject always remembers it? But then, what makes you think that the infant can't remember it? I mean, by the time you are older, you will have forgotten. But do babies remember it the next day (This is last part is purely musing)?

As for the earlobes issue, sure. Earlobes are unnecessary. If your culture finds their removal to be more attractive, great.

:dl:

Really? I must refrain from asking questions that make you out to be a bastard, but you are really just begging for it with this stuff.

(Really?)

Personally, I think unless you've been circumcised, you have no place discussing circumcision.

:D

Naturally, lest the unbiased meander into the discussion :p .

[kellyb]

I'm really fascinated by the idea that it's ok to do anything at all to another person (as long as there can be some small, obscure benefit theorized) so long as some anmesia over the trauma will set in at some point.

Patient has anterograde amnesia? No anaestesia for heart surgery. Just restrain him and try to ignore the pleas for mercy. He'll forget about the whole thing before too long.

:confused:

[Z]

:eek: What the ****. Suffering is only relevant if the subject always remembers it? But then, what makes you think that the infant can't remember it? I mean, by the time you are older, you will have forgotten. But do babies remember it the next day (This is last part is purely musing)?

Even if they remember it a week, it's irrelevant. As it is, from what I can tell, the methods used by the doctors in my sons' circumcisions were painless, making it a moot point anyway.

:dl:

Really? I must refrain from asking questions that make you out to be a bastard, but you are really just begging for it with this stuff.

(Really?)

Really. As for what that makes me out to be, you're welcome to your opinions, but I'm pretty sure my parents were married.

And it's certainly better than waiting until they're old enough to RETAIN a memory of pain or discomfort, I'd say.

Naturally, lest the unbiased meander into the discussion :p .

:dl:

You're kidding, right? There ARE no unbiased men in a circumcision discussion. Only women could make that claim - possibly.

But what's become clear so far is that uncircumcised men (the ones posting here anyway) have this sick delusion that trimming off the foreskin results in lack of feeling, weaker sexual pleasure, and who know what else - when, in fact, it doesn't. It's not traumatic or harmful. And from my experience - anecdotal, yes - having a foreskin is more of a problem than not having one, what with infections, hygeine issues, the stench, etc. I might say that having been circumcised, I probably shouldn't discuss uncircumcised men, but I am stepfather to two uncircumcised boys and have been a friend to a scant few uncircumcised men.

Are the uncircumcised men here fathers to circumcised boys, or have close friends who have been circumcised? Then perhaps they might have a claim to less bias than otherwise. But that doesn't appear to be the case.

[Z]

I'm really fascinated by the idea that it's ok to do anything at all to another person (as long as there can be some small, obscure benefit theorized)

There you go, trying to insert your erroneous opinion again. I'd say the benifits of circumcision are neither small, nor obscure, nor theoretical.

so long as some anmesia over the trauma will set in at some point.

A very short point, of course.

Patient has anterograde amnesia? No anaestesia for heart surgery.

Now you're just being silly. The shock involved could kill the patient. Of course you'd use anesthesia. Besides, restraining the patient would be too problematic.

No such problems with circumcision.

(Besides, amnesia can spontaneously reverse. An adult, on the other hand, isn't suddenly going to remember a slight pain shortly after birth.)

Is this the best you have? A few empty emotional appeals?

[Ivor the Engineer]

As long as those events resulted in a positive effect for the individual, no. Hence, anesthesia for surgery.

So you think the only reason a patient gets knocked out before having major surgery is so they don't remember it. You don't think that fear and pain come into it?

I find no form of rape acceptable, because rape does not result in a positive effect for the victim. Nor do I find drugging a person against their will acceptable.

Just remind me again, what out and out positive effects does circumcision provide for a boy in the developed world? Do you think American boys have a significant advantage to European ones?

How soon before you ask me if I've stopped beating my wife and raping my children? You anti-circers are big on making sweeping emotional pleas, aren't you?

I don't think you do those things so I'm not going to ask you. I was trying to understand how you came to the conclusion that just because pain and suffering have been forgotten, they are irrelevant.

By the way, I'm not anti-circumcision. I'm against circumcisions performed for no medical reason. If the circumcision is medically indicated and adequate pain relief is used, then I have no problem with circumcision at all.

Circumcision does result in positive effects for the individual, and the pain is forgotten if done in infancy. That pain is, therefore, irrelevant.

If it makes you feel better just keep on repeating that.

[becomingagodo]

Doesn't circumcision stop masterbation?
I heard that it is so popular because people think it does, however I haven't seen any evidence for it.

[Ivor the Engineer]

This is a very interesting insight into the mind of the circumcising parent.

I'm really thinking at this point that we need more laws in place to protect small children and others without a voice from needless suffering.

I'm amazed after reading Linda's posts that the wishes of parents for unnecessary medical treatment of their children is such a difficult (and potentially risky) thing for a physician to say no to.

I wonder what the charge against a physician could actually be for refusing to perform a circumcision when it was not medically indicated?

[Z]

So you think the only reason a patient gets knocked out before having major surgery is so they don't remember it. You don't think that fear and pain come into it?

Already addressed that.

Just remind me again, what out and out positive effects does circumcision provide for a boy in the developed world?

Already addressed that, too.

And do you honestly think that a risk of HIV doesn't exist in developed countries?

Do you think American boys have a significant advantage to European ones?

Do you really want me to go there?

By the way, I'm not anti-circumcision. I'm against circumcisions performed for no medical reason. If the circumcision is medically indicated and adequate pain relief is used, then I have no problem with circumcision at all.

Good. The first doctor to perform circumcision on one of my children advised that circumcision is an excellent preventative to infection, disease, and hygeine issues. Adequate pain relief was used. So no problem, right?

Then why all the drama?

If it makes you feel better just keep on repeating that.

Feelings have nothing to do with this.

[Z]

Doesn't circumcision stop masterbation?
I heard that it is so popular because people think it does, however I haven't seen any evidence for it.

That's something else I'd never heard until this thread. Where have you heard that?

Of course, I was raised to believe that masturbation was just fine. And our school sex ed class praised masturbation as an alternative to intercourse.

[Ivor the Engineer]

Doesn't circumcision stop masterbation?
I heard that it is so popular because people think it does, however I haven't seen any evidence for it.

I can think of only one think that would stop a boy masturbating. It's not circumcision.

Anyhow, masturbation has positive effects, don't you know. I therefore think parents should insist their sons' are taught how to masturbate at the earliest age possible, so they gain the maximum benefit and don't remember the embarrassment of talking about sex to an adult when they're a teenager:D

[Tsukasa Buddha]

Even if they remember it a week, it's irrelevant. As it is, from what I can tell, the methods used by the doctors in my sons' circumcisions were painless, making it a moot point anyway.

Well there's your problem. Was anesthesia used? What was the method? How often is anesthesia used? How often is that method used? Do you have any objective evidence that it was painless? And just for laughs, a calm baby looks similar to a baby in shock.

And it is not irrelevant. You made the ridiculous claim that suffering is irrelevant if the subject doesn't remember it later. What is your rationale?

Really. As for what that makes me out to be, you're welcome to your opinions, but I'm pretty sure my parents were married.

And it's certainly better than waiting until they're old enough to RETAIN a memory of pain or discomfort, I'd say.

But you can't know if they will choose to do the surgery later. And for me, the important part is the choice. I'd say it would be better to wait for the simple fact that it will then be their choice.

But again, that's just my crazy thinking. Kinda like your opinions that infantile suffering is irrelevant and that culturally accepted mutilation is fine as long as it doesn't take off anything too important.

:dl:

You're kidding, right?

Dur. That's why I used a smilie.

There ARE no unbiased men in a circumcision discussion. Only women could make that claim - possibly.

But what's become clear so far is that uncircumcised men (the ones posting here anyway) have this sick delusion that trimming off the foreskin results in lack of feeling, weaker sexual pleasure, and who know what else - when, in fact, it doesn't. It's not traumatic or harmful. And from my experience - anecdotal, yes - having a foreskin is more of a problem than not having one, what with infections, hygeine issues, the stench, etc. I might say that having been circumcised, I probably shouldn't discuss uncircumcised men, but I am stepfather to two uncircumcised boys and have been a friend to a scant few uncircumcised men.

Are the uncircumcised men here fathers to circumcised boys, or have close friends who have been circumcised? Then perhaps they might have a claim to less bias than otherwise. But that doesn't appear to be the case.

Congrats on admitting your bias :) . And, yes, I bolded the above just because you still say that infantile suffering is irrelevant.

[Ivor the Engineer]

...The first doctor to perform circumcision on one of my children advised that circumcision is an excellent preventative to infection, disease, and hygeine issues...

Then he was a fool or a lier. Alas, spending 5 or 6 years in medical school does not ensure a person is neither of these.

[Tsukasa Buddha]

Doesn't circumcision stop masterbation?
I heard that it is so popular because people think it does, however I haven't seen any evidence for it.

Well, it was once thought that:

And Yet Another Reason?

It was once believed that circumcision would prevent masturbation, as stated earlier, that was in the 1800s when masturbation was not looked upon as a healthy thing to be doing. Circumcision does not prevent masturbation or increase fertility. The belief that circumcision enhances the sexual experience for men or for their sexual partners may not necessarily be true, either. I can't confirm or deny this as I wasn't born with a penis, but many men have written in to say that they believe they are more 'sensitive' because of having a foreskin.

Source (http://www.coolnurse.com/circumcision.htm)

[Z]

Luckily, Australia is reconsidering circumcision, thanks to the HIV studies. And thanks to the plastibell method, circumcision is painless and almost error-free.

(BTW, yeah, masturbation should be taught to young children (in a purely textbook, hands-off approach) fairly early on, around puberty. It is quite beneficial, actually.)

[Tsukasa Buddha]

Oh, I forgot to post this from my link :p . It is actually very interesting:

Cancer Risk?

It is widely and falsely believed that uncircumcised men stand a greater risk of penile cancer. A big surprise to many in the medical community.

In March of 1999, the American Academy of Pediatrics revised its circumcision policy statement and concluded that there is not sufficient data to support the supposed potential health benefits of circumcision. The organization no longer advocates routine neonatal circumcision.

Here is part of that press release from March 1, 1999, 5 p.m. (ET) Below is a highlight of the policy published in the March issue of Pediatrics, the peer-reviewed, scientific journal of the American Academy of Pediatrics (AAP), if you care to see what they determined.

CHICAGO - After analysis of almost 40 years of available medical research on circumcision, the American Academy of Pediatrics (AAP) issued new recommendations today stating that the benefits are not significant enough for the AAP to recommend circumcision as a routine procedure.

The new policy statement was published in this month's issue of Pediatrics, the journal of the AAP. “Circumcision is not essential to a child's well-being at birth, even though it does have some potential medical benefits. These benefits are not compelling enough to warrant the AAP to recommend routine newborn circumcision. Instead, we encourage parents to discuss the benefits and risks of circumcision with their pediatrician, and then make an informed decision about what is in the best interest of their child,” says Carole Lannon, M.D., MPH, FAAP, chair of the AAP's Task Force on Circumcision. The policy concluded, however, that it is legitimate for parents to take into account cultural, religious and ethnic traditions, in addition to medical factors, when making this decision. It states that to make an informed choice, parents of all male infants should be given accurate information and be provided the opportunity to discuss this decision with their pediatrician.”

I agree with the bolded.

However, I personally disagree with doing it for cultural, religious, or ethnic reasons. Damn culture *shakes fist* :mad: .

[HawkeyeMD]

I'm amazed after reading Linda's posts that the wishes of parents for unnecessary medical treatment of their children is such a difficult (and potentially risky) thing for a physician to say no to.

I wonder what the charge against a physician could actually be for refusing to perform a circumcision when it was not medically indicated?

Charge? Did I miss something?

I didn't see anywhere that she implied the physician could be charged with anything. :confused: She's been talking about an ethical obligation, as far as I can tell, not a legal one.

[Z]

I don't think you can be charged, per se, for refusing treatment. Some nurses have been (IMHO) wrongly fired for giving their opinions to the parents, or refusing to take part in the process... but I don't think refusing treatment is considered a criminal or civil offense.

But these days, who knows? People sue each other over their own stupidity.

ETA: If there's anyone that needs to have charges brought up, it's the pharmacists who are refusing to sell birth control to their customers.

[Morrigan]

And Morri, the claimed uses of the foreskin are completely unconvincing. Having never had one, I've never had any problems from not having one; and I value my personal experience in this matter over these far-reaching attempts to justify keeping the foreskin.

Personal experience trumps the big picture. Interesting.


As for the earlobes issue, sure. Earlobes are unnecessary. If your culture finds their removal to be more attractive, great.

I see. What if I'm actually living in North America, where no one else has cut off earlobes. My child will look funny to the others. But it's part of my culture where I was born or some crap like that. Still think it's a good idea?


Personally, I think unless you've been circumcised, you have no place discussing circumcision.

:D
How convenient... eliminate different viewpoints. But will you stay out of any abortion topic, then?

There you go, trying to insert your erroneous opinion again. I'd say the benifits of circumcision are neither small, nor obscure, nor theoretical.
:newlol Genius!
Why is his opinion erroneous? We can say the same thing about yours.


And do you honestly think that a risk of HIV doesn't exist in developed countries?

Oh please, do you honestly think that circumcision will prevent AIDS for a North American? Do you really think that American males as a whle would have more HIV infections if it weren't for circumcision? (If so, provide evidence please, kthxbye)
The only way it can "help", is if the man is having unprotected sex with an HIV-positive partner. Yeah, good plan of action right there.


Good. The first doctor to perform circumcision on one of my children advised that circumcision is an excellent preventative to infection, disease, and hygeine issues.
But that's not even true! :newlol

[tabitha]

There you go, trying to insert your erroneous opinion again. I'd say the benifits of circumcision are neither small, nor obscure, nor theoretical.



What exactly are the benefits of circumcision? I know there is a small reduction in UTI's in circ'd boys but really, boys don't really suffer from UTI's, girls do more usually. UTI's are very easily treated with antibiotics. Surely this is not held up as a "benefit" of circumcision:confused:

Why do people think circumcised penis are "cleaner"? If you wash, you are clean. It isn't hard to wash a penis in the shower. This seems a silly argument to me?

There seems to be so many complications that can arise from circumcision...adhesions seem to be very common, with most circ'd infants suffering. Also phimosis, metal stenosis, dead penis, missing frenulum.and a lot more. There are pictures here. (ww w.circu mcisionquotes.com/complic ations.html) (You have to c+p, I can't post links yet)

I just don't get why a parent would put an otherwise healthy infant at risk of any of this. I am not seeing any benefits to being circumcised? What are they? Can't the child decide for themselfs as an adult if they want to be?

If the circ rate is only around 40-60% in the US right now (dpending on state, far as I can tell from googling) then the "look like daddy/same as boys at school argument doesn't work either. Actually the "look like daddy" argument makes me lol...no child's penis is going to "look like daddys", circ'd or not..you'd have to cut off all the hair first!:p

It is cosmetic surgery. Why do people put day old babies through that? I have seen the aftermath of circumcision once. It was a jewish baby.( which I can understand the reasoning for) Three days after it was done it was stil raw...he cried every time he peed. It looked so painful. I can't even imagine what it was like being done:(

[Skeptic Ginger]

.....I just think it should be made clear that what we are talking about is whether it is appropriate for you specifically and for physicians generally to make their judgment on this issue part of the discussion.

I don't have an answer, I just don't think it should be left up to individual physicians to take it upon themselves.

LindaClearly you understand what I am talking about.

If our position is justifiable, then unbiased information we give the parents should support our position. If on the other hand we don't recognize where evidence based medicine ends and personal moral decisions begin, then we won't recognize and therefore cannot respect the parents' moral decisions. What one person views as important, another may view as unimportant. And evidence based medicine cannot empirically determine the value of importance to assign decision criteria. And here is where a health care provider, I think, has a duty to maintain due care in applying personal morals to determine the importance of various criteria when drawing conclusions.

(Again, this differs from taking a position against a parent/patient decision based in ignorance or misinterpretation of facts and evidence. That is where one does not compromise and one's expertise applies.)

Due care does not mean personal morals never apply. Providers who chose to opt out of any abortion procedures as long as another provider can step in, is usually considered an acceptable standard of care. But once again, we encounter a continuum. Is it an appropriate standard of care for a provider with fundamentalist religious beliefs to apply his/her morals to patient care decisions? One argument from fundamentalists for teaching abstinence only is that the use of condoms is facilitating a sin. Better for the sinner to get HIV than for the provider to contribute to facilitating the sin. I don't think that moral position would meet very many people's standards of care.

A circumcision decision is not a black and white decision. It is a continuum decision. That is getting lost in this discussion. On this continuum people are drawing the line in different places where risk/cost and benefit intersect.

I listed a number of values which affect where one draws the line. Different values are assigned, but not limited to, such things as:

* Religion and beliefs about right and wrong.

* The child's self esteem in the grade school locker room.

* Health.

* The child's right to choose.

* The child's right to 'body integrity'.

* Risk perception.

* Beliefs about the affects on sexual pleasure.


If a parent were having the child circumcised because of religious beliefs, I don't think they'd have the same reaction to a provider referring them to someone else as in other situations. That meets an acceptable standard of care.

Right to choose and body integrity is another matter. This is a gray area of provider's moral beliefs vs parent's moral beliefs including the moral belief of whose decision and whose morals apply. This is the area where I feel the strongest about leaving my moral beliefs out of the decision. You could argue you were advocating for the patient, but then you are saying you have the right to apply your beliefs and the parents do not have the right to apply theirs.

However, it has been stated that the argument of body integrity and right to choose don't override medical necessity. This at the same time one is claiming the right of the parents to apply their beliefs regarding right to choose and body integrity does not override the right of the provider to apply his/her beliefs about body integrity and right to choose. So what is the provider's actual moral belief resting on here? I suggest it is resting on the provider's personal values being applied to risk/cost vs benefit, and not directly on body integrity and right to choose. It isn't the infant's right to choose if the decision is made for 'medical reasons'.

But the provider's personal values are affecting the conclusions from evidence based medicine about where the line is drawn in favor of medical benefit over risk/cost. The reason for the position of the AAP and the AAFP is that the medical benefit of circumcision is not zero, and opinions differ as to when the cost/risk clearly overrides that benefit.

If the value assigned to the affect on sexual pleasure is exaggerated above the evidence due to emotional factors, that could be a problem.

If the benefit of UTI prevention is being discounted without a neutral evaluation of the evidence, that could be a problem.

If the parent's risk perception of UTIs differs from the provider for legitimate reasons then whose risk perception applies to the decision?

As an evidence based provider, I need more than emotional testimony the sexual pleasure is affected as greatly as is being claimed. If such evidence exists and I provide that to the parents, I should be able to support my position. If I am acting on that emotional reaction, then I'm deciding my moral opinion overrides the parent's and that, IMO, is overstepping my role as a provider.

[Skeptic Ginger]

Now come on skeptigirl, they weren't insults, just provocatitve statements:DIt's my mission to point out fallacious debate tactics. ;)

Circumcision of a healthy infant is not an evidence based decision. It’s a whim.According to Dr Ivor, who has the expertise to evaluate and has read extensively all the medical literature in this area. I did read extensively on this topic, BTW, gathering information to discuss the issues in these three very long debates. If you go back through my posts in this thread, I believe I cited ~80% of what I read. I have not seen anything supporting "it's a whim". Care to point me in that direction with something besides blogs on an activist web site. I'll take cited research from the cites, but not emotional appeal.

What about putting yourself in the position of each person being affected by the decision. Can you put yourself in the position of the infant? Using your adult reasoning and knowledge that this procedure is not required and is going to hurt you (to a greater or lesser extent), would choose to have it performed on you?...

Thanks for your answer. The caveat of ‘not in this case’ implies there are situations where you think a child does have the right to body integrity. Could you give some examples where you think this right for the child should be supported over parent’s wishes?...

My reasoning (putting myself in each individual’s position) leads me to the conclusion that the procedure should be performed....I've thoroughly addresses all of this. Could you read my last 3 longer posts again and see if you don't understand the risk-benefit decision making continuum a little better?

Yes, pro-infant circumcision people do go on and on and on about the fact that circumcised boys have a lower incidence of UTI’s. If they also then take action to avoid all other similar magnitude risks for their child then at least they are being consistent. I bet they don’t though.I don't think the medical literature agrees with you.

Again, put yourself in the position of the child. You know that studies have shown that being circumcised has a small benefit for contracting a UTI. You know that the risk is extremely small of you contracting a UTI in the first place. You know that circumcision is not 100% effective for preventing UTI. You know that a UTI can be treated with antibiotics successfully in the vast majority of cases. I think anyone who chose to have an irreversible medical procedure for that level of benefit would need serious psychological treatment (such as for OCD hand-washing) for their perception of risk, don’t you?Have you shown that the loss of sexual pleasure is as great as is emotionally claimed? Have you filtered out all the emotional chafe that is mixed in with the evidence?

Stop with the parents! They and the physician should be advocating for the child, i.e. putting themselves in the position of the child.It's called parental rights, Ivor. It is after all one of our cultural values.

Actually, I had only an incy-wincy bit of doubt. That’s why I put that (and other provocative statements) in. I know, I’m a pri*k:DIt's called risk/cost - benefit analysis. Trouble is there is no magic marker saying "the line is here".

The CD comes from you supporting the child’s rights in one situation and parent’s rights in another when they equivalent situations.You are referring to a moral dilemma, not cognitive dissonance. Cognitive refers to 'thinking' whereas morals are more tied to emotions or 'feelings'.

No sarcasm or insult intended, just trying to clarify that the one piece of evidence that does not seem to get mentioned much (in this kind of debate) is what the assessment of an individual child’s condition is.Not true.

[ClintonHammond]

"an excellent preventative to infection, disease, and hygeine issues."
So, you mutilated your child, to prevent things that could be stopped by condoms, and soap... way to go...

URL from above
http://www.circumcisionquotes.com/complications.html

[Skeptic Ginger]

I don't think you can be charged, per se, for refusing treatment. Some nurses have been (IMHO) wrongly fired for giving their opinions to the parents, or refusing to take part in the process... but I don't think refusing treatment is considered a criminal or civil offense.

But these days, who knows? People sue each other over their own stupidity.

ETA: If there's anyone that needs to have charges brought up, it's the pharmacists who are refusing to sell birth control to their customers.Actually, there is a law against abandoning the patient. It applies to nursing. And laws have been enacted that if you are going to refuse certain care related to abortions, another provider must be available. That came up recently with pharmacists who refused to fill prescriptions for "the morning after" type birth control pills.

No physician is obligated to provide particular services, you can't discriminate against certain patients but no one says you have to provide circumcisions. That makes no sense.

[Skeptic Ginger]

So, about that evidence. From the activist web sites (not that activists sites are never valid sources of information) one finds mostly citations of studies on the nerve supply to the foreskin. These are cited as strong evidence the removal of the foreskin is a travesty.

You have to take such evidence a step further. The outcome you want to look at is the effect on the person, not the evidence for the mechanism of action. So showing loss of sensitive tissue is one thing, whether it matters is another.

here is the PubMed search for, "effect of circumcision on sexual function". These were all the relevant studies the search gave, not cherry picked studies, except those without abstracts and those were mostly correspondence re these papers. The search returned 13 citations. I also left out a couple that were related to HIV rather than sexual effects.

Sensation and sexual arousal in circumcised and uncircumcised men. (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17419812&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)METHODS: Twenty uncircumcised men and an equal number of age-matched circumcised participants underwent genital and nongenital sensory testing at baseline and in response to erotic and control stimulus films. Touch and pain thresholds were assessed on the penile shaft, the glans penis, and the volar surface of the forearm. Sexual arousal was assessed via thermal imaging of the penis. RESULTS: In response to the erotic stimulus, both groups evidenced a significant increase in penile temperature, which correlated highly with subjective reports of sexual arousal. Uncircumcised men had significantly lower penile temperature than circumcised men, and evidenced a larger increase in penile temperature with sexual arousal. No differences in genital sensitivity were found between the uncircumcised and circumcised groups. Uncircumcised men were less sensitive to touch on the forearm than circumcised men. A decrease in overall touch sensitivity was observed in both groups with exposure to the erotic film as compared with either baseline or control stimulus film conditions. No significant effect was found for pain sensitivity. CONCLUSION: These results do not support the hypothesized penile sensory differences associated with circumcision. However, group differences in penile temperature and sexual response were found.

The effect of male circumcision on sexuality (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17155977&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)OBJECTIVE: To prospectively study, using a questionnaire, the sexuality of men circumcised as adults compared to uncircumcised men, and to compare their sex lives before and after circumcision. SUBJECTS AND METHODS: The study included 373 sexually active men, of whom 255 were circumcised and 118 were not. Of the 255 circumcised men, 138 had been sexually active before circumcision, and all were circumcised at >20 years of age. As the Brief Male Sexual Function Inventory does not specifically address the quality of sex life, questions were added to compare sexual and masturbatory pleasure before and after circumcision. RESULTS: There were no significant differences in sexual drive, erection, ejaculation, and ejaculation latency time between circumcised and uncircumcised men. Masturbatory pleasure decreased after circumcision in 48% of the respondents, while 8% reported increased pleasure. Masturbatory difficulty increased after circumcision in 63% of the respondents but was easier in 37%. About 6% answered that their sex lives improved, while 20% reported a worse sex life after circumcision. CONCLUSION: There was a decrease in masturbatory pleasure and sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings.So here you have the conclusion leaving out the results of what didn't happen and emphasizing only the negative. In addition, if 20% reported their sex life worse and only 6% reported it improved, then the vast majority reported it unchanged or they didn't comment. So tell me where in this abstract is the conclusion sexual enjoyment decreased! Half said masturbating was less fun. I find the conclusion as stated in this abstract to be biased. But judge for yourselves. I do think it reinforces the conclusion emotions are affecting evaluation of the effects.

Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly? (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16037710&ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)OBJECTIVES: Currently no consensus exists about the role of the foreskin or the effect circumcision has on penile sensitivity and overall sexual satisfaction. Our study assesses the effect of circumcision on sexually active men and the relative impact this may have on informed consent prior to surgery. MATERIALS AND METHODS: One hundred and fifty men between the ages of 18 and 60 years were identified as being circumcised for benign disease between 1999 and 2002. Patients with erectile dysfunction were excluded from the study. The data was assessed using the abridged, 5-item version of the International Index of Erectile Function (IIEF-5). Questions were also asked about libido, penile sensitivity, premature ejaculation, pain during intercourse and appearance before and after circumcision. IIEF-5 data was analysed using two-tailed paired t test to compare pre-operative and post-operative score changes across the study group. For the rest of the questions, data was analysed using 'Sign Test', calculating two-sided p values and 95% confidence intervals. RESULTS: Fifty-nine percent of patients (88/150) responded. The total mean IIEF-5 score was 22.41 +/- 0.94 and 21.13 +/- 3.17 before and after circumcision, respectively (p = 0.4). Seventy-four percent of patients had no change in their libido levels, 69% noticed less pain during intercourse (p < 0.05), and 44% of the patients (p = 0.04) and 38% of the partners (p = 0.02) thought the penis appearance improved after circumcision. Penile sensation improved after circumcision in 38% (p = 0.01) but got worse in 18%, with the remainder having no change. Overall satisfaction was 61%. CONCLUSIONS: Penile sensitivity had variable outcomes after circumcision. The poor outcome of circumcision considered by overall satisfaction rates suggests that when we circumcise men, these outcome data should be discussed during the informed consent process. 2005 S. Karger AG, BaselHere where 61% were satisfied overall they call that a 'poor outcome'. Obviously accurate informed consent is valid. I think you have to look at what "overall satisfaction" meant to the respondents since the results in the abstract do not clearly support the overall satisfaction rates support a "poor outcome" In this report you need the rest of the results to assess the validity of the author's conclusions.

Circumcision in adults: effect on sexual function. (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=14751371&ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)OBJECTIVES: To evaluate the effects of adult circumcision on sexual function in men circumcised only for religious or cosmetic reasons. METHODS: The study group consisted of 42 male patients with a median age of 22.3 years (range 19 to 28) referred for circumcision from June 2002 to January 2003. Of the 42 men, 39 desired circumcision for religious reasons. Before circumcision, their sexual performance was evaluated using the Brief Male Sexual Function Inventory (BMSFI) and ejaculatory latency time. The BMSFI evaluation and ejaculatory latency time measurements were repeated after a postoperative interval of at least 12 weeks. The scores in the five main sections of the BMSFI and the ejaculatory latency times before and after circumcision were analyzed. RESULTS: The differences in the mean BMSFI scores were not statistically significant in any of the five sections. However, the mean ejaculatory latency time was significantly longer after circumcision (P = 0.02). CONCLUSIONS: Adult circumcision does not adversely affect sexual function. The increase in the ejaculatory latency time can be considered an advantage rather than a complication

Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11956453&ordinalpos=10&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)PURPOSE: Evidence concerning the effect of circumcision on sexual function is lacking. Men circumcised as adults are potentially in a unique position to comment on the effect of a prepuce on sexual intercourse. We examine sexual function outcomes in men who have experienced sexual intercourse in the uncircumcised and circumcised states. MATERIALS AND METHODS: Men 18 years old or older when circumcised were identified by billing records during a 5-year period at an academic medical center. Medical charts were reviewed for confirmation of the procedure and to identify the indication(s). These men were surveyed to assess erectile function, penile sensitivity, sexual activity and overall satisfaction. Data were analyzed using paired t tests to compare category scores before and after circumcision. RESULTS: A total of 123 men were circumcised as adults. Indications for circumcision included phimosis in 64% of cases, balanitis in 17%, condyloma in 10%, redundant foreskin in 9% and elective in 7%. The response rate was 44% among potential responders. Mean age of responders was 42 years at circumcision and 46 years at survey. Adult circumcision appears to result in worsened erectile function (p = 0.01), decreased penile sensitivity (p = 0.08), no change in sexual activity (p = 0.22) and improved satisfaction (p = 0.04). Of the men 50% reported benefits and 38% reported harm. Overall, 62% of men were satisfied with having been circumcised. CONCLUSIONS: Our findings may help urologists better counsel men undergoing circumcision as adults. Prospective studies are needed to better understand the relationship between circumcision and sexual function.

Effects of circumcision on male sexual function: debunking a myth? (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11956452&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVAbstractPlus)PURPOSE: Claims of superior sexual sensitivity and satisfaction for uncircumcised males have never been substantiated in a prospective fashion in the medical literature. We performed such a study to investigate these assertions. MATERIALS AND METHODS: The Brief Male Sexual Function Inventory (BMSFI) was administered to sexually active males older than 18 years before undergoing circumcision. After a minimum interval of 12 weeks after the operation, the survey was again administered. The 5 domains of the BMSFI (sexual drive, erections, ejaculation, problem assessment overall satisfaction) were each given a summed composite score. These scores before and after circumcision were then analyzed by Wilcoxon signed-rank testing. RESULTS: All 15 men who participated in the study between September 1999 and October 2000 were available for followup. Mean patient age plus or minus standard deviation was 36.9 +/- 12.0 years. There was no statistically significant difference in the BMFSI composite scores of reported sexual drive (p >0.68), erection (p >0.96), ejaculation (p >0.48), problem assessment (p >0.53) or overall satisfaction (p >0.72). CONCLUSIONS: Circumcision does not appear to have adverse, clinically important effects on male sexual function in sexually active adults who undergo the procedure.

As I said, there's a lot of emotion on this topic that is detracting from the actual evidence. Were I practicing in general pediatrics, I'd most certainly read these studies in full.

[Katana]

Being uncomfortable doing something does not make one a fundamentalist.

Evidence is not always clear-cut - a responsible provider must use his/her judgment in evaluating the quality of available evidence.

It is very easy to judge when one is not the person doing the procedure in question.

[kellyb]

Skeptigirl, most of those studies are using men who were circumcised because of medical reasons.

So here you have the conclusion leaving out the results of what didn't happen and emphasizing only the negative. In addition, if 20% reported their sex life worse and only 6% reported it improved, then the vast majority reported it unchanged or they didn't comment. So tell me where in this abstract is the conclusion sexual enjoyment decreased! Half said masturbating was less fun. I find the conclusion as stated in this abstract to be biased. But judge for yourselves. I do think it reinforces the conclusion emotions are affecting evaluation of the effects.

If they were circumcised because of problems with their foreskins/penises...wouldn't you expect a lot more to report an improvement...not a worsening?

[kellyb]

There you go, trying to insert your erroneous opinion again. I'd say the benifits of circumcision are neither small, nor obscure, nor theoretical.
UTI's are:
1) Rare in boys, period. Circumcised or intact.
2)Easily treated

Penis cancer is:
A rather obscure form of cancer

FACT:
For an overwhelming majority of males, circumcision will provide no medical benefit.

I can back all this up with links and figures if you insist on calling it nothing more than an opinion. Just make the request an I'll happily prove it.

Patient has anterograde amnesia? No anaestesia for heart surgery.
Now you're just being silly. The shock involved could kill the patient. Of course you'd use anesthesia.
I'm actually a little unclear on this. I'd think if performing heart surgery without anaesthesia would kill an adult from the shock, circumcision without pain relief could kill an infant in the same way. Can one of the resident doctors here give us the facts of the matter?

[Z]

Well, unless you folks can bring some logical and practical arguments to the table, instead of going for emotional punch, continuing to refer to botched, old-technique circumcision (I notice that not one of you dare refer to the painless plastibell method), and continue to compare circumcision to heart surgery or clitorectomies, I'll bow out. I don't see any valid refutation to any of the points I've raised, only emotional outcries.

Just a couple of responses though: No, I would never dare to get involved in an abortion thread (at this point in my life). Although I'm generally against abortion on principle, I'm torn at the moment between seeing embryos as living beings with rights, and seeing them as an unwanted biological infection in some cases. I'm pro-abortion in terms of rape or deformity, I feel that my position on abortion is inconsistant and unfounded. And since I've never been in a position to have to deal directly with the choice of abortion, I don't feel I'm in any position to discuss it.

Of course, this is a fairly recent decision on my part.

To Tabitha, it's obvious your only exposure to circumcisions are botched jobs and jobs done using outdated techniques. Personally, I'd require the plastibell method for all circumcision, as well as pain relief, and criminalize other forms of circumcision. This would eliminate nearly all of the problems you cite, while providing protection from UTI's, infections of the foreskin, smegma, HIV, HPA, and impotency.

To KellyB, your ploys are entirely emotion-based and meant to conflate one type of issue with another. I feel no impetus to further respond to your outbursts.

To Ivor, you've actually been arguing fairly logically, though I feel you're again arguing against outdated methods and botched procedures. I respect your opinion, and can only say I agree to disagree with you.

To the rest, well, you're entitled to your opinions, and until the U.S. outlaws circumcision, I'll rest comfortably knowing that it is still an option.

But I have a bad feeling that continuing to post in this thread is only going to result in me becoming inappropriately emotional, and emotion is a detriment to proper discussion.

Good evening, all.

[Skeptic Ginger]

Being uncomfortable doing something does not make one a fundamentalist.

Evidence is not always clear-cut - a responsible provider must use his/her judgment in evaluating the quality of available evidence.

It is very easy to judge when one is not the person doing the procedure in question.I've been a nurse practitioner for >20 years. While I haven't done circs, I think I think I'm qualified judge. So I'm really not sure what you mean.

And what does defining fundamentalism have to do with a fundamentalist imposing radical moral beliefs on others?

As to clear cut evidence, ???????????

Provide some you think contradicts what I posted. I am always interested in the best evidence based decisions. I have no qualms whatsoever in changing outdated medical recommendations to new ones.

[Skeptic Ginger]

Skeptigirl, most of those studies are using men who were circumcised because of medical reasons.



If they were circumcised because of problems with their foreskins/penises...wouldn't you expect a lot more to report an improvement...not a worsening?Come on, kelly. Did you read the studies to see what the reasons for the circs were? I was under the impression the most common reason was adoption of the Jewish faith.

Regardless, what evidence do you want? Got any large surveys of circumcised and uncircumcised men's sex lives? You have to go by the evidence you have, not unfounded conclusions. I made no effort to cherry pick those studies, unlike what you find on the activists web sites.

Show me the evidence. In the meantime, see my next post!

[Skeptic Ginger]

UTI's are:
1) Rare in boys, period. Circumcised or intact.
2)Easily treated

Penis cancer is:
A rather obscure form of cancer

FACT:
For an overwhelming majority of males, circumcision will provide no medical benefit.

I can back all this up with links and figures if you insist on calling it nothing more than an opinion. Just make the request an I'll happily prove it.

I'm actually a little unclear on this. I'd think if performing heart surgery without anaesthesia would kill an adult from the shock, circumcision without pain relief could kill an infant in the same way. Can one of the resident doctors here give us the facts of the matter?Resident doctors? I know you are not incapable of a medical literature review. Back up your claims then because I'm not sure you can.

I have now gone through the second half of my evidence based review for today and remember now why the evaluation for circumcisions considered the prevention of UTIs as a benefit worth the cost.

As is so common with people not working in a particular medical field, it is very easy to underestimate risk. Anti-vaxers do it and you are doing it with your assumptions that pediatric UTIs are minor, rare and easily treated. While you are at it looking for the rate of complications for local nerve block take a look at the risks associated with all the medical interventions discussed in the following studies, IV meds, IVPs, hospitalizations, ED visits, multiple phlebotomies, and missed & difficult diagnoses, to name a few. And do go to the links because I didn't copy the lengthy abstracts discussing all the interventions they were evaluating. Of course, that would be the risks associated with interventions. I didn't get to the risks associated with UTIs. Also, I highly recommend you all do your own pubmed searches because there were hundreds of studies and I didn't bother going past the first page.

Urinary tract infection in febrile infants younger than eight weeks of Age. (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=10654980&ordinalpos=20&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)RESULTS: There were 22 positive urine culture results of at least 100 colony-forming unit/mL. Eighteen of these 22 patients were males, and all were uncircumcised. There were significant differences for pyuria >/=5 WBCs/hpf, pyuria >/=10 WBC/microL, CRP >20 mg/L, and ESR >30 mm/hour between culture-positive and culture-negative groups (P <.05). The ROC area for hemocytometer WBC count, standard UA, peripheral WBC count, ESR, and CRP concentration were.909 +/-.045,.791 +/-.065,.544 +/-.074,. 787 +/-.060, and.822 +/-.036, respectively. The ROC curve analysis indicates that the CRP, ESR, and standard UA were powerful but imperfect tools with which to discriminate for UTI in potentially infected neonates. Hemocytometer WBC counts had the highest sensitivity, specificity, accuracy, and likelihood ratios for identifying very young infants with positive urine culture results. For all assessments, hemocytometer WBC counts were significantly different, compared with the standard urinalysis. ESR, CRP, and peripheral WBC counts were not helpful in identifying UTI in febrile infants. CONCLUSION: UTI had a prevalence of 13.6% in febrile infants <8 weeks of age. The CRP, ESR, and standard UA were imperfect tools in discriminating for UTI, and the sensitivity of these laboratory parameters was relatively low. Hemocytometer WBC count was a significantly better predictor of UTI in febrile infants.

Primary urinary tract infection in infants: prophylaxis for uncomplicated pyelonephritis. (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17371343&ordinalpos=14&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)BACKGROUND: Urinary tract infection (UTI) is one of the most common causes of unexplained fever in infants with a reported prevalence range of 5-11%. The clinical and laboratory findings were reviewed, and diagnosis and treatment for 95 infants with primary UTI were evaluated in this study. METHODS: All patients underwent renal ultrasonography, voiding cystourethrogram and 99mTc dimercaptosuccinic acid (DMSA) scan during hospitalization before treatment, with treatment consisting of 2- or 4-week appropriated antibiotic therapy for the patients associated upper UTI, followed by a second DMSA scan 6 months after therapy. RESULTS: In the present study the main symptom of UTI in infants was fever. High white blood cell count was not necessarily present, and urinalysis was also an imperfect diagnostic tool for discriminating UTI. In addition, colony count from urine culture and kidney ultrasonography was not efficacious in terms of predicting the occurrence of pyelonephritis. Intravenous antibiotic for 1 week followed by 3 weeks of the same oral antibiotic provided good prophylaxis for uncomplicated pyelonephritis. CONCLUSION: Four weeks of antibiotic treatment resulted in good recovery from pyelonephritis in the present sample of infant primary UTI cases. voiding cystourethrogram, DMSA and ultrasonography scanning should be performed in primary infant UTI.

Urinary tract infections in young febrile children. (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=9002094&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)UTI is a common and important clinical problem in infants and young children, with a prevalence of 5.3% among febrile infants seen in our Emergency Department. White females with rectal temperature > or = 39 degrees C are at particularly high risk (prevalence, 17%). [Meaning there were plenty of male patients as well]

Treatment of urinary tract infections among febrile young children with daily intravenous antibiotic therapy at a day treatment center. (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15466073&ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)We aimed to describe the feasibility and complications of outpatient management with IV antibiotics of UTI among febrile children, at the day treatment center (DTC) of a tertiary-care pediatric hospital. METHODS: Between April 1, 2002, and March 31, 2003, a prospective cohort of patients 3 months to 5 years of age who were examined in the emergency department (ED) and diagnosed as having presumed febrile UTI were treated according to a clinical protocol. Patients were treated at the DTC unless they met exclusion criteria, in which case they were hospitalized. The DTC was open 7 days per week, including holidays, from 8:30 am to 4:30 pm. At the DTC, patients were initially treated with a daily dose of IV gentamicin, until the child had been afebrile for at least 24 hours, and with oral amoxicillin, until preliminary urine culture results were available. Children allergic to penicillin received gentamicin only. IV antibiotics were administered through peripheral IV access; the IV catheter's patency was maintained with injection of 50 U of heparin once daily throughout the treatment period. Parental satisfaction with the DTC experience was assessed with an anonymous, self-administered questionnaire. RESULTS: Two hundred ninety-one episodes of presumed febrile UTI were diagnosed in the ED, of which 212 (72.9%) were sent to the DTC. There were 71 hospital admissions (24.4%);.....Four patients with UTI treated in the DTC had positive blood cultures, 2 with Escherichia coli (both successfully treated at the DTC) and 2 with contaminants. For 4 children treated at the DTC, UTI was caused by gentamicin-resistant E coli. One patient became afebrile within 24 hours after treatment initiation with IV gentamicin; he was then treated with oral cefixime. A second patient was treated with IV ceftriaxone, administered at the DTC once culture results were available, and remained febrile for <72 hours. The last 2 patients were hospitalized; one, who was also allergic to cephalosporins, had been febrile for 72 hours at the time of hospitalization (once hospitalized, he was treated with IV amikacin), and the other was admitted to the hospital for an unrelated problem, namely, scalp cellulitis.

Nonresponders: prolonged fever among infants with urinary tract infections. (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=10799623&ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)BACKGROUND: The majority of young children with fever and urinary tract infections (UTIs) have evidence of pyelonephritis based on renal scans. Resolution of fever during treatment is 1 clinical marker of adequate treatment. Theoretically, prolonged fever may be a clue to complications, such as urinary obstruction or renal abscess.

[First urinary tract infection in healthy infants: epidemiology, diagnosis and treatment] (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11578537&ordinalpos=10&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)RESULTS: We studied 131 patients (median age: 90 days). In infants younger than 30 days, UTI was more prevalent in males. The most frequent symptom was fever (73.3 %). Seventy-one patients fulfilled the criteria for acute pyelonephritis. The presence of nitrituria was low. Escherichia coli was isolated in 90.1 % of the patients. Voiding cystourethrogram detected vesicoureteric reflux in 18.4 % of the patients. Scintigraphy revealed renal scarring in 15.1 %. No significant correlations were found between renal scarring in late scintigraphy and a diagnosis of acute pyelonephritis and/or alterations in the cystourethrogram. CONCLUSIONS: Fever was the main symptom. E. coli was the most commonly isolated microorganism. Nitrituria had low sensitivity in infants. Ultrasonography had low specificity. Scintigraphy showed the highest sensitivity and specificity in the detection of renal scarring. Predictability improved when scintigraphy was performed a few months after acute infection.

Does this really sound like no big deal? (Oh yeah, and be careful, it's easy to read febrile as female when you think mostly girls get UTIs.)

[kellyb]

Come on, kelly. Did you read the studies to see what the reasons for the circs were? I was under the impression the most common reason was adoption of the Jewish faith.
#1- n/a
#2- doesn't say what the reason was.
#3- circumcised for "benign diseases"
#4- religion and cosmetic
#5- circumcised for foreskin problems
#6- doesn't say

What makes you think the "unknowns" were all adopting Judaism?

Show me the evidence. In the meantime, see my next post!
The evidence is all over the place. Do you want to count studies or something?

[Skeptic Ginger]

It's all coming back to me now, how the other two threads went and why I didn't come away convinced.

[Skeptic Ginger]

I don't know the reasons for adult circs were for religious conversions. I said that was the most common reason I was aware of.

Adult Circumcision; AFP (http://www.aafp.org/afp/990315ap/1514.html)Medical indications for this procedure include phimosis, paraphimosis, recurrent balanitis and posthitis (inflammation of the prepuce). Nonmedical reasons may be social, cultural, personal or religious....Circumcision is performed on an estimated one out of six male newborns worldwide.1 Over 60 percent of male newborns were circumcised in the United States in 1992.2 Circumcision in adults is performed much less often; however, accurate statistics are not available. Adult patients often have a medical indication for the procedure, but circumcision may also be done for social or purely personal reasons.

[Skeptic Ginger]

Circumcision for Sexual Reasons (http://www.swedish.org/16905.cfm)

In Dr. Sharlip's experience, less than 5% of men who undergo circumcision do so for non-medical reasons. Some of these men are prompted by the request of their sexual partners or by expectations that being circumcised will provide enhanced feeling during sex. One 1997 study found that in comparison to circumcised men, uncircumcised men over 45 years of age are significantly more likely to lack enjoyment of sex, be anxious about their performance, and have difficulty maintaining erection. These differences were not present in younger men. No studies have compared mens’ sexual functioning before and after circumcision.Since the statement, no studies compare function before and after, isn't correct, it's hard to say if the 5% is correct. Interesting though that men >45 are reported as having more trouble if uncircumcised. But again, hard to say if this is reliable. It must be something anecdotally reported by this treating physician.

I'm going to go walk my dogs. Back later.

[kellyb]

Resident doctors?
Didn't mean to offend you, Skeptigirl. Can you answer the question? If you performed an extremely painful surgery on an adult without pain relief, would the pain put them into shock and possible kill them? Would this be more likely to happen with an adult than an infant for some reason? I was under the impression that not that long ago, all kinds of surgeries were performed on infants without pain relief of any kind. The little I know about shock leads me to suspect that pain doesn't usually actually induce the state as a general rule, but honestly, I don't know much about it. I know when I was giving birth the thought crossed my mind that the pain should really have rendered me unconscious somehow. :)

I know you are not incapable of a medical literature review. Back up your claims then because I'm not sure you can.
Which ones?

As is so common with people not working in a particular medical field, it is very easy to underestimate risk. Anti-vaxers do it and you are doing it with your assumptions that pediatric UTIs are minor, rare and easily treated.

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15890696

CONCLUSIONS: Circumcision reduces the risk of UTI. Given a risk in normal boys of about 1%, the number-needed-to-treat to prevent one UTI is 111. In boys with recurrent UTI or high grade vesicoureteric reflux, the risk of UTI recurrence is 10% and 30% and the numbers-needed-to-treat are 11 and 4, respectively. Haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%. Assuming equal utility of benefits and harms, net clinical benefit is likely only in boys at high risk of UTI.

Over 100 circumcisions to prevent ONE UTI??? Circumcision having no UTI benefit in the other 99-109 babies?
That's not me underestimating risk. That's realism to say that circumcision provides no medical benefit in an overwhelming majority of circumcised males.
Would you like to move onto the penis cancer stats now?


Does this really sound like no big deal? (Oh yeah, and be careful, it's easy to read febrile as female when you think mostly girls get UTIs.)

Mostly girls DO get UTIs.
http://www.emedicine.com/ped/topic2366.htm

During the first few months of life, the incidence of UTI in boys exceeds that in girls. By the end of the first year and thereafter, both first-time and recurrent UTIs are most common in girls.

[Skeptic Ginger]

#1- n/a
#2- doesn't say what the reason was.
#3- circumcised for "benign diseases"
#4- religion and cosmetic
#5- circumcised for foreskin problems
#6- doesn't say

What makes you think the "unknowns" were all adopting Judaism?


The evidence is all over the place. Do you want to count studies or something?So having now looked at the reasons for the circs in the studies, it would seem that not all of the men had medical problems. And if you still think the studies are not relevant, then on what evidence are you basing the claim circs have such a great impact on men's (and women's for that matter) sexual pleasure?


I'll settle for a couple citations to start with:

Evidence UTIs are minor, rare, and easily treated?
Evidence that the studies of nerve tissue in the foreskin translates into significant impact on sexual function/pleasure when removed?

Oh, the resident DR thing didn't offend me. Expecting an appeal to authority was going to be convincing was the issue.

[Skeptic Ginger]

So, looking at that analysis Circumcision was associated with a significantly reduced risk of UTI (OR = 0.13; 95% CI, 0.08 to 0.20; p<0.001) with the same odds ratio (0.13) for all three types of study design. CONCLUSIONS: Circumcision reduces the risk of UTI. Given a risk in normal boys of about 1%, the number-needed-to-treat to prevent one UTI is 111.how did they determine the value of 111 circs to one UTI?

For example, one could measure deaths from UTIs. How many circs to prevent one death are reasonable?

While UTI was counted, did they include rates of complications and risks from procedures? Risks from just being hospitalized are significant. How many bleeding circs led to deaths? How many UTIs led to eventual kidney failure?

And do you think 1 of every 100 kids getting a UTI is rare? And, are those infants with "In boys with recurrent UTI or high grade vesicoureteric reflux" supposed to have a couple UTIs before circs are considered? How else would you know that was going to occur? That would make the kids with those problems likely to be self selected uncircumcised infants. How did they control for self selection in the analysis?

[kellyb]

So, looking at that analysis how did they determine the value of 111 circs to one UTI?

For example, one could measure deaths from UTIs. How many circs to prevent one death are reasonable?

While UTI was counted, did they include rates of complications and risks from procedures? Risks from just being hospitalized are significant. How many bleeding circs led to deaths? How many UTIs led to eventual kidney failure?

http://www.emedicine.com/ped/topic2366.htm

Neonatal circumcision decreases the risk of UTI by about 90% in male infants during the first year of life. The risk of UTI in a circumcised infant is about 1 in 1000 during the first year, whereas an uncircumcised male infant has a 1 in 100 risk of developing a UTI. Given this risk, 111 healthy male infants must be circumcised to prevent 1 UTI. The risk and long-term effect of scarring due to 1 preventable UTI in a male infant are not known.

What percentage of UTI's lead to death? One in 10,000?

I wonder if "death by foreskin" affects child mortality in Europe in any calculable way?

And do you think 1 of every 100 kids getting a UTI is rare?
Yes.

And, are those infants with "In boys with recurrent UTI or high grade vesicoureteric reflux" supposed to have a couple UTIs before circs are considered?
Yes. I mean, you can't go around removing the sex organs of thousands of infants in an attempt to preventatively help the one or two with structural abnormalities, can you?

That would make the kids with those problems likely to be self selected uncircumcised infants. How did they control for self selection in the analysis?
The fulltext is free:

Data extraction
Randomised studies were assessed using the guidelines provided by the CONSORT statement.17 Aspects of study design including allocation concealment, blinding, follow up, outcome measurement, and analysis by intention to treat were assessed.

Quality assessment for observational studies was carried out using the guidelines provided by the MOOSE statement.18 The quality of studies identified was assessed according to the study setting, completeness and duration of follow up, validity and completeness of exposure and outcome ascertainment, comparability of the control group, and adjustment for known confounding variables.

ETA:

I'll settle for a couple citations to start with:

Evidence UTIs are minor, rare, and easily treated?

Minor:
http://www.nlm.nih.gov/medlineplus/ency/article/000521.htm

Expectations (prognosis)

Cystitis is uncomfortable, but usually responds well to treatment.

http://www.emedicine.com/ped/topic2366.htm

Mortality/Morbidity:

Mortality related to UTI is exceedingly rare for otherwise healthy children in developed countries.

Easily treated:

http://www.emedicine.com/ped/topic2366.htm

Antibiotics are used to treat urinary tract infection (UTI) and to prevent recurrences.

"Rare" is apparently in the eye of the beholder.

Oh, the resident DR thing didn't offend me. Expecting an appeal to authority was going to be convincing was the issue.
I was asking a question. I don't know if you've noticed, but you're the only pro-circer in this discussion providing any evidence at all and who's not just making things up. I honestly know nothing about shock, so if you'd answer the question, it would be nice. :)

(If it makes you feel better, I did attempt to look up the answer myself, but was unable to find it.)

[Skeptic Ginger]

Let me put this back in perspective. The first one is to keep in mind what we are talking about here. We are talking about risk/cost vs benefit of circumcisions. We are also talking about whether there is or is not overwhelming evidence one way or the other. My position has been throughout this thread, that the decision based on medical evidence is equivocal.

I have seen no overwhelming evidence that circumcisions are as devastating as is being made out here. The activists sites are even worse calling them amputations. While patient choice vs parent choice has some legitimacy, body integrity is a little more of a stretch since the only outcry one hears from adult circumcised males is from a vocal minority. (Prove otherwise and I'll correct that conclusion.)

At the same time that risk/cost is IMO being exaggerated (again, prove otherwise, I've posted my sources and reason innervation studies of the foreskin are not sufficient), the benefit is being understated.

Take kellyb in post #575 (I can't believe I'm still arguing this)UTI's are:
1) Rare in boys, period. Circumcised or intact.
2)Easily treated

Penis cancer is:
A rather obscure form of cancer

FACT:
For an overwhelming majority of males, circumcision will provide no medical benefit. Talking about "being in the eye of the beholder" is exactly what I have been.

The point here isn't if kellyb thinks a 1% prevalence of UTIs is rare, the point is can a parent not make that assessment on their terms? Does kellyb or Ivor or Dr Hawk get to say, "that's 'nothing'" to a parent who disagrees? Do they get to decide for the parent that circumcision is horrendous if the parent doesn't agree? You are going to tell a father who has never thought twice about his own circumcision that he should believe his son will be forever harmed by it? That would be reasonable if you had evidence and not merely anecdotal opinion to back that claim up.

I don't consider a 1% prevalence rare. In fact, it's darn common. 1 in 100,000 is rare. Measles kills one in a 1,000 cases. That's frightening. So there is an issue here of relative risk.

Mortality being rare is not the same as morbidity being rare. Death from complications which develop over years are not going to be included in death from UTI. Death from a nosocomial hospital acquired infection or a medical error are not doing to be recorded as a UTI death.

In addition, we have few new antibiotics in the pipeline and each new one developed is untested for serious risk. And they are never tested on kids until they've been on the market a while. No infection should be viewed as a minor issue as drug resistant bacteria out pace new antibiotics or if new antibiotics are not affordable to low income patients. Two recent pediatric patients in Seattle almost died from rapidly invasive strep after a minor injury, one lost a leg and the other is on his last of umpteenth facial reconstruction surgeries. More than one healthy child has died from community acquired antibiotic resistant infections. I do not view infection as a minor issue.

Urinary tract infections in children younger than 5 years of age: epidemiology, diagnosis, treatment, outcomes and prevention; 2001 (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11310718&ordinalpos=12&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)Although the true incidence of urinary tract infections (UTIs) in children is difficult to estimate, they are one of the most common bacterial infections seen by clinicians who care for young children. Except for the first 8 to 12 weeks of life, when infection of the urinary tact may be secondary to a haematogenous source, UTI is believed to arise by the ascending route after entry of bacteria via the urethra. Enterobacteriaceae are the most common organisms isolated from uncomplicated UTI. Infection with Staphylococcus aureus is rare in children without in-dwelling catheters or other sources of infection, and coagulase-negative staphylococci and Candida spp. are associated with infections after instrumentation of the urinary tract. The diagnosis of UTI in young children is important as it is a marker for urinary tract abnormalities and, in the newborn, may be associated with bacteraemia. Early diagnosis is critical to preserve renal function of the growing kidney. A urine specimen for culture is necessary to document a UTI in a young child. Prior to culture, urinalysis may be useful to detect findings supporting a presumptive diagnosis of UTI. The goals of the management of UTI in a young child are: (i) prompt diagnosis of concomitant bacteraemia or meningitis, particularly in the infant; (ii) prevention of progressive renal disease by prompt eradication of the bacterial pathogen, identification of abnormalities of the urinary tract and prevention of recurrent infections; and (iii) resolution of the acute symptoms of the infection. Delay in initiation of the antibacterial therapy is associated with an increased risk of renal scarring. The initial choice of antibacterial therapy is based on the knowledge of the predominant pathogens in the patient's age group, antibacterial sensitivity patterns in the practice area, the clinical status of the patient and the opportunity for close follow-up. Imaging studies to detect congenital or acquired abnormalities are recommended following the first UTI in all children aged <6 years. Patients with significant urinary tract abnormalities and/or frequent symptomatic UTI may benefit from prophylactic antibacterials. The main long term consequence of UTI is renal scarring which may lead to hypertension and end-stage renal disease. Prevention of recurrent UTI focuses on detection, and correction if possible, of urinary tract abnormalities. Interventions that have been associated with a decrease in symptomatic UTI in children with a history of recurrent UTI include relief of constipation and voiding dysfunction.Does that sound like no big deal to you kelly? Uncommon, no risk, as minor as a runny nose? Every first UTI is followed up with an invasive exam. EVERY ONE.

Here are the AAP practice recommendations for UTI in kids 2 months to 2 years. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. (http://aappolicy.aappublications.org/cgi/reprint/pediatrics;103/4/843.pdf)Recommendation 1
The presence of UTI should be considered in infants and young children 2 months to 2 years of age with unexplained fever (strength of evidence: strong).

The prevalence of UTI in infants and young children 2 months to 2 years of age who have no fever source evident from history or physical examination is high, ;5%.4–8 The genders are not affected equally, however. The prevalence of UTI in febrile girls age 2 months to 2 years is more than twice that in boys (relative risk, 2.27).

The prevalence of UTI in girls younger than 1 year of age is 6.5%; in boys, it is 3.3%. The prevalence of UTI in girls between 1 and 2 years of age is 8.1%; in boys it is 1.9%. The rate in circumcised boys is low, 0.2% to 0.4%.9–13 The literature suggests that the rate in uncircumcised boys is 5 to 20 times higher than in circumcised boys.

Infants and young children are at higher risk than are older children for incurring acute renal injury with UTI. The incidence of vesicoureteral reflux (VUR) is higher in this age group than in older children (Fig 1), and the severity of VUR is greater, with the most severe form (with intrarenal reflux or pyelotubular backflow) virtually limited to infants. Infants and young children with UTI warrant special attention because of the opportunity to prevent kidney damage. Infants and young children with UTI warrant special attention because of the opportunity to prevent kidney damage. First, the UTI may bring to attention a child with an obstructive anomaly or severe VUR.

Second, because infants and young children with UTI may have a febrile illness and no localizing findings, there may be a delay in diagnosis and treatment of the UTI. Clinical and experimental data support the concept that delay in instituting appropriate treatment of acute pyelonephritis increases the risk of kidney damage.14,15 Third, the risk of renal damage increases as the number of recurrences increases16 (Fig 2).

Recommendation 3
If an infant or young child 2 months to 2 years of age with unexplained fever is assessed as being sufficiently ill to warrant immediate antimicrobial therapy, a urine specimen should be obtained by SPA or transurethral bladder catheterization; the diagnosis of UTI cannot be established by a culture of urine collected in a bag (strength of evidence: good). [A low risk procedure but cathing the kid can introduce organisms and sticking a needle in a kid's belly for a urine spec is never totally risk free.]

Recommendation 6
If the infant or young child 2 months to 2 years of age with suspected UTI is assessed as toxic, dehydrated, or unable to retain oral intake, initial antimicrobial therapy should be administered parenterally and hospitalization should be considered (strength of evidence: opinion/consensus).

Recommendation 7
In the infant or young child 2 months to 2 years of age who may not appear ill but who has a culture confirming the presence of UTI, antimicrobial therapy should be initiated, parenterally or orally (strength of evidence: good).

Recommendation 9
Infants and young children 2 months to 2 years of age, including those whose treatment initially was administered parenterally, should complete a 7- to 14-day antimicrobial course orally (strength of evidence: strong).

Recommendation 10
After a 7- to 14-day course of antimicrobial therapy and sterilization of the urine, infants and young children 2 months to 2 years of age with UTI should receive antimicrobials in therapeutic or prophylactic dosages until the imaging studies are completed (strength of evidence: good).

Recommendation 11
Infants and young children 2 months to 2 years of age with UTI who do not demonstrate the expected clinical response within 2 days of antimicrobial therapy should undergo ultrasonography promptly, and either voiding cystourethrography (VCUG) or radionuclide cystography (RNC) should be performed at the earliest convenient time. Infants and young children who have the expected response to antimicrobials should have a sonogram and either VCUG or RNC performed at the earliest convenient time (strength of evidence: fair).

VCUG; RNC
Either traditional contrast VCUG or RNC is recommended for detecting reflux. Although children may have pyelonephritis without reflux, the child with reflux is at increased risk of pyelonephritis and of scarring from UTI. With VCUG and RNC, a voiding phase is important because some reflux occurs only during voiding. If the predicted bladder capacity is not reached, the study may underestimate the presence or degree of reflux. VCUG with fluoroscopy characterizes reflux better than does RNC. In addition, RNC does not show
urethral or bladder abnormalities; for this reason, boys, whose urethra must be examined for posterior urethral valves, or girls, who have symptoms of voiding dysfunction when not infected, should have a standard fluoroscopic contrast VCUG as part of their initial studies.RNC has a lower radiation dose and therefore may be preferred in follow-up examinations of children with reflux. However, the introduction of low-dose radiographic equipment has narrowed the gap in radiation between the VCUG and RNC.50

There is no benefit in delaying performance of these studies as long as the child is free of infection and bladder irritability is absent. While waiting for reflux study results, the child should be receiving an antimicrobial, either as part of the initial treatment or as posttreatment prophylaxis (Table 5).

Radionuclide Renal Scans
Renal cortical scintigraphy (with 99 m Tc-DMSA or 99 m Tc-glucoheptonate) and enhanced computed tomography are very sensitive means of identifying acute changes from pyelonephritis or renal scarring. However, the role of these imaging modalities in the clinical management of the child with UTI still is unclear.So here's a better description of that no big deal UTI.

If the parents don't bring the kid in soon enough he is likely to need IV antibiotics. He is going to be on oral antibiotics for another 1-2 weeks, but after that he is going to be on antibiotics until the radionuclide or a contrast [injected dye] and fluoroscopic exam are completed. And that is on every single first UTI in an infant to toddler.

So to add this up you have to add up the risk of those invasive procedures. I've worked in the bone marrow transplant units with kids with leukemia. I'm terribly concerned about radiation exposure to infants. I was upset my son had an unnecessary chest X-ray after delivery. If I were told a UTI would mean a certain fluoroscope or nuke med study on my infant if he got a UTI, I would need a lot of evidence that circ was such a big deal. And I would be disgusted with any physician who felt they had a right to judge those risks and benefits for my child.

I can also imagine a parent who had strong feelings about not circumcising their child might be offended by any provider who had strong feelings about the medical risks of not circumcising and made the parent feel they were putting their child at risk by not circumcising.

This is the parent's decision and respect means accepting that. There is not sufficient evidence one way or the other to say either decision is wrong. The committees of experienced physicians at both the AAP and the AAFP weighed this research and came to the same conclusion.

[Ivor the Engineer]

Charge? Did I miss something?

I didn't see anywhere that she implied the physician could be charged with anything. :confused: She's been talking about an ethical obligation, as far as I can tell, not a legal one.

Yep. When Linda was still talking to me, she mentioned she thought refusing this kind of treatment would open a physician to legal attack. I'll find the post if you want me to.

[Ivor the Engineer]

The prevalence of UTI in girls younger than 1 year of age is 6.5%; in boys, it is 3.3%. The prevalence of UTI in girls between 1 and 2 years of age is 8.1%; in boys it is 1.9%. The rate in circumcised boys is low, 0.2% to 0.4%.9–13 The literature suggests that the rate in uncircumcised boys is 5 to 20 times higher than in circumcised boys.

So:

a) Girls have a higher incidence of UTI than boys and they get treated with antibiotics.

b) Circumcision does not eliminate the risk in boys.

c) The number of children (male or female) who have serious complications if they get a UTI is small.

And from these facts, the learned physicians at the AAP deduced that this procedure is worth while doing if the parents want it done? What next, will they be recommending children’s hands are washed every 5 minutes?

Skeptigirl, I thought someone like you would be politically aware enough to see through this crap. It is blindingly obvious to me that they came to a conclusion that would not offend the American public. A rational evaluation of the evidence does not lead to the conclusion that circumcision provides a clinically significant benefit for the vast majority of patients. An NNT of ~100 for a rare, non life-threatening condition in the vast majority of people who contract it is ridiculous. Some people aren’t convinced a NNT of ~50 is good enough to fight HIV in Africa.

In the vast majority of patients all it raises are ethical problems for the physicians performing the procedure and society at large. By all means, keep on ignoring the ethical issues of parents physically modifying their children for such insignificant benefits. By the way, parents not only have rights, they also have responsibilities, which include respecting the child’s human rights.

European doctors must be laughing their socks off at their American colleagues.

You crazy Americans!

ETA: Check out this (http://www.jr2.ox.ac.uk/bandolier/band140/b140-3.html)

ETA2: And what treatment is being considered to reduce the rate of UTI's in girls and can it be applied to boys?

[Skeptic Ginger]

Ivor, you are judging for everyone. What gives you the right to?

See through the crap of my hours of literature review? Excuse me?

ETA, that meta-a is no different than the Cochrane kelly cited. They probably reviewed some if not all of the same research.

I think I can say I made a more thorough evaluation of all aspects of this matter than anyone else here. Some of you have presented very little except anecdotally based beliefs and exaggerated risk over understated benefit. Not to mention continually mis-stating my position as pro circ when in reality it is pro-parental right to chose as no compelling medical evidence points one way or the other. The decision rests on risk perception and personal values and beliefs. If it rested on medical evidence, some of the arguments about provider choosing over parental choice would be reasonable. But no one here has proved one side outweighs the other. All you have is each of your personal opinions about which decision is correct. The tie breaker goes to the parents and I accept their choice with no qualms.

ETA, not everyone has been stating anecdotally supported opinions, some have been much more reasoned. And I don't claim to know what research anyone has reviewed that they haven't posted here.

[fls]

Originally Posted by fls
I think that your behaviour is immaterial, except maybe to serve to emphasize your disagreement with the parents' choice. And this may be a good thing. I think ethical concerns can and should be a part of some discussions. But I am more interested in whether others understand and have given due consideration to the issues, than I am about whether we ultimately agree, because otherwise I worry that I am attempting to impose my own beliefs onto someone else. When you make a point of saying that you won't perform circumcisions for non-medical reasons, it could be taken as though you are allowing your beliefs to take priority over the beliefs of your patient's surrogate decision makers. What saves you is that the circumstances won't actually result in a denial of service, so it really just serves to somewhat quantify the strength of your disagreement. I just think it should be made clear that what we are talking about is whether it is appropriate for you specifically and for physicians generally to make their judgment on this issue part of the discussion.

I don't have an answer, I just don't think it should be left up to individual physicians to take it upon themselves.

So you see no role for your own judgment in the care of your patients?

I was attempting to describe (obviously quite unsuccessfully :)) how I saw the role for my own judgment. I think it should be made clear to the patient and myself when my opinion is the result of personal bias rather than my medical judgment. And I think we should resist introducing our personal bias into medical decisions - that we give thoughtful consideration as to whether its appropriate, first.

I realize that the code of ethics of professional organizations in different countries differ in some interesting ways on the details. You're a physician, right? Where do you practice?

Linda

[fls]

Charge? Did I miss something?

I didn't see anywhere that she implied the physician could be charged with anything. :confused: She's been talking about an ethical obligation, as far as I can tell, not a legal one.

I'm not going to look for it, but I did bring up the issue of the consequences of refusing treatment. It would rarely be criminal, though - more likely civil or professional. I just wanted to make the point that physicians don't generally have the right to refuse service without qualification. The details are relevant.

Linda

[fls]

But you seem to be assuming that my 'belief' has something to do with something other than the medical necessity or value of the procedure. If another kind of 'belief' is involved, then the parents are free to seek out another provider.

It is my impression that if the same degree of benefit was conferred by an inoculation (some routine vaccinations confer less benefit than that of circumcision), you would not quibble over medical necessity - that it is the nature of the procedure that leads to the benefit that is the problem. And while the parents have decided that inaction will, on balance, lead to some harm to their infant (taking into consideration the list of factors that Skeptigirl outlined earlier), you disagree. I think we all agree that the majority of the reasons for perceived harm (in the parents) are cultural/religious, rather than medical. While there may be situations where the parents are persuaded by the presentation of the medical benefits, I suspect that most of the time, the parents are weighing harm (and both medical and social harms weigh the scale in favour of circumcision). And I think that you are considering medical harm, but not social/cultural harm. So I agree that your belief is based on medical necessity. I think the conflict with the parents comes about because their belief is based on more than that.

I don't understand what you mean by "left up to individual physicians to take it upon themselves." I've said several times that I would never try and stop parents who really wanted it done, for whatever reason.

I understand that. My statement was meant to apply to the preceding statement "I just think it should be made clear that what we are talking about is whether it is appropriate for you specifically and for physicians generally to make their judgment on this issue part of the discussion."

Stated more directly - Is it appropriate for physicians to dismiss considerations of social harm in this situation specifically or generally?

But there's no way I have to do something just because someone wants it. What if it's a parent of a child who absolutely wants their kid's cold to be treated with antibiotics, because they "know it will help"? Is their 'belief' supposed to trump my training and knowledge that antibiotics don't help colds, that they're overprescribed, and that they confer a risk of side effects including anaphylaxis?

And is the fact that the parent can probably talk some other overworked doctor into writing the script supposed to convince me to just go ahead and give it anyway, because that's what their belief is and my judgment shouldn't trump theirs?

The difference with this situation is that this is essentially just a medical decision and they are basing their request on a misunderstanding. It is considered good medical practice to not provide antibiotics in this situation.

The standard of care with regards to circumcision in the US, is that physicians have recognized that cultural/religious issues are relevant when considering possible harm. Of course there is variation in the extent to which physicians agree with this practice. But in this case, to completely dismiss the relevance of social harm goes against standard medical practice. That is how I distinguish the two situations.

Linda

[Ivor the Engineer]

Ivor, you are judging for everyone. What gives you the right to?

80% of men world-wide? 90%+ of neonatal boys in European countries? The UN charter on human rights?

See through the crap of my hours of literature review? Excuse me?

No, through the politically sensitive statement that the AAP came out with.

ETA, that meta-a is no different than the Cochrane kelly cited. They probably reviewed some if not all of the same research.

And what was wrong with it? Over 400000 patients in the Cohort study, which determined the rates of UTI to be 1.1% in uncircumcised boys and 0.13% in circumcised boys.

Except for a randomized controlled trial, what is better than a Cohort study?

So, ignoring the totally ridiculous risk reduction of penile cancer (NNT > 600), this gives a NNT of 99. So you are ok with 99 children having their human rights violated for 1 of them to avoid a highly treatable condition?

That is some bias you have there, skeptigirl!

I think I can say I made a more thorough evaluation of all aspects of this matter than anyone else here. Some of you have presented very little except anecdotally based beliefs and exaggerated risk over understated benefit. Not to mention continually mis-stating my position as pro circ when in reality it is pro-parental right to chose as no compelling medical evidence points one way or the other. The decision rests on risk perception and personal values and beliefs. If it rested on medical evidence, some of the arguments about provider choosing over parental choice would be reasonable. But no one here has proved one side outweighs the other. All you have is each of your personal opinions about which decision is correct. The tie breaker goes to the parents and I accept their choice with no qualms.

The argument is that all people are afforded the same human rights, whether they can speak or understand them. In the case of parents and physicians, they should be made aware of or already know what the child's rights are.

A non-reversible physical alteration is a violation of those rights, unless not performing the circumcision is likely to violate the child's right to life or health. The evidence from the cohort study suggests that circumcision is only appropriate if the estimated risk of the child contracting a UTI (~1% for normal children) is greater than the risk of complications from the circumcision (~2%). It is not.

But if there is a history of UTI for the child then circumcision would probably be indicated. Even here, some physicians who specialize in UTI disagree, since the causes of the particular UTI might not be caused by bacteria entering the urinary tract via the opening of the urethra.

The decision to circumcise should be made on a case-by-case basis, with the child protected from unsupportable whims of its parents.

ETA, not everyone has been stating anecdotally supported opinions, some have been much more reasoned. And I don't claim to know what research anyone has reviewed that they haven't posted here.

No, I have not. You either believe every individual has human rights or you don't. As I said earlier, if a person believes that parents’ choice is supreme then it is pointless arguing with them about this.

[Katana]

I've been a nurse practitioner for >20 years. While I haven't done circs, I think I think I'm qualified judge. So I'm really not sure what you mean.


Does that make you qualified to generalize repeatedly about the differences between nurses and docs? My training emphasized patient-centered care and shared decision making, and my medical school was by no means unique. These principles are central to the care provided in my hospital, as well. Certainly, not every doc practices this way, but, by no means do all nurses behave in a manner that I would consider as advocates for patients. When you continually repeat the same claims about nurses being patient advocates and docs being paternalistic or controlling, you compromise your credibility with some of us.

Until you are the one holding the scalpel, your perspective will be different. You have already admitted that the medical evidence for elective circumcisions is equivocal. Well, taking the knife in your hand in the face of that fact can be more or less uncomfortable to the responsible physician. One group of docs will feel that uncertainty more profoundly than others and may decide that that is enough to opt out and refer to another provider, but both groups of docs will likely be equally-comfortable doing the same procedure were it medically-necessary. However, what we are debating is, at the end of the day, an elective procedure.

If there is any situation when a doc opting out of a procedure should be understandable, it would be in this one. I would not approve of that physician discouraging the procedure, and he/she should be willing to refer to another who is willing to do it, but simply opting out is acceptable.

And what does defining fundamentalism have to do with a fundamentalist imposing radical moral beliefs on others?

I don't understand what you mean with this question, so I will go back to why I posted what I did.

You wrote:

Due care does not mean personal morals never apply. Providers who chose to opt out of any abortion procedures as long as another provider can step in, is usually considered an acceptable standard of care. But once again, we encounter a continuum. Is it an appropriate standard of care for a provider with fundamentalist religious beliefs to apply his/her morals to patient care decisions? One argument from fundamentalists for teaching abstinence only is that the use of condoms is facilitating a sin. Better for the sinner to get HIV than for the provider to contribute to facilitating the sin. I don't think that moral position would meet very many people's standards of care.



Physicians who opt out of abortion procedures do not always do so out of "fundamentalist religious beliefs". The reasons why someone may are often much more complicated than that. It is what that person does after that fact that separates the fundamentalists from the others. Would a fundamentalist make available another physician who could help his/her patient obtain the procedure in question? I think not.

Again, opting out when someone else is available is acceptable. However, blocking access to it or opting out of a medically-necessary procedure when no one else is available is not.

I was attempting to describe (obviously quite unsuccessfully :)) how I saw the role for my own judgment. I think it should be made clear to the patient and myself when my opinion is the result of personal bias rather than my medical judgment. And I think we should resist introducing our personal bias into medical decisions - that we give thoughtful consideration as to whether its appropriate, first.

I realize that the code of ethics of professional organizations in different countries differ in some interesting ways on the details. You're a physician, right? Where do you practice?

Linda


I understand. :)

You're right. We ALL need to be vigilant about avoiding inserting bias, but, if we cannot in certain situations, we need to be honest with ourselves and our patients when our advice may be colored by personal beliefs or experiences. That's when it is appropriate to get someone else involved. That is being human, but that is also being a responsible physician, one who ensures that your patients' needs are being met even if you may not be able to meet them personally.

There is a difference between using one's judgment in the care of one's patients and judging one's patients and their decisions and imposing one's own agenda on them.

If the evidence that we use in medicine, or the literature, as it were, were so black and white, our jobs would be far easier. When there is overwhelming support for something, that's ideal, but not everything is so clear-cut. The issue is that any study has its strengths and weaknesses, contradictory findings in the literature abound, and it is often up to us to interpret the evidence and apply it as best we can.

I practice in New England. How 'bout you?

[Ivor the Engineer]

Stated more directly - Is it appropriate for physicians to dismiss considerations of social harm in this situation specifically or generally?

Linda

If there was a significant number of uncircumcised men in the culture who were "socially harmed" (the mind boggles) by being left intact, then no, it would not be.

Is there a web site for these men? I can't find one.

[fls]

You're right. We ALL need to be vigilant about avoiding inserting bias, but, if we cannot in certain situations, we need to be honest with ourselves and our patients when our advice may be colored by personal beliefs or experiences. That's when it is appropriate to get someone else involved. That is being human, but that is also being a responsible physician, one who ensures that your patients' needs are being met even if you may not be able to meet them personally.

Yes. And I alluded to this earlier - if your own bias will impair your ability to provide the best care, it is better to involve a different physician.

There is a difference between using one's judgment in the care of one's patients and judging one's patients and their decisions and imposing one's own agenda on them.

If the evidence that we use in medicine, or the literature, as it were, were so black and white, our jobs would be far easier. When there is overwhelming support for something, that's ideal, but not everything is so clear-cut. The issue is that any study has its strengths and weaknesses, contradictory findings in the literature abound, and it is often up to us to interpret the evidence and apply it as best we can.

And I think that is where even just making our biases explicit helps keep interpretations as objective as possible.

I practice in New England. How 'bout you?

I have practiced in the US and Canada, but mostly in Canada. And my ethics have been most strongly influenced by the five principles of the Canada Health Act and the Canadian Medical Association's Code of Ethics, which promote a greater responsibility to the patient and includes recognition of the contribution of the community and society to health. And I do see subtle differences in physician attitudes, although of course I have no idea how representative my observations are.

Linda

[ClintonHammond]

Circumcision is barbaric and pointless... Full stop.

[fls]

Circumcision is barbaric and pointless... Full stop.

Ah, the crucial piece of information missing in the conversation to this point.

Linda

[Ivor the Engineer]

Still can't find any evidence of men who've been left intact being 'socially harmed'.

A related question is how many men wish to change their status from intact to circumcised?

This relates to Linda's point about the parents trying to figure out what the child would want when it is older. They should be informed that most intact men do not opt to be circumcised.

Here's how I seen the future of infant circumcision:

When a vaccine becomes available for HIV, that reason will be gone.

When a preventative treatment for UTI's in girls (which will most likely be applicable to boys as well) is developed, that reason will disappear.

And when penile cancer is curable in most men, that won't be a significant advantage.

But I have a feeling that even when all these treatments have been developed, Americans will still be circumcising their boys.

Let's just hope they learn to insist on and use effective pain relief.

NB: I must say as a person who stutters, I think I know a thing or two about being 'socially harmed'. I find the idea of someone being 'socially harmed' because of an organ they themselves can elect to change at any time rather insulting:rolleyes:

[JJM 777]

I haven't read any of this looooong discussion, but:

Can anyone summarize the medical reasons that would require a circumcision, and their statistical prevalence among males?

Please also consider whether this said medical condition actually requires a full-scale circumcision. Perhaps an alternative operation would solve the problem and restore the body into its most natural and healthy state?

I somehow like the original design of nature. It's cool.

[Ivor the Engineer]

I haven't read any of this looooong discussion, but:

Can anyone summarize the medical reasons that would require a circumcision, and their statistical prevalence among males?

Tight foreskin (phimosis) is the most common reason. 0.6% of boys are medically indicated by the age of 15 for this.

There is evidence to suggest that circumcision reduces the incidence of Urinary Tract Infections (UTI's) in the developed world from 1% to 0.1%.

There is evidence that circumcision protects against penile cancer, which in the developed world has a lifetime risk of 1 in 600.

There is strong evidence to suggest that circumcision provides ~60% risk reduction of contracting HIV in areas of the world with high incidence of the disease.

Please also consider whether this said medical condition actually requires a full-scale circumcision. Perhaps an alternative operation would solve the problem and restore the body into its most natural and healthy state?

I somehow like the original design of nature. It's cool.

I don't think that's feasible. The only reason we know about the above is from looking at the incidence of disease in circumcised boys and/or men. How would you determine the optimal amount to cut off ethically?

[fls]

I haven't read any of this looooong discussion, but:

Can anyone summarize the medical reasons that would require a circumcision, and their statistical prevalence among males?

Please also consider whether this said medical condition actually requires a full-scale circumcision. Perhaps an alternative operation would solve the problem and restore the body into its most natural and healthy state?

I somehow like the original design of nature. It's cool.

Circumcision is used to treat phimosis (foreskin doesn't retract fully) and paraphimosis (retracted foreskin cannot be returned to natural position) and to prevent balanitis (infection/inflammation of the head of the penis) - prevalence varies depending upon your criteria and which condition you are talking about, but a ballpark figure is less than 5%. Whether circumcision is required depends upon whether serious complications (urinary obstruction, problems with intercourse, recurrent infection) have developed from any of these conditions. Even then, if you are determined to save your foreskin, you probably can as there are alternative treatments. It depends upon how much discomfort/inconvenience you're willing to tolerate, too.

Linda

[kellyb]

Hormone creams can be used to treat most foreskin problems, sort of like what they do with girls for labial adhesions:
http://www.emedicine.com/ped/topic1267.htm
http://pediatrics.aappublications.org/cgi/content/full/102/4/e43

[JJM 777]

there are alternative treatments.
It just occurred to me that if I were a medical doctor, I probably would try to heal people's bodies, instead of amputating everything that does not seem to function properly.

Just an idea.

[robinson]

You know, that idea is catching on some places.

[fls]

It just occurred to me that if I were a medical doctor, I probably would try to heal people's bodies, instead of amputating everything that does not seem to function properly.

Just an idea.

Yeah. I think if I were a concert pianist I would wear an evening dress instead of a tube top and shorts.

Linda

[ClintonHammond]

"There is strong evidence to suggest that circumcision provides ~60% risk reduction of contracting HIV in areas of the world with high incidence of the disease."
There's MORE evidence that proper condom use provides MUCH higher risk reduction....

I can't believe the hoops people are jumping through, trying to justify mutilating their male children.

[Ivor the Engineer]

"There is strong evidence to suggest that circumcision provides ~60% risk reduction of contracting HIV in areas of the world with high incidence of the disease."
There's MORE evidence that proper condom use provides MUCH higher risk reduction....

I can't believe the hoops people are jumping through, trying to justify mutilating their male children.

Yep, they do. Now all you have to do is get them to the men and women (only 1 in 5 couples have access to condoms in Africa) and get them to use them.

[Darat]

Hormone creams can be used to treat most foreskin problems, sort of like what they do with girls for labial adhesions:
http://www.emedicine.com/ped/topic1267.htm
http://pediatrics.aappublications.org/cgi/content/full/102/4/e43

I hope they also offer the parents the choice of a quick cut and snip to solve that problem - I mean have you seen the labia - gross untidy looking thing - a quick trim would do wonders for the appearance. ;)

[Ivor the Engineer]

Yeah. I think if I were a concert pianist I would wear an evening dress instead of a tube top and shorts.

Linda

If I were a Doctor I'd be brilliant!:D

[fls]

"There is strong evidence to suggest that circumcision provides ~60% risk reduction of contracting HIV in areas of the world with high incidence of the disease."
There's MORE evidence that proper condom use provides MUCH higher risk reduction....

I can't believe the hoops people are jumping through, trying to justify mutilating their male children.

It's my impression that most people in North America don't consider circumcision because of medical reasons, like reducing the risk of acquiring HIV. I've looked at a number of surveys and the most common reason seems to be "hygiene" followed by "tradition" and "father is circumcised". Medical reasons usually seem to be lower on the list.

Linda

[ClintonHammond]

"only 1 in 5 couples have access to condoms in Africa"
I'm not in charge of shipping.... I'm not even sure who is. Maybe ask "The Pope".... He seems to have an opinion on condom usage...

"the most common reason seems to be "hygiene"
Which has already been shot down as a very good reason in posts above....

"followed by "tradition" and "father is circumcised"
Traditions change... Hopefully for the better.... Because one person was mutilated sure is a DUMB reason to mutilate anyone else. It's a damn good thing we don't do the same when it comes to "Eat By Alligators"...

[fls]

"only 1 in 5 couples have access to condoms in Africa"
I'm not in charge of shipping.... I'm not even sure who is. Maybe ask "The Pope".... He seems to have an opinion on condom usage...

"the most common reason seems to be "hygiene"
Which has already been shot down as a very good reason in posts above....

I suspect the vast majority of parents do not read the JREF forum, though. :)

I'm not sure how useful it is to re-iterate all these points here.

Linda

[ClintonHammond]

"I suspect the vast majority of parents do not read the JREF forum"
That aughta be classified as Child Neglect! ,-)

[Ivor the Engineer]

It's my impression that most people in North America don't consider circumcision because of medical reasons, like reducing the risk of acquiring HIV. I've looked at a number of surveys and the most common reason seems to be "hygiene" followed by "tradition" and "father is circumcised". Medical reasons usually seem to be lower on the list.

Linda

Or in the case of my father, his Jewish grandmother insisted.

[ClintonHammond]

"his Jewish grandmother insisted"
Now that's a spectacularly STUPID reason... if she wants someones penis chopped up, let her start with hers.

[kellyb]

Most people in North America vaguely think that if you don't circumcise, there's a pretty good chance the penis will turn gangrenous and rot off. Upon hearing several times that it's not true, it turns to a vague notion of "lots of problems, then." I had to meet a lot of intact guys myself before I was able to shake those fuzzy ideas off. It's just an impression we form in childhood that's seen as a "fact"...like "the earth is round".

"Boys are cirumcised because, otherwise, their penises get lots of infections and it's really gross. So it has to be done."

All of the other "reasons" flow from that initial impression, in my opinion and experience.

[Darat]

It used to be same over in the UK but for some reason it rather quickly died away. My father was circumcised in the 1940s when it was apparently just routine, yet by the time I was born in the 60s it was no longer routine (but still not uncommon if not common).

[Ivor the Engineer]

Most people in North America vaguely think that if you don't circumcise, there's a pretty good chance the penis will turn gangrenous and rot off. Upon hearing several times that it's not true, it turns to a vague notion of "lots of problems, then." I had to meet a lot of intact guys myself before I was able to shake those fuzzy ideas off. It's just an impression we form in childhood that's seen as a "fact"...like "the earth is round".

"Boys are cirumcised because, otherwise, their penises get lots of infections and it's really gross. So it has to be done."

All of the other "reasons" flow from that initial impression, in my opinion and experience.

And just think of the number of boys who thought they were gambling with their eyesight:D

[kellyb]

I hope they also offer the parents the choice of a quick cut and snip to solve that problem - I mean have you seen the labia - gross untidy looking thing - a quick trim would do wonders for the appearance. ;)

Can you imagine how much suffering could possibly be prevented if we just preventatively snipped girtls at birth?

http://www.betterhealth.vic.gov.au/BHCV2/bhcarticles.nsf/pages/Labial_adhesions?OpenDocument


Possible complications
Some of the possible complications of labial adhesions include:
Urination problems - such as changes to the direction of the urine stream (for example, the urine may squirt sideways instead of straight down) and dribbling urine after going to the toilet (because a small amount of urine collects within the fused labia).
Urinary tract infections - about 20 per cent of girls with labial adhesions develop asymptomatic bacteriuria (bacteria in the urine without symptoms of infection) and up to 40 per cent experience urinary tract infections. Hydronephrosis - if the labial adhesions block the urethra, the child is unable to empty their bladder. Without treatment, this will lead to an abnormally enlarged kidney (hydronephrosis) caused by the build-up of urine.

So let's see...the rate of UTIs in females is what?

http://www.emedicine.com/ped/topic2366.htm

In a systematic review, investigators calculated crude estimates of UTI during the first 24 months of life. Rates were 3% in boys younger than 1 year, 2% in boys older than 1 year, 7% in girls younger than 1 year, and 8% in girls aged 1-2 years (Downs, 1999).

If we snipped girls at birth, that could almost bring the female rate of UTIs down to what we see in intact boys!
And make Allah happy to boot!
And it would be prettier, too!

Where are the clinical trials? Is society so sexist that life-threatening bacterial infections in females don't matter?

[Ivor the Engineer]

Can you imagine how much suffering could possibly be prevented if we just preventatively snipped girtls at birth?

http://www.betterhealth.vic.gov.au/BHCV2/bhcarticles.nsf/pages/Labial_adhesions?OpenDocument




So let's see...the rate of UTIs in females is what?

http://www.emedicine.com/ped/topic2366.htm



If we snipped girls at birth, that could almost bring the female rate of UTIs down to what we see in intact boys!
And make Allah happy to boot!
And it would be prettier, too!

Where are the clinical trials? Is society so sexist that life-threatening bacterial infections in females don't matter?

Hey! My ingrown toenail prevention strategy is the next to be trialled. Wait your turn!

[rwp]

Circumcision is based on irrational, delusional religious tradition/beliefs, not on any medical "evidence". finding "evidence" to support circumcision is no different than coming up with explainations of "psychic" phenomena or "evidence" to support it.

The penis is naturally an internal organ and there is no rational reason dramatic enough that one should want to change that.

I was entertained and somewhat disgusted by the show that Penn and Teller made on the issue, which I do not see mentioned previously. It offers many advantages to keeping your skin. In some cases "large" advantages.

[fls]

Circumcision is based on irrational, delusional religious tradition/beliefs, not on any medical "evidence". finding "evidence" to support circumcision is no different than coming up with explainations of "psychic" phenomena or "evidence" to support it.

Argument by scare quotes?

The penis is naturally an internal organ and there is no rational reason dramatic enough that one should want to change that.

I was entertained and somewhat disgusted by the show that Penn and Teller made on the issue, which I do not see mentioned previously. It offers many advantages to keeping your skin. In some cases "large" advantages.

That's what this thread's been missing! It's not really a party until someone refers to the authority of Penn and Teller.

Linda

[NewtonTrino]

I honestly haven't read this entire thread, but I have done quite a bit of research on this topic over the years.

Now, I'm going to get (possibly) a little gross here and definitely a little personal. However, to me this could be one of the major issues, and possibly a major reason that this started.

I'm a fully intact male (born in Canada in the 70's). When I "whack off", which is quite often, I don't have to use any kind of external lubrication at all. In addition the idea of using lubrication sounds insane to me as the system seems to be built to "just work". For many years I've heard jokes about "get out the lotion" etc which never made any sense to me. Many people seem to take it as a given that you need to use external lubrication to whack it.

Here is my question for anyone that wants to respond. Are you able to jack off without lube, not just able to do it, but very comfortably do it? Oh, and I guess you might want to mention if you are cut or uncut.

What I'm trying to find out here is this. Does the penis actually have reduced sexual function when the foreskin is removed (e.g. ability to whack it without external lube). My theory is that it is diminished, although by how much I think it's hard to say. Obviously cut men can still have sex but how things "feel" is very difficult to quantify in a meaningful way, so there could be a lot more disfunction than we know.

PS This is my first post! I've been around for a while lurking (like 6 years) and I was at TAM5. I'm trying to be more active in the skeptic community.

[BlackKat]

I honestly haven't read this entire thread, but I have done quite a bit of research on this topic over the years.

Now, I'm going to get (possibly) a little gross here and definitely a little personal. However, to me this could be one of the major issues, and possibly a major reason that this started.

I'm a fully intact male (born in Canada in the 70's). When I "whack off", which is quite often, I don't have to use any kind of external lubrication at all. In addition the idea of using lubrication sounds insane to me as the system seems to be built to "just work". For many years I've heard jokes about "get out the lotion" etc which never made any sense to me. Many people seem to take it as a given that you need to use external lubrication to whack it.

Here is my question for anyone that wants to respond. Are you able to jack off without lube, not just able to do it, but very comfortably do it? Oh, and I guess you might want to mention if you are cut or uncut.

What I'm trying to find out here is this. Does the penis actually have reduced sexual function when the foreskin is removed (e.g. ability to whack it without external lube). My theory is that it is diminished, although by how much I think it's hard to say. Obviously cut men can still have sex but how things "feel" is very difficult to quantify in a meaningful way, so there could be a lot more disfunction than we know.

PS This is my first post! I've been around for a while lurking (like 6 years) and I was at TAM5. I'm trying to be more active in the skeptic community.

And what a first post it is...

Use lubricant to masturbate? That's a first. Never heard of anyone using that, circumcised or with a foreskin.

Well if you read back a few pages (or the whole thread before posting) Skeptigirl posted about 10 studies showing that men who have been circumcised do not have any significant loss of sexual satisfaction or function (and in some cases more sexual satisfaction or function in certain ways).

And i can tell you (although this is just a personal anectodote) that I have no loss of sexual satisfaction or function. In fact it is my opinion that foreskins are not a nice thing to have (although I will admit to having my views colored by the fact that nobody I know well is uncircumcised, nor do any of the women I have "known" like them). This is most likely due to the fact that I am from the U.S. where (depending on the region) most to nearly all babies (especially Caucasian, Arabic, and Jewish which make up the majority population in Boston) are circumcised. They are circumcised primarily because their fathers and peers are all circumcised as the foreskin in American culture is considered not attractive.

I'm also somewhat surprised you are not circumcised yourself considering where and when you were born... but if you enjoy your foreskin then that's your right. It's kind of silly to presume that people without them are missing much (besides smelling their penis--yuck). The primary penile nerve is in the dorsal area of the penis with many nerve endings in the glans. Circumcision has little to no effect on these areas.

[Roadtoad]

Peggy and I wound up discussing this tonight because of this thread. And while I haven't read all the links, I'm thinking much of it is becoming repetitious.

In the case of my four sons, we, (meaning my now ex-wife and my current wife), decided against circumcision. In all four cases, we talked with the doctors, both the OB-GYNs, and with the pediatricians who would be caring for my sons. All of them told us the same thing: Circumcision was a waste of time and effort, and any benefits were extraordinarily limited.

The dissent came from several quarters, but for the most part, not the medical community. We had one pastor tell us that circumcision was an excellent idea because it would keep our sons from masturbating. (I don't know how the hell you would get THAT out of circumcision. If you want to have a good wank, you'll do it whether you're cut or not.)

As it happened, Matt, my youngest, picked up an infection. It took some time to clear up, and we wound up using not only a prescribed antibiotic wipe, but also, I believe, a rather strong antibiotic pill. To the best of my knowledge, once it was cleared up, Matt realized that Dad and Mom weren't so stupid when it came to making sure certain private areas were really clean, and there hasn't been a reoccurance.

I'm reminded of a study that took place years ago in Pennsylvania. Two towns were separated by a couple of hills, both of them small, and both served by small hospitals and a smaller medical community in each. In one town, nearly 98% of all people had undergone an appendectomy, while in the other town, less than 1% had done so. (Consumer Reports mentioned this in their call for socialized medicine, which we can discuss in yet another thread.) In the one town, it was simply assumed that nearly everyone would have appendicitis, while in the other town, a more reactive approach was accepted. And while this is simply one study, with a rather nebulous outcome, the point Consumer Reports was trying to make was that some medical professionals, and others as well, were recommending a medical procedure which was genuinely unnecessary for most people.

To date, I still have my appendix, and my tonsils to boot. I suppose in one sense I can credit my parents' wide variance of attention, either a stage of complete indifference, or a stage of near pathological control. I suppose I managed to catch it right in the medical side for the most part, as I've rarely had to go in for any sort of surgery. The negative on this is that my parents did insist I be circumcised, simply because it was the practice of the day, even though by then, it was widely known it was a wasted effort.

I realize some people think they're helping their kids, and still others see this as a parental rights issue, that a child is theirs and theirs alone, and they alone have the right to decide such issues. But the reality remains: It's benefits are cursory at best, and ultimately, a child grows up and makes his or her own decisions.

I'm forced to compare this to the forced sterilization of young girls back in the '50's, for reasons which were as varied as the parents who subjected their children to this process. It was cruel and barbaric, and ultimately, there were lawsuits. To what end did this occur? I've yet to hear a solid answer that would serve in a scientific review. The only thing it did was prevent girls from becoming pregnant, ever. The parents had no right to pull such a stunt.

I guess when it all comes down to it, I didn't have it done to my sons simply because I saw no real benefit. Why waste the time of the doctors and why mutilate the children I love?

[JJM 777]

When I ... :o ... I don't have to use any kind of external lubrication at all. In addition the idea of using lubrication sounds insane to me ... Many people seem to take it as a given
The quality of an erotic experience is related to the quality of sensory input on your skin, what you see with your eyes, etc.

The worst possible sensory input on your skin would be too cold, too boiling hot or too violent injuring touch. Under such circumstances it might be impossible to have an erotic experience of high quality.

At the other end of the scale, the best possible sensory input on your skin would be soft, wet and slimy touch at the temperature of 40 degrees Celsius. These circumstances maximize the blood circulation under your skin, which is an essential factor in feeling pleasure. Also chemicals play a role here: saliva and vaginal liquids contain chemicals that are absorbed through your skin, enhancing the blood circulation and quality of sensory input beyond what dry skin or a skin wet of water would offer.

While it is possible to experience something erotic in circumstances less than best possible, there is a difference between good quality, better quality and best possible quality.

[robinson]

"Why waste the time of the doctors and why mutilate the children I love?"

Because of religion. Barbaric primitive religions believe all kinds of whacky things. Cutting off part of the penis is a religious ritual.

[Skeptic Ginger]

Does that make you qualified to generalize repeatedly about the differences between nurses and docs? My training emphasized patient-centered care and shared decision making, and my medical school was by no means unique. These principles are central to the care provided in my hospital, as well. Certainly, not every doc practices this way, but, by no means do all nurses behave in a manner that I would consider as advocates for patients. When you continually repeat the same claims about nurses being patient advocates and docs being paternalistic or controlling, you compromise your credibility with some of us. Tell me, in the hospital(s) where you practice, do the physicians have a separate area from other staff in the cafeteria for meals? And if not, have you seen these areas in other hospitals? Have you observed a sufficient number of different nurse practitioner patient interactions to say you see no indication of any philosophical difference between patient-provider interactions?

You and Hawkeye both continue to misinterpret what I've said, regardless of the clarifications I keep posting. Surely you recognize the different roles of physicians and nurses are going to result in different reactions to patients' autonomy?

Nowhere in my posts have I said, bad doctors, good nurses. There is no reason for any defensiveness distorting perceptions of what I posted. Of course doctors are compassionate! Just as some nurses aren't. That has absolutely nothing to do with my point.

I was pointing out the difference in the worlds of each profession. If you don't think such basic differences in the philosophy established in the educational and professional milieu have any affect on patient-physician and patient-nurse interactions, then what is your reasoning? I'll say it again, this is not about skills, compassion, clearly divided philosophies, patient respect in either profession. Think of it more like two overlapping bell curves with slightly shifted peaks (or maybe moderately shifted in some cases).

Changing face of medical curricula (http://www.thelancet.com/journals/lancet/article/PIIS0140673600041349/abstract), 2001 The focus of health care has shifted from episodic care of individuals in hospitals to promotion of health in the community, and from paternalism and anecdotal care to negotiated management based on evidence of effectiveness and safety. You can't exactly change from paternalistic training unless it was the status quo originally.

Here's an extreme version: Pediatrician Refuses To Treat Patient Because of Mom’s Tattoos (http://www.medschoolhell.com/2007/02/18/pediatrician-refuses-to-treat-patient-because-of-moms-tattoos/)Hoover 18 Feb, 2007 Physicians, Off Beat News

Sound crazy? It is. A pediatrician has refused to treat a patient because the patient’s mother has tattoos. In fact, Dr. Gary Merrill has the following sign in his office:

“This is a private office. Appearance and behavior standards apply.”...
........ Tasha Childress’ response after Dr. Merrill refused to treat her daughter’s ear infection?

I felt totally discriminated against, like I wasn’t good enough to talk to, Tasha Childress said, like he didn’t have to give me any reason for not wanting to see my daughter because I have tattoos and piercings.

You would think that this guy was the only pediatrician in town. If patients aren’t happy with the services rendered, simply go see another doc.

Problem solved.The author's attitude says a lot as well.

Paternalism is addressed in any number of medical ethics classes. It is approached differently now than years passed and it is approached differently in different settings and countries. But the fact there are so many classes and articles that address the issue speaks to its existence.

Dissecting Room, Conduct and Compassion - Non-compliance (http://www.thelancet.com/journals/lancet/article/PIIS0140673604164295/fulltext) Non-compliance is a value laden term, heavily weighted against the patient who, by definition, refuses to yield or conform to the doctor's advice. Because of the nature of their diseases, chronically ill patients are most likely to be labeled non-compliant. Indeed, they are often considered “problem patients” simply by virtue of their diagnoses.1 Without attempting to understand why patients won't or can't make lifestyle and other changes critical to their care, the physician-patient relationship becomes more adversarial than collaborative. ...Of course most doctors are not going to come anywhere close to this description.

Compare that to this article which fully explores nursing treatment of non-compliance. Therapeutic Compliance Posttransplantation – A Nurse’s Perspective; Research Studies for Measurement and Prediction of Compliance. (http://www.medscape.com/viewarticle/512906_3) Rather than a discussion of the potential for non-compliance to be an issue, it's a nursing diagnosis. It's our job to deal with it. How would this not result in at least some different practice philosophies between doctors and nurse practitioners? I actively promote patient autonomy. I've not seen many doctors do that.

Until you are the one holding the scalpel, your perspective will be different. You have already admitted that the medical evidence for elective circumcisions is equivocal. Well, taking the knife in your hand in the face of that fact can be more or less uncomfortable to the responsible physician. One group of docs will feel that uncertainty more profoundly than others and may decide that that is enough to opt out and refer to another provider, but both groups of docs will likely be equally-comfortable doing the same procedure were it medically-necessary. However, what we are debating is, at the end of the day, an elective procedure. If you are simply describing your personal feelings with a difficult medical dilemma in terms of performing circs, fine. But if you are trying to tell me I can't possibly understand this unless I've done circ procedures, I don't accept that at all. You have no idea what practice experiences I've had. And you are making the false assumption that somehow my evaluation and perception of this matter are naive. I might suggest to you that unless you've tried futilely to revive an infant that has just succumbed to a respiratory infection or taken care of a 3 year old that is about to have all four limbs amputated from a meningococcal infection, that you can't empathize with my position. But that would be stupid because I don't know what your experiences have been. It wouldn't bother me to perform a circ because I have no dilemma over doing circumcisions. And lots of NPs perform circs, BTW.

There's one big glaring problem here. For whatever reason, I read a repeating theme in these posts that there is some unanimous perception of the infection risk. I gave the example of the hypothetical parent who had lost a previous child to infection unrelated to any underlying medical condition. Experience affects beliefs and values. How is such a parent wrong who finds the risk reduction of UTI a compelling reason in favor of circumcision?

If there is any situation when a doc opting out of a procedure should be understandable, it would be in this one. I would not approve of that physician discouraging the procedure, and he/she should be willing to refer to another who is willing to do it, but simply opting out is acceptable.I don't want to be judgmental toward the physician who opts out any more than the parents who opt in. That wasn't the point.

It was the underlying assumptions about 'not medically indicated' I object to. In addition, I disagreed with Dr Hawk's perception that providing another provider respected the parent's views.

We are interpreting "respect" differently in this discussion. I interpret respect as recognizing different people have different values and those values are just as valid as anyone else's in this case. Dr H is interpreting it to mean she doesn't recognize those values, doesn't recognize why the parents' decision is just as legitimate as hers. Dr H instead made the non-evidence based declaration, "there is no medical indication for a circumcision in a healthy infant" so if the parents want one, they are wrong, but I won't interfere.

She doesn't say, the parents have different values and are valuing prevention of UTI while I (DrH) value something else so I don't personally want to do the circumcision.

My point in arguing this matter concerns what I see (and it's very clear in my view) as distortions of the empirical evidence. I see a failure of people to recognize that more than one value is legitimate in weighing the risk and benefit.

I don't understand what you mean with this question, so I will go back to why I posted what I did.

You wrote:
Originally Posted by skeptigirl
Due care does not mean personal morals never apply. Providers who chose to opt out of any abortion procedures as long as another provider can step in, is usually considered an acceptable standard of care. But once again, we encounter a continuum. Is it an appropriate standard of care for a provider with fundamentalist religious beliefs to apply his/her morals to patient care decisions? One argument from fundamentalists for teaching abstinence only is that the use of condoms is facilitating a sin. Better for the sinner to get HIV than for the provider to contribute to facilitating the sin. I don't think that moral position would meet very many people's standards of care.I was describing one end of the continuum, not saying, 'refusing circs', was on that end.

Physicians who opt out of abortion procedures do not always do so out of "fundamentalist religious beliefs". The reasons why someone may are often much more complicated than that. It is what that person does after that fact that separates the fundamentalists from the others. Would a fundamentalist make available another physician who could help his/her patient obtain the procedure in question? I think not.Re-read what I said. I bolded it for you. I said nothing about anti-abortion beliefs being "fundamentalist religious beliefs". I do however think pushing abstinence only education is reaching the fundamentalist end of the continuum of beliefs.

Again, opting out when someone else is available is acceptable. However, blocking access to it or opting out of a medically-necessary procedure when no one else is available is not.I said nothing about acceptable practice. I don't agree with the denial of the equivocal medical evidence regarding circumcisions. It is not respecting the parent's choice if you cannot recognize they have just as much justification deciding the lowered risk of infection is more important to them than the questionable significance of the foreskin.

If you are willing to perform a circumcision for medically indicated reasons, but you are unwilling to accept the fact that there is a legitimate argument any circumcision can be viewed as medically indicated, then you are not looking objectively at the empirical evidence. You are applying weight to the value of your perceptions about the foreskin. You are not applying weight to the value of infection risk reduction. That's fine until you say the person who does value infection risk reduction more than you do, is wrong based on empirical evidence. This is a values difference, not an evidence based difference. And the lack of evidence that the circumcision is as damaging as the emotional appeals would have one believe speaks to that.

[Skeptic Ginger]

I haven't read any of this looooong discussion, but:

Can anyone summarize the medical reasons that would require a circumcision, and their statistical prevalence among males?

Please also consider whether this said medical condition actually requires a full-scale circumcision. Perhaps an alternative operation would solve the problem and restore the body into its most natural and healthy state?

I somehow like the original design of nature. It's cool.Go back through my posts on the last 3-4 pages and there are a number of citations.

[Skeptic Ginger]

I honestly haven't read this entire thread, but I have done quite a bit of research on this topic over the years.

Now, I'm going to get (possibly) a little gross here and definitely a little personal. However, to me this could be one of the major issues, and possibly a major reason that this started.

I'm a fully intact male (born in Canada in the 70's). When I "whack off", which is quite often, I don't have to use any kind of external lubrication at all. In addition the idea of using lubrication sounds insane to me as the system seems to be built to "just work". For many years I've heard jokes about "get out the lotion" etc which never made any sense to me. Many people seem to take it as a given that you need to use external lubrication to whack it.

Here is my question for anyone that wants to respond. Are you able to jack off without lube, not just able to do it, but very comfortably do it? Oh, and I guess you might want to mention if you are cut or uncut.

What I'm trying to find out here is this. Does the penis actually have reduced sexual function when the foreskin is removed (e.g. ability to whack it without external lube). My theory is that it is diminished, although by how much I think it's hard to say. Obviously cut men can still have sex but how things "feel" is very difficult to quantify in a meaningful way, so there could be a lot more disfunction than we know.

PS This is my first post! I've been around for a while lurking (like 6 years) and I was at TAM5. I'm trying to be more active in the skeptic community.I'm not aware many men use any lubrication to masturbate. While I am not male, there are times when one assists such as when you are too PG and still intimate.

[shecky]

I'm a fully intact male (born in Canada in the 70's). When I "whack off", which is quite often, I don't have to use any kind of external lubrication at all. In addition the idea of using lubrication sounds insane to me as the system seems to be built to "just work". For many years I've heard jokes about "get out the lotion" etc which never made any sense to me. Many people seem to take it as a given that you need to use external lubrication to whack it.

Here is my question for anyone that wants to respond. Are you able to jack off without lube, not just able to do it, but very comfortably do it? Oh, and I guess you might want to mention if you are cut or uncut.





Are you able to have penetrative sex with your partner sans lubrication, natural or otherwise?

[Ivor the Engineer]

…I actively promote patient autonomy…

Yeah, right. That’s why you let the parents decide, usually for the trivial reasons that Linda listed earlier. This is your delusion, your woo. At least we all know what it is, even if you can’t see it yourself.

[Ivor the Engineer]

I've just been reading up on the incidence of ingrown toenail. Apparently 2% of the American public suffer with this particular condition, which can lead to chronic infection until it is treated. 10% of Americans suffer with other foot problems, of which several are undoubtedly related to toenails.

As the loss of function (sexual or otherwise) from removing a toenail is minimal, I think it's only fair that all American parents ought to at least be able to elect to remove their child's big toenails at birth. There may be a slightly elevated risk at first, but I'm sure after the procedure has been refined for 100 years complication rates will be very low.

I think I know at least one nurse practitioner who'll help you out, since all you need to sway her is provide some evidence of benefit, which no doubt will be added to once more children are given this significant preventative treatment.

[fls]

While I appreciate that I have a choice, parents shouldn't be allowed* to act as surrogate-decision-makers for their children unless their choices coincide with mine?

Linda

*whatever form that takes

[Darat]

While I appreciate that I have a choice, parents shouldn't be allowed* to act as surrogate-decision-makers for their children unless their choices coincide with mine?

Linda

*whatever form that takes

That is as much a strawman as if I tried to say to you that your view is

"As a parent I can do anything I wish to my child since it is my property".

Do you disagree with this statement:

"Parent's shouldn't be allowed to abuse their children"

[E.J.Armstrong]

Yep, they do. Now all you have to do is get them to the men and women (only 1 in 5 couples have access to condoms in Africa) and get them to use them.
So lets cut bits off them then in a non-colonial way. We do know what's best for the natives don't we?

If you take that argument to it's logical conclusion you would cut off other body parts that could get diseased, such as fingers.

After all a finger is not essential and it is the parents right to tidy up such untidy looking appendages, especially as the child will not remember the pain when it is grown up.

N'est ce pas?

There is no way around it I am afraid. Circumcision of male babies amounts to docking the child for the parents' convenience. Something many rational people have stopped doing to dogs.

[fls]

Changing face of medical curricula (http://www.thelancet.com/journals/lancet/article/PIIS0140673600041349/abstract), 2001 You can't exactly change from paternalistic training unless it was the status quo originally.

I don't think anyone denies that it was once the status quo. However, in the 20+ years I've been involved in medical education (either as a student or a professor), the teaching has been directed toward patient autonomy and the status quo is now very different. I think classes and articles that address paternalism reflect 1) that it takes considerable effort to dramatically alter beliefs and attitudes and 2) that physicians are serious about that effort.

Here's an extreme version: Pediatrician Refuses To Treat Patient Because of Mom’s Tattoos (http://www.medschoolhell.com/2007/02/18/pediatrician-refuses-to-treat-patient-because-of-moms-tattoos/)The author's attitude says a lot as well.

Paternalism is addressed in any number of medical ethics classes. It is approached differently now than years passed and it is approached differently in different settings and countries. But the fact there are so many classes and articles that address the issue speaks to its existence.

Dissecting Room, Conduct and Compassion - Non-compliance (http://www.thelancet.com/journals/lancet/article/PIIS0140673604164295/fulltext) Of course most doctors are not going to come anywhere close to this description.

Compare that to this article which fully explores nursing treatment of non-compliance. Therapeutic Compliance Posttransplantation – A Nurse’s Perspective; Research Studies for Measurement and Prediction of Compliance. (http://www.medscape.com/viewarticle/512906_3) Rather than a discussion of the potential for non-compliance to be an issue, it's a nursing diagnosis. It's our job to deal with it. How would this not result in at least some different practice philosophies between doctors and nurse practitioners?

I know that you know better than this. You use extreme examples (and does not the fact that they are noteworthy suggest that they are not the status quo?) to illustrate physician practice and then arbitrarily assign a particular approach solely to a nursing perspective. I am familiar with the physician side of the issue of compliance in transplant patients at a national (technically international) level, and all of the issues discussed in that article receive the attention and consideration of physicians as well.

I actively promote patient autonomy. I've not seen many doctors do that.

I actively promote patient autonomy. I have seen many other doctors do that.

Linda

[Ivor the Engineer]

While I appreciate that I have a choice, parents shouldn't be allowed* to act as surrogate-decision-makers for their children unless their choices coincide with mine?

Linda

*whatever form that takes

Any idiot can become a parent. Look at the parents insisting WiFi is removed from schools. Sometimes you have to legislate to protect children from the lowest common denominator.

What's the point in training physicians, dentists, etc. if their advice is going to be ignored because of parents who wish to "pimp their child" so they look cool in the locker room?

If the child does feel embarrassed because he is not circumcised, it can be rectified quickly and safely if he wants. If only all "afflictions" were so easily remedied:rolleyes:

What anybody has done to their body should be their choice. It does not have to be a free choice (if there exists such a thing in the first place), but they should believe they had a say in what happened to them. The only exceptions I see are if it is unlikely they will ever be able to make the choice themselves because of life-threatening illness, an illness that is likely to cause significant disability and the patient cannot be communicated with before treatment begins, prior brain damage / metal illness that means they cannot understand or communicate, or where treatment has such clear benefits and low risk that it would be considered unreasonable not to proceed. Otherwise, hands-off until you've asked them.

I am amazed that intelligent people here think this approach of maximizing patient input to the decision making process is paternalistic. I view it as the exact opposite.

[fls]

That is as much a strawman as if I tried to say to you that your view is

"As a parent I can do anything I wish to my child since it is my property".

I was trying to understand the reason for the parade of "well, I wouldn't circumcise my child" posts, since after all, no one is saying you must.

Do you disagree with this statement:

"Parent's shouldn't be allowed to abuse their children"

Isn't it obvious that there is tremendous variation as to whether or not circumcision is considered abuse? And that parents who consider it abuse do not choose it for their child, making your statement a tautology?

Linda

[fls]

So lets cut bits off them then in a non-colonial way. We do know what's best for the natives don't we?

If you take that argument to it's logical conclusion you would cut off other body parts that could get diseased, such as fingers.

After all a finger is not essential and it is the parents right to tidy up such untidy looking appendages, especially as the child will not remember the pain when it is grown up.

N'est ce pas?

There is no way around it I am afraid. Circumcision of male babies amounts to docking the child for the parents' convenience. Something many rational people have stopped doing to dogs.

If it's about convenience, then I'll get all their teeth pulled so I don't have to worry about nagging them to brush their teeth. That's turning into a pain in the a**, I tell ya. I have a blender (wedding present), after all.

And all this laundry is pretty inconvenient, so I'm thinking of getting "clothes" tattooed on all my kids. I won't circumcise them, though, cuz it's probably easier to tattoo a foreskin than it is to tattoo a glans.

And if we're making Africans do what we want them to do, I say make them send more chocolate my way.

Linda

[JJM 777]

parents who consider it abuse do not choose it for their child
Kinda forgotten that it is the body of the child we're talkin about? The decision cannot possibly belong to anyone else, if any sense of justice be respected.

Not that it really would matter much. As far as I can see, people are having a life on both sides of the hedge.

[Darat]

...snip...


Isn't it obvious that there is tremendous variation as to whether or not circumcision is considered abuse? And that parents who consider it abuse do not choose it for their child, making your statement a tautology?

Linda

It is only a tautology if you believe the first statement I made is correct.

[fls]

It is only a tautology if you believe the first statement I made is correct.

How so? It is my impression that parents think they are benefiting the child, not themselves.

Linda

[fls]

Kinda forgotten that it is the body of the child we're talkin about? The decision cannot possibly belong to anyone else, if any sense of justice be respected.

This discussion has taken that into consideration.

Linda

[NewtonTrino]

Are you able to have penetrative sex with your partner sans lubrication, natural or otherwise?

Well there is always the natural "lube" that comes out when you get excited that works quite well for regular sex. I think regular sexual function is probably less affected by circumcision because the foreskin naturally gets pulled back during regular sex.

This "lube" also plays a role in masturbation although it isn't actually needed when you have a foreskin. Basically the foreskin itself because it can kind of "roll" is almost like having a vagina built into your penis. I honestly have a hard time picturing how it would work without it.

[NewtonTrino]

And what a first post it is...
I'm also somewhat surprised you are not circumcised yourself considering where and when you were born... but if you enjoy your foreskin then that's your right. It's kind of silly to presume that people without them are missing much (besides smelling their penis--yuck). The primary penile nerve is in the dorsal area of the penis with many nerve endings in the glans. Circumcision has little to no effect on these areas.

The incidence of it is a lot less in Canada than in the US. My dad (born in Canada in the 40's) is also uncircumcised so I'm guessing he had something to do with it as well.

I live in the states and both my first wife and my current girlfriend were surprised but don't think it's a big deal.

[NewtonTrino]

The quality of an erotic experience is related to the quality of sensory input on your skin, what you see with your eyes, etc.

The worst possible sensory input on your skin would be too cold, too boiling hot or too violent injuring touch. Under such circumstances it might be impossible to have an erotic experience of high quality.


While it is possible to experience something erotic in circumstances less than best possible, there is a difference between good quality, better quality and best possible quality.

Interestingly enough there is a pretty large amount of the population that really enjoys more intense sensory play. At the end of the day though most people do want a softer touch. I don't want to get too crazy in this thread, but I've seen some stuff that would absolutely blow the average persons mind.

[Ivor the Engineer]

How so? It is my impression that parents think they are benefiting the child, not themselves.

Linda

How could they think that when the physician will have told them that the procedure is not medically required for their child?

Does any parent elect to have their child's wisdom teeth removed unless a dentist advises it?

A parent could make all sorts of judicious changes to their child's anatomy to give it an 'advantage'.

It is ironic that a country that has inflicted its culture on so many others round the globe needs to resort the the concept of cultural relativism to defend its own practices.

[Roadtoad]

How could they think that when the physician will have told them that the procedure is not medically required for their child?

Does any parent elect to have their child's wisdom teeth removed unless a dentist advises it?

A parent could make all sorts of judicious changes to their child's anatomy to give it an 'advantage'.

It is ironic that a country that has inflicted its culture on so many others round the globe needs to resort the the concept of cultural relativism to defend its own practices.

Why does this surprise you, Ivor? Consider the weirdness we get from the Fundamentalists. When you think about it, it's right in synch.

[JJM 777]

I think I just became an anti-circumcisionist.

Never been clearly for or against the practice before, but today I have seen the Great Light of Truth.

From now on I shall think that circumcising a person younger than 21 years is primitive, soo primitive. (Googleing for photos of Australian aborigines, to get into the right mood...) Soo primitive.

[Darat]

How so? It is my impression that parents think they are benefiting the child, not themselves.

Linda

Because for it to be a tautology you must be saying that it is up to the parents to decide what is abuse or not for their child which means that you are in fact saying "As a parent I can do anything I wish to my child since it is my property".

[fls]

I think I just became an anti-circumcisionist.

Is the pay any good?

Linda

[Roadtoad]

Is the pay any good?

Linda

Nah. And there's no health benefits, either.

[fls]

Because for it to be a tautology you must be saying that it is up to the parents to decide what is abuse or not for their child which means that you are in fact saying "As a parent I can do anything I wish to my child since it is my property".

There is a minimal consideration of "abuse" which would be respresented in the legal system by the "reasonable person", and there is individual opinion. So I think it would more accurately be stated "as a parent I can do anything a reasonable person would do to my child". The "since it is my property" doesn't follow though. There are many reasons that people take action - use of property is just one of many. "Since I am entrusted with the care of this person" could just as easily be inserted, especially since children are not legally considered property in the US (I don't know where you are).

ETA: D'oh! I should have looked at your info.

Linda

[fls]

Nah. And there's no health benefits, either.

Considering the direction your initial post took, shouldn't that be...

"But the health benefits are."

(Otherwise someone will be tempted to use it against you. ;))

Linda

[RobertoDebunker]

Concerning alleged "medical benefits" of circumcision:

How could natural selection create, and preserve, an anatomical feature that is actually harmful to the organism (as the foreskin is alleged to be)? If that were true, nature would select for men with smaller foreskins, and then eventually with none at all.

And it's not just the human male we're talking about. All male mammals possess a foreskin. That's an awful lot of natural selection weighing in there. Kind of makes it very difficult to believe the line about "having a foreskin may be hazardous to your health."

Genital modifications or "mutilations" (except to correct actual medical problems) carried out on either male or female unconsenting victims, are remnants of primitive savagery and have no place in the modern world.

Robert

[Ivor the Engineer]

There is a minimal consideration of "abuse" which would be respresented in the legal system by the "reasonable person", and there is individual opinion. So I think it would more accurately be stated "as a parent I can do anything a reasonable person would do to my child". The "since it is my property" doesn't follow though. There are many reasons that people take action - use of property is just one of many. "Since I am entrusted with the care of this person" could just as easily be inserted, especially since children are not legally considered property in the US (I don't know where you are).

ETA: D'oh! I should have looked at your info.

Linda

Given that 80% of the world's men are not circumcised, then American parents are being unreasonable if significantly more that 20% of their boys are circumcised.

By the way, how "local"* do you go to judge what's reasonable? How many people does it take to form a culture?

Cultural relativism is all fine and dandy if your culture does not intend on interacting with any other. It tends to go tits up when two or more cultures meet though. From what I can tell, the US is not exactly isolating itself from the rest of the world.

For large numbers of people from different cultures to live closely together in peace, idiosyncratic practices of different cultures have to disappear or be assimilated by all. Circumcision is definitely an idiosyncratic cultural practice.

*British readers will get this I hope:D

[fls]

Concerning alleged "medical benefits" of circumcision:

How could natural selection create, and preserve, an anatomical feature that is actually harmful to the organism

That is a misconception about natural selection known as adaptionism. From Dawkins' The Extended Phenotype - "that approach to evolutionary studies which assumes without further proof that all aspects of the morphology, physiology and behavior of organisms are adaptive optimal solutions to problems". Dawkins lists six constraints to perfection - time lags, historical constraints, available genetic variation, constraints of costs and materials, imperfections at one level due to selection at another level, and mistakes due to environmental unpredictability of "malevolence".

There are numerous example of vestiges and remnants of formerly useful parts hanging around where the drive of harm has not yet been sufficient to lead to their loss. Don't read too much into it.

Linda

[kellyb]

How could they think that when the physician will have told them that the procedure is not medically required for their child?

Does any parent elect to have their child's wisdom teeth removed unless a dentist advises it?

A parent could make all sorts of judicious changes to their child's anatomy to give it an 'advantage'.

.

How many other anatomical changes were supposedly commanded by a certain angry Middle Eastern deity, though?

That whole thing sure is one heck of a coincidence, isn't it?

Either that, or religion really is good for science.

[JJM 777]

Is the pay any good?

I feel that I just became a better person. A higher creature.

[kellyb]

I feel that I just became a better person. A higher creature.

Learn the proper use of the phrase "Bronze Age blood ritual" and you're on your way. :)

[fls]

How many other anatomical changes were supposedly commanded by a certain angry Middle Eastern deity, though?

That whole thing sure is one heck of a coincidence, isn't it?

Either that, or religion really is good for science.

How many bits and pieces are there that could be easily lopped off in an infant that wouldn't be immediately harmful, though? I also wonder whether this is a pattern that would emerge any time you finish the job of removing something that is on its way to becoming vestigial - a small benefit that would not have been sustained if the process of evolution had led to the disappearance. For example, if men had evolved to lack a foreskin, the rate of HIV acquisition would be the same as it is now for uncircumcised men.

But I think we should do it on mice, first.

Linda

[Ivor the Engineer]

How many bits and pieces are there that could be easily lopped off in an infant that wouldn't be immediately harmful, though? I also wonder whether this is a pattern that would emerge any time you finish the job of removing something that is on its way to becoming vestigial - a small benefit that would not have been sustained if the process of evolution had led to the disappearance. For example, if men had evolved to lack a foreskin, the rate of HIV acquisition would be the same as it is now for uncircumcised men.

But I think we should do it on mice, first.

Linda

But is it random?:D

ETA: Do you have any evidence that the foreskin is "on its way to becoming vestigal"? Or is everything that a human can survive without to be considered vestigal? E.g., a kidney, a lung, etc.

[Katana]

Tell me, in the hospital(s) where you practice, do the physicians have a separate area from other staff in the cafeteria for meals? And if not, have you seen these areas in other hospitals? Have you observed a sufficient number of different nurse practitioner patient interactions to say you see no indication of any philosophical difference between patient-provider interactions?


No. There is no separate area for physicians. I have seen them in other hospitals.

My take on it is that there is an argument to be made for having a separate clinical staff cafeteria so nurse practitioners, nurses, docs, etc could talk a bit more freely over lunch about tough cases or the like. I don't think that docs need to have an area separate from other clinical staff, but it is awkward to have a patient or patients' family members corner me in the sandwich line to discuss sensitive issues.

You and Hawkeye both continue to misinterpret what I've said, regardless of the clarifications I keep posting. Surely you recognize the different roles of physicians and nurses are going to result in different reactions to patients' autonomy?

Nowhere in my posts have I said, bad doctors, good nurses. There is no reason for any defensiveness distorting perceptions of what I posted. Of course doctors are compassionate! Just as some nurses aren't. That has absolutely nothing to do with my point.

I was pointing out the difference in the worlds of each profession. If you don't think such basic differences in the philosophy established in the educational and professional milieu have any affect on patient-physician and patient-nurse interactions, then what is your reasoning? I'll say it again, this is not about skills, compassion, clearly divided philosophies, patient respect in either profession. Think of it more like two overlapping bell curves with slightly shifted peaks (or maybe moderately shifted in some cases).


I have thought about what I said and your response to it, skeptigirl, and I should apologize for the tone of my post. You are right in that I took offense, responded in defense, and my reaction is likely due more to experiences that I have had on the job with nurses throwing the "I'm the patient advocate" accusation at docs, including me (obviously), when they clearly weren't.

More often than not, I am impressed by your posts and your efforts to support your positions with evidence.

My frustration is that, yes, docs and nurses will ultimately have different roles and with those differences comes some differences in philosophy (? is that the right word even - I don't know).

However, I think that the greatest disservice to all of us in the healthcare field is perpetuating this idea that these differences are so vast. I'm not saying that that's what you're doing. I'm just venting.

It never fails to amaze me that docs and nurses always have different patient sign-outs at the end of the day. When I sit in on nurses' sign-outs, I learn so much, and I have always found that they feel the same when they participate in ours. We have much more to learn from each other than not.

For that matter, why does the ob/gyn department in my hospital have a meeting that includes nurses, midwives, nurse practitioners, and docs only once a year? It's ridiculous.

Anyway, I digress a bit...

Changing face of medical curricula (http://www.thelancet.com/journals/lancet/article/PIIS0140673600041349/abstract), 2001 You can't exactly change from paternalistic training unless it was the status quo originally.

{snip}

Paternalism is addressed in any number of medical ethics classes. It is approached differently now than years passed and it is approached differently in different settings and countries. But the fact there are so many classes and articles that address the issue speaks to its existence.


You're right. I just seek to point out that it's changing, and you have acknowledged that. I just think that when young docs hear generalizations lodged at them (or think that they are hearing them ;)) based on conclusions formed from exposure to people trained using old-fashioned models, they will become defensive. Most of us really do strive for better and believe in a different approach.


Compare that to this article which fully explores nursing treatment of non-compliance. Therapeutic Compliance Posttransplantation – A Nurse’s Perspective; Research Studies for Measurement and Prediction of Compliance. (http://www.medscape.com/viewarticle/512906_3) Rather than a discussion of the potential for non-compliance to be an issue, it's a nursing diagnosis. It's our job to deal with it. How would this not result in at least some different practice philosophies between doctors and nurse practitioners? I actively promote patient autonomy. I've not seen many doctors do that.


How do you see yourself as doing that? And how do you contrast that with what doctors do? That's a distinction that you are making that I wish to understand. What does it mean to you to promote patient autonomy? How are docs not doing that? What do you wish they would do instead?

If you are simply describing your personal feelings with a difficult medical dilemma in terms of performing circs, fine. But if you are trying to tell me I can't possibly understand this unless I've done circ procedures, I don't accept that at all. You have no idea what practice experiences I've had. And you are making the false assumption that somehow my evaluation and perception of this matter are naive. I might suggest to you that unless you've tried futilely to revive an infant that has just succumbed to a respiratory infection or taken care of a 3 year old that is about to have all four limbs amputated from a meningococcal infection, that you can't empathize with my position. But that would be stupid because I don't know what your experiences have been. It wouldn't bother me to perform a circ because I have no dilemma over doing circumcisions. And lots of NPs perform circs, BTW.


I am not suggesting that, because someone does not do circs, that he/she cannot speak to the matter, though I can understand why the general tone of my post may have conveyed that.

I was putting forth the fact that, in the face of equivocal medical evidence for its value, being the one actively doing an elective procedure puts things in a different light. I don't mean to demean anyone's opinions. I meant only to point out that this level of uncertainty in the "evidence" so to speak can cause varying amounts of discomfort in the one yielding the scalpel. Yes. I learned that first-hand.

It was the underlying assumptions about 'not medically indicated' I object to. In addition, I disagreed with Dr Hawk's perception that providing another provider respected the parent's views.

We are interpreting "respect" differently in this discussion. I interpret respect as recognizing different people have different values and those values are just as valid as anyone else's in this case. Dr H is interpreting it to mean she doesn't recognize those values, doesn't recognize why the parents' decision is just as legitimate as hers. Dr H instead made the non-evidence based declaration, "there is no medical indication for a circumcision in a healthy infant" so if the parents want one, they are wrong, but I won't interfere.

She doesn't say, the parents have different values and are valuing prevention of UTI while I (DrH) value something else so I don't personally want to do the circumcision.

My point in arguing this matter concerns what I see (and it's very clear in my view) as distortions of the empirical evidence. I see a failure of people to recognize that more than one value is legitimate in weighing the risk and benefit.

I guess I don't see HawkeyeMD's actions in the same light at all. As I said, in a situation with equivocal evidence, as the one doing the procedure, the simple desires of the parents may not be enough. In this instance, that's ok. She hasn't obstructed their ability to obtain this procedure. She just is not willing to do it herself. I guess I understand.

Re-read what I said. I bolded it for you. I said nothing about anti-abortion beliefs being "fundamentalist religious beliefs". I do however think pushing abstinence only education is reaching the fundamentalist end of the continuum of beliefs.

I won't disagree there. The way the posts read, it came across differently.

I said nothing about acceptable practice. I don't agree with the denial of the equivocal medical evidence regarding circumcisions. It is not respecting the parent's choice if you cannot recognize they have just as much justification deciding the lowered risk of infection is more important to them than the questionable significance of the foreskin.

In the same vein, I don't see how, in the face of equivocal evidence, opting out of an elective procedure and referring the parents to someone else compromises their ability to choose.

Having said all of that, we clearly will not agree on all things, but I do respect your opinion, what I learn from your posts (even in threads in which I am not a participant), and your obvious passion for your work.

[kellyb]

How many bits and pieces are there that could be easily lopped off in an infant that wouldn't be immediately harmful, though?

Not a lot, but some parts of the female anatomy could go, ear lobes, probably other parts of the ear, some toes, parts of the lips?

I also wonder whether this is a pattern that would emerge any time you finish the job of removing something that is on its way to becoming vestigial

How can you say the foreskin is on it's way to becoming vestigial? The foreskin of the human penis is more developed than what you see in other primates.

a small benefit that would not have been sustained if the process of evolution had led to the disappearance. For example, if men had evolved to lack a foreskin, the rate of HIV acquisition would be the same as it is now for uncircumcised men.

I would be interesting to know what would have happened with HIV in a hypothetical world where men were born without foreskins. But since biology will always throw you for a loop, it's equally plausible that different negatives would have popped up over time instead....epidemics that didn't take off because of the foreskin. My impression of how pathogens evolve leads me to think that we would have entirely different STDs, or that the STDs we have right now would behave very differently, if humans were born with a different sexual anatomy. Change the selective pressures and the pathogens will be different.

[Ivor the Engineer]

Not a lot, but some parts of the female anatomy could go, ear lobes, probably other parts of the ear, some toes, parts of the lips?



How can you say the foreskin is on it's way to becoming vestigial? The foreskin of the human penis is more developed than what you see in other primates.



I would be interesting to know what would have happened with HIV in a hypothetical world where men were born without foreskins. But since biology will always throw you for a loop, it's equally plausible that different negatives would have popped up over time instead....epidemics that didn't take off because of the foreskin. My impression of how pathogens evolve leads me to think that we would have entirely different STDs, or that the STDs we have right now would behave very differently, if humans were born with a different sexual anatomy. Change the selective pressures and the pathogens will be different.

Yep. The best you can do is play with the hand you've been dealt. However, I think the idea Linda was getting at was that if you can remove a body part that is only a minor change for you, but a step change for the pathogen, then you can have a net benefit if the pathogen's reproductive success is significantly reduced.

[fls]

Not a lot, but some parts of the female anatomy could go, ear lobes, probably other parts of the ear, some toes, parts of the lips?

I agree with the female anatomy and the ear lobes. I suspect that once you involve bones, the risk of serious infection becomes an issue. And that lips would interfere with breastfeeding. So the latter two might end up immediately harmful. We've got the female genitalia covered. Surely there's some culture somewhere that lops off the ear lobes? Or maybe piercing counts.

How can you say the foreskin is on it's way to becoming vestigial? The foreskin of the human penis is more developed than what you see in other primates.

That would support my supposition, though. The selection pressures are likely to be higher in other primates, so they are further along the path that we are following. Just saying that it's an obvious possibility.

I would be interesting to know what would have happened with HIV in a hypothetical world where men were born without foreskins. But since biology will always throw you for a loop, it's equally plausible that different negatives would have popped up over time instead....epidemics that didn't take off because of the foreskin. My impression of how pathogens evolve leads me to think that we would have entirely different STDs, or that the STDs we have right now would behave very differently, if humans were born with a different sexual anatomy. Change the selective pressures and the pathogens will be different.

Yeah, I'm thinking similar equilibriums would be reached regardless of the details.

Linda

[kellyb]

Yep. The best you can do is play with the hand you've been dealt. However, I think the idea Linda was getting at was that if you can remove a body part that is only a minor change for you, but a step change for the pathogen, then you can have a net benefit if the pathogen's reproductive success is significantly reduced.

Right. I agree. And that's why I can see how people in Africa might want circumcision. Since HIV is an epidemic of quasi-Armageddon proportions, desperate measures do seem to be called for.

But in complete seriousness (honestly not an "emotional appeal") I really do think removing some of the female labia and some other forms of FGC would disrupt the transmission cycles of both herpes and HIV, as well, especially as the two viruses work together. But we all know that kind of "desperate measure" would be unethical to even explore as an option or potential area of scientific research.
How do you resolve that logical disconnect?

[Ivor the Engineer]

Right. I agree. And that's why I can see how people in Africa might want circumcision. Since HIV is an epidemic of quasi-Armageddon proportions, desperate measures do seem to be called for.

But in complete seriousness (honestly not an "emotional appeal") I really do think removing some of the female labia and some other forms of FGC would disrupt the transmission cycles of both herpes and HIV, as well, especially as the two viruses work together. But we all know that kind of "desperate measure" would be unethical to even explore as an option or potential area of scientific research.
How do you resolve that logical disconnect?

That's what I can't get with the likes of the pro-circumcision people and skeptigirl. They're fast enough to defend parents rights to choose circumcision for their boys, but balk at the idea of doing a clinical trial of a very specific form of FGM with consenting adult volunteers. I don't see how you can have an issue with one but not the other.:confused:

[kellyb]

I agree with the female anatomy and the ear lobes. I suspect that once you involve bones, the risk of serious infection becomes an issue. And that lips would interfere with breastfeeding.
Regarding breastfeeding, just like the tribes that practiced religious circumcision figured out that the 8th day was best (probably because of vitamin K), "god" would probably command a culture to remove lip parts after the local age of weaning. I can even see it being a cultural symbol of transition into middle childhood or something.

That would support my supposition, though. The selection pressures are likely to be higher in other primates, so they are further along the path that we are following. Just saying that it's an obvious possibility.

Huh. I guess you're right. It could have gone either way.
Of course, if the "sperm competition" theory relating to the penis size to testical size ratio is correct, the the male anatomy is in the process of changing quite a bit, probably. And not in a way that many men would find appealing. :)

[Ivor the Engineer]

Of course, if the "sperm competition" theory relating to the penis size to testical size ratio is correct, the the male anatomy is in the process of changing quite a bit, probably. And not in a way that many men would find appealing. :)

But at least I have an excuse now. Thanks.;)

[NewtonTrino]

That's what I can't get with the likes of the pro-circumcision people and skeptigirl. They're fast enough to defend parents rights to choose circumcision for their boys, but balk at the idea of doing a clinical trial of a very specific form of FGM with consenting adult volunteers. I don't see how you can have an issue with one but not the other.:confused:

Uh, yeah. I still don't get what gives the parents the right to perform unnecessary and unreversable surgery on their children. I also personally think it's unethical for medical profressionals to participate in this.

[BlackKat]

That's what I can't get with the likes of the pro-circumcision people and skeptigirl. They're fast enough to defend parents rights to choose circumcision for their boys, but balk at the idea of doing a clinical trial of a very specific form of FGM with consenting adult volunteers. I don't see how you can have an issue with one but not the other.:confused:

Well I'm not sure that there is a basis for such a test so far. Nobody has put forward any particular theories nor have then been any noticable trends that would lead to such theories. But it seems unlikely they will find anything positive.

And here's something I think you'll enjoy. Aparently circumcision is not alone...
http://seattletimes.nwsource.com/html/health/2002246171_healthhelmet20.html

[BlackKat]

Uh, yeah. I still don't get what gives the parents the right to perform unnecessary and unreversable surgery on their children. I also personally think it's unethical for medical profressionals to participate in this.

And I still don't get what makes people think foreskins are a good thing...

I guess that makes us even.

[Ivor the Engineer]

Well I'm not sure that there is a basis for such a test so far. Nobody has put forward any particular theories nor have then been any noticable trends that would lead to such theories. But it seems unlikely they will find anything positive.

And here's something I think you'll enjoy. Aparently circumcision is not alone...
http://seattletimes.nwsource.com/html/health/2002246171_healthhelmet20.html

When I read mis-shaped heads I got worried...:jaw-dropp

The difference between that procedure and circumcision is that it is a cosmetic procedure that can only be performed at that age.

I have far more sympathy for parents of kids with mild deformities like that than ones who select circumcision for a healthy child, since the latter can be performed at any age.

[tek]

And I still don't get what makes people think foreskins are a good thing...

I guess that makes us even.

I'm not sure that's how debate works.

It's certainly a rational opinion to believe that the benefits of circumcision outweigh the costs-- it's a subjective judgement based on the applicable evidence, but it can be done in a rational manner. I agree with the recent posters in that I don't see how you could deny it on a rational basis and then categorically say all types of FGM are morally unjust; that's not rational at all; though it might be the case that FGM doesn't have the same cost-benefit ratio as male circumcision, presently there isn't really a lot of research done in this area. If you support research for male circumcision to fight AIDS, then it logically follows you should support research determining whether the cost of FGM in some form is worth the potential benefits.


Well I'm not sure that there is a basis for such a test so far. Nobody has put forward any particular theories nor have then been any noticable trends that would lead to such theories. But it seems unlikely they will find anything positive.

It seems like there is plenty of basis, in that male circumcision slightly reduces chance of an UTI and signifigantly reduces the contraction of AIDS. It seems like a fair bet that in toughening and reducing sensitive tissues you would get a similar effect regardless of gender, at least to my admittedly non-medically trained eyes.

In my opinion the right of integrity of body and the loss of sensation are heavy weights, but it would be foolish to say there is no point at which medical concerns do not weigh even heavier, or even that those concerns are not based strongly in the contemporary and surrounding medical landscape.

[kellyb]

Well I'm not sure that there is a basis for such a test so far. Nobody has put forward any particular theories nor have then been any noticable trends that would lead to such theories. But it seems unlikely they will find anything positive.





http://www.aegis.com/conferences/IASHIVPT/2005/TuOa0401.html

INTRODUCTION: It has been postulated that female circumcision might increase the risk of HIV infection either directly, through the use of unsterile equipment, or indirectly, through an increase in genital lacerations or the substitution of anal intercourse. The authors sought to explain an unanticipated significant crude association of lower HIV risk among circumcised women [RR=0.51; 95% CI 0.38,0.70] in a recent survey by examining other factors which might confound this crude association.

METHODS: Capillary blood was collected onto filter paper cards from a nationally representative sample of women age 15 to 49 during the 2004 Tanzania Health Information Survey. Eighty-four percent of eligible women gave consent for their blood to be anonymously tested for HIV antibody. Interview data was linked via barcodes to final test results for 5753 women. The chi-square test of association was used to examine the bivariate relationships between potential HIV risk factors with both circumcision and HIV status. Restricting further analyses to the 5297 women who had ever had sexual intercourse, logistic regression models were then used to adjust circumcision status for other factors found to be significant.

RESULTS: By self-report, 17.7 percent of women were circumcised. Circumcision status varied significantly by region, household wealth, age, education, years resident, religion, years sexually active, union status, polygamy, number of recent and lifetime sex partners, recent injection or abnormal discharge, use of alcohol and ability to say no to sex. In the final logistic model, circumcision remained highly significant [OR=0.60; 95% CI 0.41,0.88] while adjusted for region, household wealth, age, lifetime partners, union status, and recent ulcer.

CONCLUSIONS: A lowered risk of HIV infection among circumcised women was not attributable to confounding with another risk factor in these data. Anthropological insights on female circumcision as practiced in Tanzania may shed light on this conundrum.

So, who's going to volunteer to follow up on this?

[osmosis]

Prove that the foreskin is 'useful'. Or, should I say, prove that the benefits of having a foreskin outweigh the benefits of not having one. So far, the benefits of having one appear minimal at best, while the benefits of not having one are somewhat greater (at least in our society).

Waitaminute, that's not how it works. Noone needs to justify leaving a child intact, it is the proponents of any alteration that must justify THEIR positions. In short, the burden of proof is on you.

Personally, I agree that parents ought to have the right (and, in fact, they DO have the right) to have surgery done on their children to improve their appearance. But then, I'm something of an extremist in this area, and my commentaries should be treated accordingly.

I literally shudder at the thought of being your child.

[Ivor the Engineer]

http://www.aegis.com/conferences/IASHIVPT/2005/TuOa0401.html



So, who's going to volunteer to follow up on this?

My guess: Nobody. The powers that be have decided that FGM is "wrong" in all its forms and circumcision is "right", so long as a parent does it out of concern for their child's well-being.

I wonder if a physician in the US would still be ok performing a circumcision if a parent explicitly said they thought the health benefits were insignificant and the real reason they were insisting on their child's foreskin be removed was because they believed the foreskin was ugly and disgusting?

But given the US is a country with child beauty pageants, I guess it wouldn't make much difference:rolleyes:

[Darat]

There is a minimal consideration of "abuse" which would be respresented in the legal system by the "reasonable person", and there is individual opinion. So I think it would more accurately be stated "as a parent I can do anything a reasonable person would do to my child". The "since it is my property" doesn't follow though. There are many reasons that people take action - use of property is just one of many. "Since I am entrusted with the care of this person" could just as easily be inserted, especially since children are not legally considered property in the US (I don't know where you are).

ETA: D'oh! I should have looked at your info.

Linda


Dropping the "because they are property" clause doesn't alter your position, for your claim of a tautology it has to be that parents determine what is abusive or not for their child.

[Skeptic Ginger]

I don't think anyone denies that it was once the status quo. However, in the 20+ years I've been involved in medical education (either as a student or a professor), the teaching has been directed toward patient autonomy and the status quo is now very different. I think classes and articles that address paternalism reflect 1) that it takes considerable effort to dramatically alter beliefs and attitudes and 2) that physicians are serious about that effort.

I know that you know better than this. You use extreme examples (and does not the fact that they are noteworthy suggest that they are not the status quo?) to illustrate physician practice and then arbitrarily assign a particular approach solely to a nursing perspective. I am familiar with the physician side of the issue of compliance in transplant patients at a national (technically international) level, and all of the issues discussed in that article receive the attention and consideration of physicians as well.

I actively promote patient autonomy. I have seen many other doctors do that.

LindaI agree that younger doctors are exposed to a different world than the education and socialization of their older peers. But the idea the medical community has suddenly reversed a century old philosophy is absurd. OTOH, how many times do I have to say various versions of, "not all doctors" and "overlap" and "subtle philosophical difference, not concrete or absolute difference"? I am really being misunderstood here. I have to assume I am not explaining my self well. I am describing an underlying philosophical difference, not some black and white, doctors are this, nurses are that. I'm talking about more subtle differences. And of course there are physicians who are less paternalistic than others.

I see equivocal empirical medical evidence. I find the importance of reducing infection risk just as legitimate as valuing an intact foreskin. I see my role as giving the parents the information they need to make an informed choice. I don't see my role as imposing my personal values in this case.

I have observed many physician patient interactions and my approach is often much more oriented toward giving patients information to make decisions while physicians are much more inclined to give the patient their medical opinion. That doesn't mean all physicians are going to approach problems in the same way. Nor are all nurses the same either.

Since I'm being challenged that there is a difference, I gave the extreme example to point out an underlying philosophy which you will not find in nursing. I'm trying to show you what the difference is that I am talking about. I'm not using the example to say anything about the majority of physicians. Yet it appears you are the third MD here to deny there is a difference. I'm wondering if you all really can't see the difference or whether you don't understand what I am describing.

I have never observed a nurse expressing offense that a patient did not accept the nurse's opinion. The nurse might be annoyed with a difficult patient, but not offended that the patient rejected the nurse's advice. Tell me you've never seen an MD take offense to a patient rejecting the MD's opinion? I've seen that many times. Maybe as nurses we are less often in a relationship where we are giving the patient 'opinions' but regardless, nurse patient and doctor patient relationships are very different.

But this is really getting off the point. I was speculating about what might be the reason for my differing viewpoint here. The reason is not as relevant as the fact it differs. Take my position here compared to Hawkeye's as an example. She is less willing to consider the legitimacy of personal assignment of weight to different aspects of the risk benefit analysis of the issue, she is willing to 'allow' the parents their choice, and she considers that the equivalent of 'respecting' their choice. From my point of view, as long as the parents are operating with valid facts, then I would respect the decision they arrived at. I don't need to 'allow' it, that isn't my place.

[Skeptic Ginger]

Kinda forgotten that it is the body of the child we're talkin about? The decision cannot possibly belong to anyone else, if any sense of justice be respected.

Not that it really would matter much. As far as I can see, people are having a life on both sides of the hedge.People are assigned medical guardianship for any number of reasons. The parents own that position until the child is older. So like it or not, it is most certainly their right to make a medical decision for their child.

[Skeptic Ginger]

Concerning alleged "medical benefits" of circumcision:

How could natural selection create, and preserve, an anatomical feature that is actually harmful to the organism (as the foreskin is alleged to be)? If that were true, nature would select for men with smaller foreskins, and then eventually with none at all. ....
RobertTake a genetic science course and you'll see the folly of that argument.

[Skeptic Ginger]

No. There is no separate area for physicians. I have seen them in other hospitals.

My take on it is that there is an argument to be made for having a separate clinical staff cafeteria so nurse practitioners, nurses, docs, etc could talk a bit more freely over lunch about tough cases or the like. I don't think that docs need to have an area separate from other clinical staff, but it is awkward to have a patient or patients' family members corner me in the sandwich line to discuss sensitive issues. .....I can relate to that.

I really have been trying to describe something very subtle and realize it is coming across in a different light. And I also am not saying this subtle difference matters in every case, nor that one philosophy is better than the other. I have had many patients not the least bit interested in information or decision making, they want the provider to be in control. I know from the replies I'm coming across like I am saying the whole medical profession is paternalistic but that isn't what I mean at all. So now I'm sorry I brought it into the conversation.

As far as perpetuating the differences and the differences being 'vast', I totally agree with you and the differences are in no way vast. Nurses can be our own worst enemy but I probably shouldn't get started on that one.

In this discussion in particular, I am most concerned about the discounting of infection risk reduction, as if that was just no big deal. The impact of a child dying from infection is so overwhelming. These are often kids who were fine only a few days earlier. The medical evidence is that many of those infants with UTIs were also septic. And if one is going to cite evidence that a UTI is rarely serious or rarely fatal, then evidence is needed that death from septicemia secondary to a UTI is included in those numbers.

From my perspective, I can't imagine not affording any parent the right to hold the value that infection risk reduction was important and to make their decision based on that value. But maybe my position in this case has less to do with a difference in professional roots as in having had more than a few experiences with dying children.

[fls]

Dropping the "because they are property" clause doesn't alter your position, for your claim of a tautology it has to be that parents determine what is abusive or not for their child.

My point was that the parents are not the only source for what is considered abusive with respect to their child - they are sufficient, but not necessary.

Linda

[Darat]

My point was that the parents are not the only source for what is considered abusive with respect to their child - they are sufficient, but not necessary.

Linda

That's just saying the same thing with different words. If a parent is sufficient i.e. "as much as is needed" to determine if something is abusive (or not) for their child then you are saying you agree with my first statement "As a parent I can do anything I wish to my child".

[fls]

I agree that younger doctors are exposed to a different world than the education and socialization of their older peers. But the idea the medical community has suddenly reversed a century old philosophy is absurd. OTOH, how many times do I have to say various versions of, "not all doctors" and "overlap" and "subtle philosophical difference, not concrete or absolute difference"? I am really being misunderstood here. I have to assume I am not explaining my self well. I am describing an underlying philosophical difference, not some black and white, doctors are this, nurses are that. I'm talking about more subtle differences. And of course there are physicians who are less paternalistic than others.

I got it. Honest. :)

It looked like (and still looks like) you were attempting to push the overlapping curves apart, while I am attempting to push them closer together. I think that within group differences account for much more of what you see than between group differences in attitude.

Of course I'm not claiming that we have suddenly reversed a centuries old philosophy. It was you who brought up the idea of the underlying models and my point is that the underlaying model has changed which is leading to real changes in the behaviour and attitudes of physicians.

I see equivocal empirical medical evidence. I find the importance of reducing infection risk just as legitimate as valuing an intact foreskin. I see my role as giving the parents the information they need to make an informed choice. I don't see my role as imposing my personal values in this case.

I have observed many physician patient interactions and my approach is often much more oriented toward giving patients information to make decisions while physicians are much more inclined to give the patient their medical opinion. That doesn't mean all physicians are going to approach problems in the same way. Nor are all nurses the same either.

Since I'm being challenged that there is a difference, I gave the extreme example to point out an underlying philosophy which you will not find in nursing. I'm trying to show you what the difference is that I am talking about. I'm not using the example to say anything about the majority of physicians. Yet it appears you are the third MD here to deny there is a difference. I'm wondering if you all really can't see the difference or whether you don't understand what I am describing.

I have never observed a nurse expressing offense that a patient did not accept the nurse's opinion. The nurse might be annoyed with a difficult patient, but not offended that the patient rejected the nurse's advice. Tell me you've never seen an MD take offense to a patient rejecting the MD's opinion? I've seen that many times. Maybe as nurses we are less often in a relationship where we are giving the patient 'opinions' but regardless, nurse patient and doctor patient relationships are very different.

There are many reasons for those differences that are not based on paternalism. As you point out, the amount and kind of situations where nurses provide an opinion are quite different from situations involving physicians. Many of the medical decisions involve extensive knowledge and experience that cannot be sufficiently conveyed to the patient in order to let them make the informed decision, leading to situations where providing an expert opinion rather than an inadequate education better serves the patient. The nature of some of the things that physicians recommend (treatment, diagnostic tests) make it obvious when they are rejected, whereas the rejection of a nurse's recommendation may have little opportunity to be discovered. Your contention that you provide education while physicians provide opinion in comparable situations may look different to a neutral third-party.

I think you realize all this. It seemed to me that emphasizing differences in attitude (which I agree is present - less so in comparison of the ideal and more so in comparison of actual practice) ignored the more obvious differences in the nature of the roles and within group variation. And that your examples spoke more to the latter than to the former. I jumped in because your illustration of the situation seemed biased, as does mine, but together they might form some sort of useful picture.

But this is really getting off the point. I was speculating about what might be the reason for my differing viewpoint here. The reason is not as relevant as the fact it differs. Take my position here compared to Hawkeye's as an example. She is less willing to consider the legitimacy of personal assignment of weight to different aspects of the risk benefit analysis of the issue, she is willing to 'allow' the parents their choice, and she considers that the equivalent of 'respecting' their choice. From my point of view, as long as the parents are operating with valid facts, then I would respect the decision they arrived at. I don't need to 'allow' it, that isn't my place.

Don't you think, in this case, that it is practice and experience that probably accounts for much more of the difference than attitude? You both seem to have a similar attitude, but Hawkeye pictures her anticipated response differently than how you picture your response. Hers is necessarily speculative, but yours is based on experience. How to help parents (and patients) make decisions is something that you learn, after all.

Linda

[fls]

That's just saying the same thing with different words. If a parent is sufficient i.e. "as much as is needed" to determine if something is abusive (or not) for their child then you are saying you agree with my first statement "As a parent I can do anything I wish to my child".

If discovered, an abusive parent can be held accountable by the criminal justice system.

Linda

[Ivor the Engineer]

If discovered, an abusive parent can be held accountable by the criminal justice system.

Linda

So there is an external reference that is used to judge parents behaviour toward their child, just as there is one for physicians and nurses behaviour toward their patient.

Anyone care to speculate on the source of these values and their validity across cultures?

[Darat]

If discovered, an abusive parent can be held accountable by the criminal justice system.

Linda

And if you use that definition my statement that I asked you about i.e.

"Parent's shouldn't be allowed to abuse their children"

is not as you claimed a tautology.

[E.J.Armstrong]

EJ Armstrong makes an attempt to associate circumcision with indecency.

Perhaps your emotional response prevented you from addressing any part of my argument?

Male infant circumcision is genital mutilation for the cosmetic purposes of the parents if there is no immediate medical reason to do so. As an unnecessary act of mutilation there is a risk that the child will be permanently damaged in the process.

The question is begged as to why stop at genital mutilation? After all, the appendix is a redundant organ but I see little justification for a widespread removal of the appendix in case it should get diseased at a later stage in life.

For a discussion of some of the myths supporting circumcision please see http://mothersagainstcirc.org/. Should a barbaric practice brought in partly because of an ill conceived attempt to prevent masturbation be allowed to continue in decent societies in the twenty first century.

[fls]

And if you use that definition my statement that I asked you about i.e.

"Parent's shouldn't be allowed to abuse their children"

is not as you claimed a tautology.

No, not generally. In the context where you made that statement (i.e. with reference to circumcision), it becomes a tautology because it is necessary as well as sufficient for a parent to consider it abuse, since parental consent to circumcision is not a criminal act.

Linda

[Darat]

No, not generally. In the context where you made that statement (i.e. with reference to circumcision), it becomes a tautology because it is necessary as well as sufficient for a parent to consider it abuse, since parental consent to circumcision is not a criminal act.

Linda

None of which is relevant to the statement I asked you about i.e. "Parent's shouldn't be allowed to abuse their children." (which was in a post that I pointing out a strawman you had posted). That statement was not and is not a tautology.

[Katana]

Perhaps your emotional response prevented you from addressing any part of my argument?

Male infant circumcision is genital mutilation for the cosmetic purposes of the parents if there is no immediate medical reason to do so. As an unnecessary act of mutilation there is a risk that the child will be permanently damaged in the process.

The question is begged as to why stop at genital mutilation? After all, the appendix is a redundant organ but I see little justification for a widespread removal of the appendix in case it should get diseased at a later stage in life.

For a discussion of some of the myths supporting circumcision please see http://mothersagainstcirc.org/. Should a barbaric practice brought in partly because of an ill conceived attempt to prevent masturbation be allowed to continue in decent societies in the twenty first century.


This is only to address the "If we circ, then why not remove the appendix, too" argument here.

Doing a routine circumcision on a newborn is an extremely quick and safe procedure (again, all arguments about long-term benefits/risks notwithstanding). Removing an appendix is a much different proposition. It is abdominal surgery, requiring general anesthesia (along with all of its risks), time in the operating room, significantly higher costs, and, though rare, the complications can be devastating.

There was a time when appendices were removed routinely during other surgery. The thought was, well, we're here anyway. Why not spare the patient trouble later? This went out of favor as the rate of complications from this began to out-pace the potential benefits.

[E.J.Armstrong]

If it's about convenience, then I'll get all their teeth pulled so I don't have to worry about nagging them to brush their teeth. That's turning into a pain in the a**, I tell ya. I have a blender (wedding present), after all.

And all this laundry is pretty inconvenient, so I'm thinking of getting "clothes" tattooed on all my kids. I won't circumcise them, though, cuz it's probably easier to tattoo a foreskin than it is to tattoo a glans.

And if we're making Africans do what we want them to do, I say make them send more chocolate my way.

Linda

I may be mistaken because your post failed to make any recognisably concrete points, but you may be agreeing that there is normally no medical reason to genitally mutilate male babies and that the primary reason is a cosmetic choice of the parent and as such you might as well remove the appendix at birth.

Non medical male circumcision of babies is equivalent to docking dogs and something many rational people no longer do.

If the lust to chop perfectly healthy bits off those who cannot stick up for themselves is unstoppable, perhaps genital mutilation supporters could pick on someone their own size in the future and see what the reaction is? Just a thought.

Should they approach an adult member of the public while wielding a sharp knife and proclaiming that 'this is not going to hurt when you grow up.' I respectfully suggest that the word 'off' will immediately follow a word a decent person couldn't print on the JREF.

Babies just don't have the vocabulary these days.

[fls]

None of which is relevant to the statement I asked you about i.e. "Parent's shouldn't be allowed to abuse their children." (which was in a post that I pointing out a strawman you had posted). That statement was not and is not a tautology.

I'm agreeing with you. My original reference to it being a tautology was only for the specific circumstance that I outlined, not as a general statement.

Linda

[fls]

I may be mistaken because your post failed to make any recognisably concrete points...

I may have misunderstood your original intent. I thought your post was a parody and I was responding in kind.

Linda

[E.J.Armstrong]

This is only to address the "If we circ, then why not remove the appendix, too" argument here.

Doing a routine circumcision on a newborn is an extremely quick and safe procedure (again, all arguments about long-term benefits/risks notwithstanding). Removing an appendix is a much different proposition. It is abdominal surgery, requiring general anesthesia (along with all of its risks), time in the operating room, significantly higher costs, and, though rare, the complications can be devastating.

There was a time when appendices were removed routinely during other surgery. The thought was, well, we're here anyway. Why not spare the patient trouble later? This went out of favor as the rate of complications from this began to out-pace the potential benefits.

I don't believe that the ease of genital mutilation is a valid argument in favour of genital mutilation per se.

I suspect you were not trying to argue that it is.

My example was merely to address the illogical argument that circumcision is OK because it deals with unnecessary human bits and pieces, such as the appendix. If there is no intrinsic difference other than degree of difficulty I could ask why not cut off the ear lobe or the tips of the fingers or the toenails?

My primary argument still remains. Non-medical male infant circumcision is equivalent to the docking of dogs for for the owners/parents cosmetic preferences. As such it is genital mutilation for no rational purpose and therefore fundamentally abhorrent.

[Darat]

I'm agreeing with you. My original reference to it being a tautology was only for the specific circumstance that I outlined, not as a general statement.

Linda

Sorry I misunderstood your last comment.

[fls]

Waitaminute, that's not how it works. Noone needs to justify leaving a child intact, it is the proponents of any alteration that must justify THEIR positions. In short, the burden of proof is on you.

It actually looks like the claim being made is that we should or should not be rabid on this issue. And it seems that the default is to be selectively rabid, rather than selectively non-rabid. However, it could be laziness rather than rationality which leads me to assume the former.

Linda

[Quakeulf]

We have great fun, my foreskin and I.

[Ivor the Engineer]

It actually looks like the claim being made is that we should or should not be rabid on this issue. And it seems that the default is to be selectively rabid, rather than selectively non-rabid. However, it could be laziness rather than rationality which leads me to assume the former.

Linda

Yes, you're right. It is laziness on your part.

[fls]

It actually looks like the claim being made is that we should or should not be rabid on this issue. And it seems that the default is to be selectively rabid, rather than selectively non-rabid. However, it could be laziness rather than rationality which leads me to assume the former.

Linda

Hmmm.....might depend upon sex.

http://eurheartj.oxfordjournals.org/cgi/content/full/25/10/867

Linda

[Ivor the Engineer]

Hmmm.....might depend upon sex.

http://eurheartj.oxfordjournals.org/cgi/content/full/25/10/867

Linda

Yeah, very funny.

You win - you are annoying me. I am pissed at you because I see your position in particular as hypocritical.

Life must be so much easier when you see so few things wrong with the world, or simply can't be bothered to stand up for what you believe.

[Chicken Pot Pie]

My three oldest sons had this done at birth.

My 4th son had to have this done when he was six years old because he wasn't being good about keeping it clean. Mom can only clean for them for so long, you know. His brothers, all in high school at the time were present. As we walked out, one of the boys told him:

"Wow, you're doing great! When I had mine done I couldn't walk for a year!"

Chicken Pot Pie

[HawkeyeMD]

I agree that younger doctors are exposed to a different world than the education and socialization of their older peers. But the idea the medical community has suddenly reversed a century old philosophy is absurd. OTOH, how many times do I have to say various versions of, "not all doctors" and "overlap" and "subtle philosophical difference, not concrete or absolute difference"? I am really being misunderstood here. I have to assume I am not explaining my self well. I am describing an underlying philosophical difference, not some black and white, doctors are this, nurses are that. I'm talking about more subtle differences. And of course there are physicians who are less paternalistic than others.

Then stop bringing it up. Seriously. The more times you qualify your statements with things like "of course there are physicians who are less paternalistic than others", the more it sounds like your underlying message is "but of course they're all that way underneath." The very sentence you wrote implies it--if some are "less", then clearly all of us are.

I can't find the thread I referred to earlier, where you were arguing with someone claiming to be a doctor and spouting off about things like "nurses just take orders and doctors give them", but as I said, I agreed with you there. The idea of nursing and medicine as overlapping magisteria, if you will, is not a bad place to begin, and as I also said, I agreed with what you were saying there. But neither profession has a headlock on education. OR paternalism.

I see equivocal empirical medical evidence. I find the importance of reducing infection risk just as legitimate as valuing an intact foreskin. I see my role as giving the parents the information they need to make an informed choice. I don't see my role as imposing my personal values in this case.

I think, from what you have written, that you find the importance of reducing infection risk to be by far the weightiest issue. I find it hard to believe that in the process of educating a parent, this viewpoint would not come across more strongly than the idea that there is "equivocal medical evidence". Anyone who is medically educated and is in the position of advising a patient is going to color their advice by their own knowledge and experience. That's not paternalism.

I know you've undoubtedly read the famous Emanuel/Emanuel paper on medical models (which, by the way, we were given during our first semester in med school). The idea that the patient should be solely given information and should make all decisions alone, with the caregiver as a technical informer only, is the 'informative' model and it isn't considered ideal either. There has to be some guidance or interpretation, otherwise the caregiver might as well be Google.com (TM).

I'm not using the example to say anything about the majority of physicians. Yet it appears you are the third MD here to deny there is a difference.

Point of information: I'm not a physician yet. I appreciate the brevet rank, though. :cool:

You keep claiming this, and yet clearly, three different people are getting a different message. Is it not possible to state that there are differences between the professions of medicine and nursing without implying that one of them is intrinsically better? I know you will respond that you were doing no such thing. But that's how it's coming across.

I have never observed a nurse expressing offense that a patient did not accept the nurse's opinion. The nurse might be annoyed with a difficult patient, but not offended that the patient rejected the nurse's advice.

I have. I've seen nurses who are openly scornful about patients not listening to them, even when it's something as simple as when they should get out of bed. Doesn't mean a darn thing about nurses in general. Your constant use of absolutes ("I have never seen a nurse do this") and implication of rare exceptions (Not all doctors are like this") is what is leading to the appearance that you *are* generalizing about "all doctors".

If that is, as you say, not what you mean, then please stop bringing it up to bolster your position on this specific topic. I agree with Katana that you are clearly extremely knowledgable and you know your subject well; I have no doubt that your patients are well served by you. You are doing yourself and those who might learn from you a disservice by injecting your argument with what is obviously being interpreted as, if not a personal attack, then a professional one.

Take my position here compared to Hawkeye's as an example. She is less willing to consider the legitimacy of personal assignment of weight to different aspects of the risk benefit analysis of the issue, she is willing to 'allow' the parents their choice, and she considers that the equivalent of 'respecting' their choice. From my point of view, as long as the parents are operating with valid facts, then I would respect the decision they arrived at. I don't need to 'allow' it, that isn't my place.

Yes, let's, shall we? Only let's deal with my actual position. My position is that based on the medical evidence, I do not believe circumcision is warranted for every male child. Therefore, since I am considering it as a medical procedure, I don't intend to perform them routinely. As fls has pointed out, most parents are not primarily concerned with the risk of infection (whether of HIV, which seemed to be the predominant example early in the thread, or of UTIs, which have taken over lately) when considering circumcision. If a parent is concerned about UTI, then that is a medical question and a situation in which I would consider the procedure.

Your characterization of "willing to allow" and "respecting" other choices is specious. I do think that societal and cultural issues have weight, but I think that my input into them is far less than my input into a medical question. I don't even know what you think you mean by this. By 'respecting' a choice, you mean I should wholeheartedly support it and act on it just because it's the parents' decision? Sorry, but if I don't agree with it, I can't. I assure you I would never roll my eyes and say, "Well, if you MUST do it...." You seem to be assuming a level of judgmentalism on my part. It isn't like that. I really don't think circumcision is harmful. I think it's unncessary. That is different from "how dare you consider mutilating your child". Which, given the direction of some posts in this thread, I do see where that was coming from, but...don't ascribe that tone to me, because I have never and would never use it.

[kellyb]

I'm not seeing the difference between selective rabidness and selective non-rabidness.

:confused:

[fls]

I'm not seeing the difference between selective rabidness and selective non-rabidness.

:confused:

Does one select only those issues one feels most passionate (maybe based on rational criteria, but could be other) about to throw their heart into, or does one throw their heart into most everything, excluding only the excessively non-controversial?

Linda

[Ivor the Engineer]

I don't think routine circumcision of infants particularly harms the child. I think it harms the society that tolerates it.

Not so long ago a person could be bought and sold, legally.

Not so long ago a man could rape his wife, legally.

Not so long ago a child could be beaten, legally.

But of course, YOU think routine circumcision is different.

[Katana]

I don't think routine circumcision of infants particularly harms the child. I think it harms the society that tolerates it.

Not so long ago a person could be bought and sold, legally.

Not so long ago a man could rape his wife, legally.

Not so long ago a child could be beaten, legally.

But of course, YOU think routine circumcision is different.


You state here that you don't think that routine circumcision of infants hurts the children.

All of the other acts hurt the individuals who we now protect with our laws.

By your own statements, circumcision IS different.

:con2:

[kellyb]

Does one select only those issues one feels most passionate (maybe based on rational criteria, but could be other) about to throw their heart into, or does one throw their heart into most everything, excluding only the excessively non-controversial?

Linda

It's rather difficult to throw your heart into something you don't feel passionate about, isn't it?
Exclusing some circumstances or qualifying exceptional situations is necessary when you feel great passion about conflicting issues. Sometimes different things one feels strongly about will converge in opposition, creating the effect of tempering.
I don't think that's "excluding only the excessively non-controversial", though. It's balancing conflicting ideals in an attempt to preserve the integrity of both.

[robinson]

So there is an external reference that is used to judge parents behavior toward their child, just as there is one for physicians and nurses behavior toward their patient.

Anyone care to speculate on the source of these values and their validity across cultures?

The Courts, as in, the Law, and Religion, as in, God said it. Perhaps Medical Ethics Boards, and maybe the Mores.

I don't think there is a cross cultural validity. Different cultures have different Mores, Laws and Religions. Circumcision seems to be a Jewish based belief, which by proxy spread to Christianity and Muslims.

It probably started as a way to mark men as slaves. Only slaves were circumcised, a way to ensure they couldn't ever pass themselves off as free men.

In these more enlightened times, we don't do primitive rites anymore. Circumcision is not medically necessary. The American Academy of Pediatrics (AAP) does not recommend circumcision as a routine procedure for newborn males.

[Roadtoad]

Perhaps your emotional response prevented you from addressing any part of my argument?

Male infant circumcision is genital mutilation for the cosmetic purposes of the parents if there is no immediate medical reason to do so. As an unnecessary act of mutilation there is a risk that the child will be permanently damaged in the process.

The question is begged as to why stop at genital mutilation? After all, the appendix is a redundant organ but I see little justification for a widespread removal of the appendix in case it should get diseased at a later stage in life.

For a discussion of some of the myths supporting circumcision please see http://mothersagainstcirc.org/. Should a barbaric practice brought in partly because of an ill conceived attempt to prevent masturbation be allowed to continue in decent societies in the twenty first century.

Ask yourself if the practice even works, then ask yourself if it's barbaric or not. It doesn't. It is.

(Geez, EJ, something you and I agree on! :eek: )

Ivor brought up and interesting point: we have changed over the years. And while slavery, rape, and child abuse continue, their status within advanced societies has changed. You cannot buy or sell people legally, you cannot rape a woman legally, you cannot beat your child legally. we have come to understand that people have rights to and of themselves. Why is the issue of circumcision any different? Unless you're doing it for a specific medical reason, it simply should not be done.

[Ivor the Engineer]

You state here that you don't think that routine circumcision of infants hurts the children.

All of the other acts hurt the individuals who we now protect with our laws.

By your own statements, circumcision IS different.

:con2:

What long term physical harm does rape do? No more than circumcision.

What long term physical harm does beating a child do? No more than circumcision.

What long term physical harm does enslaving a person do? No more than circumcision.

The people who supported and carried out these acts weren't monsters. They were just like you and me. Ever heard "Spare the rod, ruin the child."?

[Katana]

What long term physical harm does rape do? No more than circumcision.

What long term physical harm does beating a child do? No more than circumcision.

What long term physical harm does enslaving a person do? No more than circumcision.

The people who supported and carried out these acts weren't monsters. They were just like you and me. Ever heard "Spare the rod, ruin the child."?


There is more than physical harm to be weighed. Have you ever met a rape victim? I suspect that you have not. When you do, tell her that you doubt her experience caused her long-term harm. I dare you. I also suspect that you have not seen the trauma that forced intercourse can do. That CAN have real, lasting, debilitating physical consequences. So comparing this scenario to circumcision, particularly after you claim that circumcision does not harm the child is ignorant at best and offensive at worst. :mad:

As for long-term harm from beating children, well those beaten to death, brain damaged, or otherwise handicapped might take issue with your statements, too. When you bring up the beating of children, that which is illegal, you're raising a category of treatment that is far outside of that of spanking. That's why it is against the law, after all.

Long-term harm of enslaving people? Well, aside from robbing them of their human rights, separating families against their will, depriving them of opportunities for livelihood, and compromising their earning potential not to mention the physical abuses handed down upon them by virtue of their being viewed as property even if that abuse turns out to be lethal, oh I can't think of any real long-term harm that that would cause.

[INRM]

It does make maintenance easier, easier to get a woman to perform fellatio on you, slightly reduced vulnerability to certain infections, and having it done at birth is far easier than having it done in your teens. Sure it hurts either way, but most people aren't even aware of what happened until they're about 2 so it's not a big deal.

And while some will complain it reduces sensation, I can state as a healthy 29 year old that I've had PLENTY of sensation, and lots of fun with my circumcized penis.

Tony L

[Ivor the Engineer]

There is more than physical harm to be weighed. Have you ever met a rape victim? I suspect that you have not. When you do, tell her that you doubt her experience caused her long-term harm. I dare you. I also suspect that you have not seen the trauma that forced intercourse can do. That CAN have real, lasting, debilitating physical consequences. So comparing this scenario to circumcision, particularly after you claim that circumcision does not harm the child is ignorant at best and offensive at worst. :mad:

As for long-term harm from beating children, well those beaten to death, brain damaged, or otherwise handicapped might take issue with your statements, too. When you bring up the beating of children, that which is illegal, you're raising a category of treatment that is far outside of that of spanking. That's why it is against the law, after all.

Long-term harm of enslaving people? Well, aside from robbing them of their human rights, separating families against their will, depriving them of opportunities for livelihood, and compromising their earning potential not to mention the physical abuses handed down upon them by virtue of their being viewed as property even if that abuse turns out to be lethal, oh I can't think of any real long-term harm that that would cause.

Do you see what you did there? You picked the most extreme forms of the acts I used as examples. Some forms of circumcision can be pretty extreme too. Can you think of any?

A person could be enslaved by people who cared for them. Not every slave was tortured. They did not know they were individuals because society decided they were not.

A man could force himself on his wife because she was lead to believe that was her role in life. Love and Obey. She got that idea from society.

A child could be beaten without leaving marks. The child learned that it was the correct way to deal with disobedience. Not every child was beaten to death.

[HawkeyeMD]

What long term physical harm does rape do? No more than circumcision.

What long term physical harm does beating a child do? No more than circumcision.

What long term physical harm does enslaving a person do? No more than circumcision.

The people who supported and carried out these acts weren't monsters. They were just like you and me. Ever heard "Spare the rod, ruin the child."?

:boggled: Are you serious?

Ivor, I have pointed out before that I think basically we agree on this issue. Why on earth you would use the implication that rape, child abuse and slavery are exact equivalents to circumcision is beyond me. You are abandoning your very cogent arguments for nonintervention for the sake of a pithy, oversimplistic smart answer. Please don't do that, and don't let your emotional involvement in the issue lead you into making such comparisons.

I have worked in a rape-crisis center. The very idea of implying that there is no long-term harm involved, or that the long-term harm is no more than that of a minor medical procedure, is absolutely unconscionable.

[Roadtoad]

(Hawk, I think Ivor's being sarcastic.)

[Katana]

Do you see what you did there? You picked the most extreme forms of the acts I used as examples. Some forms of circumcision can be pretty extreme too. Can you think of any?

A person could be enslaved by people who cared for them. Not every slave was tortured. They did not know they were individuals because society decided they were not.

A man could force himself on his wife because she was lead to believe that was her role in life. Love and Obey. She got that idea from society.

A child could be beaten without leaving marks. The child learned that it was the correct way to deal with disobedience. Not every child was beaten to death.


No. Sorry. You can't do that now. You stated that you do not feel that routine circumcision harms the infant. Period.

You then went on to assert that rape, human slavery, and the beating of children are no more harmful. Period.

There is no such thing as a routine rape, beating, or enslavement. They are extreme by their very nature.

[HawkeyeMD]

(Hawk, I think Ivor's being sarcastic.)

I'm not so sure, based on his next post. He appears to be defending the position.

In any event, those are particularly charged and unwarranted comparisons to make.

[Ivor the Engineer]

Ok, let's try an example a bit closer to our time and hopefully something you can relate to.

A women not being able to have a higher education and a professional career, such as a physician.

I am not trying to exactly equate the acts of rape with slavery with child beating with the lack of recognition of women as equals with circumcision on a physical level, though some of these practices were often not as brutal as we like to think they were.

I am trying to make you see that the morality of these acts against certain people was wrong for exactly the same reason routine infant circumcision is wrong.

Just because the law allows parents to choose to circumcise their infant, so it allowed the acts I listed at the time periods they were prevalent. We now see them for what they were. Violations of basic human rights.

My reactions to rape is just as intense as yours. Do you think it would be if we had been alive at the time a women was expected to provide sexual favors whenever her husband demanded it? The same goes for child beating and slavery. Sometimes we cannot see the abuses that go on in front of our eyes because we are so used to them. They become normal.

Do you think the men in Afghanistan hate their female children? Do you think they believe they are doing something wrong by stopping them being educated?

[Darat]

...snip...

My reactions to rape is just as intense as yours. Do you think it would be if we had been alive at the time a women was expected to provide sexual favors whenever her husband demanded it?

...snip...

Just as a FYI it was as late as 1992 that in England & Wales it was finally decided by the Law Lords that a husband could be found (lgeally) guilty of raping his wife. Before that in England & Wales being married was a legal defence for a husband accused of raping his wife.

[HawkeyeMD]

And do you think that making that comparison is any way to "make" us see anything your way?

Back up. Take a breath. Remember that you are battering people who agree with you with these statements.

Now. What you expect to accomplish by comparing the morality of discrimination against women to the morality of circumcision escapes me. I agree with you, Ivor. I think that unless a permanent physical alteration is medically necessary, it should not be done. I can't think of any comparable reason for keeping a woman from being a doctor. Is that occasionally medically warranted? The two situations are not comparable.

When you say you are trying to "make me see" something, you come uncomfortably close to my "oh no you don't" line. Most people react poorly to being "made to see" anything. Just because I do not phrase my position in tones of extreme moral outrage does not make my thinking on the subject any less solid, nor my conclusions any less heartfelt, than your own. I honestly don't understand how you are swinging so freely between the two extremes (conceding that you do not find circumcision harmful, but then condemning anyone who does not find it a complete moral outrage). You can't have both positions at the same time.

My feeling is that you are letting your annoyance with fls lead you into some intemperate posting, and I am trying to point out that you are coming off as being as bludgeoning as those historical examples you speak against.

[Ivor the Engineer]

I'm not trying to batter anybody, especially you, HawkeyeMD. This is more directed toward those people (and physicians and nurse practitioners) who can't (or don't want to) accept what they tolerate every single day and do nothing to protest.

It isn't the acts themselves that are necessarily equivalent, it is the morality of those acts which are. E.g., the powerful in society inflicting their will on the powerless. The powerless just accept it.

How many men who have not been circumcised as infants change there mind when they are older? Very, very few. It is crazy to therefore argue that parents are representing their child's wishes when he is older.

We see all forms of FGM as morally wrong. What is so special about male circumcision, apart from we in the "civilized" world have been performing it for a long time?

[HawkeyeMD]

But some of them really do think that they are conferring a medical benefit. Equating them with rapists and child-abusers does not strike me as a good way to open a dialogue.

Look, I get the frustration. Honest. But once you agree that "the acts themselves are (not) necessarily equivalent", you should not then proceed as though the reaction to them should be. Do you see what I mean? You asked earlier if I thought Afghani fathers (and why not add in mothers) hated their daughters. That in itself is a loaded question, but leaving that aside, let me ask you this. Am I likely to be more successful in convincing them to educate their daughters by calling them names?

I really shouldn't use the example, because again, I don't consider it to be an equivalent. But let's try and look at the situation dispassionately. I think that many parents simply have never thought about it one way or the other--they simply opt for circumcision because that's what they think is normal. It's my hope to get at least some of them to think more about the 'normalcy' of the act--to change their cultural viewpoint, perhaps. But if the two sides of the coin are either "circumcise" or "you are an evil mutilator", I can't imagine that they'd listen at all.

What I am saying is that if you are looking at this as a question of morality and not as one of physical harm, you will never convince about the issue if you attack anyone who disagrees with you as though they are intrinsically evil, because then they are on the defensive from the outset. I am willing to put myself out there as someone who thinks that things should change, but I could never equate a parent who wanted their child circumcised with a child abuser. I said it before: the ethics of pediatrics are complicated. (I'm going to PM you about a specific case.)

As far as why not many men who have not been circumcised as infants change their minds later...:eek: (That's a joke, BTW.)

[Ivor the Engineer]

There is no such thing as a routine rape, beating, or enslavement. They are extreme by their very nature.

Only in the developed world today. But in the past (and alas elsewhere in the world today) these activities were (are) accepted by both the oppressors and the oppressed as normal.

My parents both had the cane across their hands. I can't even see the scars.

Some slaves' lives actually improved after being sold.

Not all rape is at knife-point.

[Ivor the Engineer]

But some of them really do think that they are conferring a medical benefit. Equating them with rapists and child-abusers does not strike me as a good way to open a dialogue.

Look, I get the frustration. Honest. But once you agree that "the acts themselves are (not) necessarily equivalent", you should not then proceed as though the reaction to them should be. Do you see what I mean? You asked earlier if I thought Afghani fathers (and why not add in mothers) hated their daughters. That in itself is a loaded question, but leaving that aside, let me ask you this. Am I likely to be more successful in convincing them to educate their daughters by calling them names?

I really shouldn't use the example, because again, I don't consider it to be an equivalent. But let's try and look at the situation dispassionately. I think that many parents simply have never thought about it one way or the other--they simply opt for circumcision because that's what they think is normal. It's my hope to get at least some of them to think more about the 'normalcy' of the act--to change their cultural viewpoint, perhaps. But if the two sides of the coin are either "circumcise" or "you are an evil mutilator", I can't imagine that they'd listen at all.

What I am saying is that if you are looking at this as a question of morality and not as one of physical harm, you will never convince about the issue if you attack anyone who disagrees with you as though they are intrinsically evil, because then they are on the defensive from the outset. I am willing to put myself out there as someone who thinks that things should change, but I could never equate a parent who wanted their child circumcised with a child abuser. I said it before: the ethics of pediatrics are complicated. (I'm going to PM you about a specific case.)

As far as why not many men who have not been circumcised as infants change their minds later...:eek: (That's a joke, BTW.)

I have already stated that I don't believe that the vast majority of the people who committed what we would now find abhorrent acts were monsters. Milgram showed us that. I do not think parents who choose to have their boys circumcised for the tiniest of benefits or trivial reasons are evil. I think they don't understand the ethical double-standard they are using to justify it.

I personally think that your approach is probably the only feasible way for you to both stay employed (and hopefully help lots of people and their children) and at the same time indicate that you disagree with the child being circumcised for non-medical reasons.

[Skeptic Ginger]

That's what I can't get with the likes of the pro-circumcision people and skeptigirl. They're fast enough to defend parents rights to choose circumcision for their boys, but balk at the idea of doing a clinical trial of a very specific form of FGM with consenting adult volunteers. I don't see how you can have an issue with one but not the other.:confused:
What are you talking about? You have to have a good hypothesis and pass medical ethics committees before some clinical trial of FGM for HIV prevention. This is just getting idiotic, Ivor.

What's you hypothesis and where is your supporting evidence?

[Skeptic Ginger]

Uh, yeah. I still don't get what gives the parents the right to perform unnecessary and unreversable surgery on their children. I also personally think it's unethical for medical profressionals to participate in this.

Supporting the claim it is "unnecessary" is the issue here.

[Skeptic Ginger]

...
The difference between that procedure and circumcision is that it is a cosmetic procedure that can only be performed at that age.
....What? Cosmetic? By whose standards?

[Skeptic Ginger]

I got it. Honest. :)

It looked like (and still looks like) you were attempting to push the overlapping curves apart, while I am attempting to push them closer together. I think that within group differences account for much more of what you see than between group differences in attitude.

Of course I'm not claiming that we have suddenly reversed a centuries old philosophy. It was you who brought up the idea of the underlying models and my point is that the underlaying model has changed which is leading to real changes in the behaviour and attitudes of physicians.



There are many reasons for those differences that are not based on paternalism. As you point out, the amount and kind of situations where nurses provide an opinion are quite different from situations involving physicians. Many of the medical decisions involve extensive knowledge and experience that cannot be sufficiently conveyed to the patient in order to let them make the informed decision, leading to situations where providing an expert opinion rather than an inadequate education better serves the patient. The nature of some of the things that physicians recommend (treatment, diagnostic tests) make it obvious when they are rejected, whereas the rejection of a nurse's recommendation may have little opportunity to be discovered. Your contention that you provide education while physicians provide opinion in comparable situations may look different to a neutral third-party.

I think you realize all this. It seemed to me that emphasizing differences in attitude (which I agree is present - less so in comparison of the ideal and more so in comparison of actual practice) ignored the more obvious differences in the nature of the roles and within group variation. And that your examples spoke more to the latter than to the former. I jumped in because your illustration of the situation seemed biased, as does mine, but together they might form some sort of useful picture.



Don't you think, in this case, that it is practice and experience that probably accounts for much more of the difference than attitude? You both seem to have a similar attitude, but Hawkeye pictures her anticipated response differently than how you picture your response. Hers is necessarily speculative, but yours is based on experience. How to help parents (and patients) make decisions is something that you learn, after all.

Linda

I completely agree with you. I will give you another example though, where nursing intervention is called for and not many doctors recognize it. It also, however, is specific to my experience.

I have been seeing workers for blood exposures for ~18 years, (17 on my own and 1 as a hospital employee health practitioner). It's rare that these exposures lead to infection, and I certainly know the medical protocols and provide the needed medical care. However, exposure to blood really has as big an emotional reaction as any medical need. Some workers are petrified, some worried about their family, and some not so much. I'd say 90% of the intervention is taking care of the emotional reaction and 10% is medical intervention. In addition, the drugs used for HIV risk are really risky in themselves. One protease inhibitor, no longer used, caused one worker's liver failure which necessitated a liver transplant.

For exposures, I'm very conservative with medical interventions and liberal treating the emotional response. I also see many workers who already went to the ED so I see what the Docs have already done. I use many more nursing skills than most physicians who tend to offer the medical interventions with these patients and really don't address the emotional issues much at all. Reassurance if not done right, often comes across as downplaying the risk the worker feels.

So do you think physicians are given an education which says, the PEP drugs in such a situation are often not needed, but addressing the exposed worker's fears is the most important intervention? Keep in mind also, this is often an ED Dr. There are a couple hospitals in this area who still refuse to do the worker's baseline HIV test, opting instead to refer the worker to a PMD the next day. Their reason? Our state law requires pre and post test HIV counseling and they didn't want to take on that task.

I think most medical care involves a mix of medical and nursing skills. I recognize that easily as someone with a nursing education which focused on nursing diagnoses and interventions. (Nursing got little credit for such skills until we figured out you had to name them and describe them.) I'd be very interested to know how much focus is given in med schools today covering those "nursing diagnoses" and whether any med school ever refers to them as "nursing orders".

[Skeptic Ginger]

Then stop bringing it up. Seriously. ....You are much too defensive here. Some people have differing points of view. If you take offense to that, it isn't very conducive to a discussion.

[Skeptic Ginger]

Having second thoughts, I'll try one more time.Then stop bringing it up. Seriously. The more times you qualify your statements with things like "of course there are physicians who are less paternalistic than others", the more it sounds like your underlying message is "but of course they're all that way underneath." The very sentence you wrote implies it--if some are "less", then clearly all of us are.This is your paranoia and defensiveness. The more I try to restate what I'm saying in response to your misinterpretations, the more defensive you get.

I can't find the thread I referred to earlier, where you were arguing with someone claiming to be a doctor and spouting off about things like "nurses just take orders and doctors give them", but as I said, I agreed with you there. The idea of nursing and medicine as overlapping magisteria, if you will, is not a bad place to begin, and as I also said, I agreed with what you were saying there. But neither profession has a headlock on education. OR paternalism.It was this thread, Medical and Healthcare phishing (http://forums.randi.org/showthread.php?t=55112) and no one was buying skepticdoc's absolutely unbelievable nonsense. But it was an opportunity for me to describe the nursing profession, something which the public doesn't hear nearly often enough.

I think, from what you have written, that you find the importance of reducing infection risk to be by far the weightiest issue. I find it hard to believe that in the process of educating a parent, this viewpoint would not come across more strongly than the idea that there is "equivocal medical evidence". Anyone who is medically educated and is in the position of advising a patient is going to color their advice by their own knowledge and experience. That's not paternalism.Perhaps you find that hard to believe because you still don't get the fact I believe what I say, that where the medical evidence is equivocal, then individual assignment of priorities is a neutral medical decision.

You have erroneously concluded the example I gave of a parent who might have reason to value infection risk reduction meant I was promoting that position. I used that example to try to show those people here who were simply discounting the medical evidence of UTI risk that there was another side of the coin. I have had to support the argument for infection risk reduction because no one else here seems to recognize it. It is a valid medical indication for a circumcision in a healthy infant. Either you, as a 4th year medical student, don't believe that the AAP or the AAFP committees who wrote the respective position statements for those organizations were sincere, or you must believe you have the qualifications to contradict their conclusions.

I believe the reduction in infection risk is reasonable. I don't believe the evidence for risk reduction is strong enough to override someone like Ivor or yourself who are convinced the foreskin is so important. And at the same time I have not seen any convincing empirical evidence that circumcisions are a big deal to a majority of men.

Believe it or not, some of us actually believe in the positions we promote. I find the evidence equivocal.

I know you've undoubtedly read the famous Emanuel/Emanuel paper on medical models (which, by the way, we were given during our first semester in med school). The idea that the patient should be solely given information and should make all decisions alone, with the caregiver as a technical informer only, is the 'informative' model and it isn't considered ideal either. There has to be some guidance or interpretation, otherwise the caregiver might as well be Google.com (TM).Actually, I haven't read it.

Linda noted there was a knowledge difference and that it plays a big role in one's ability to simply inform a patient and have the patient decide. I agree with this completely. And at the risk of having you conclude if I say something I must really mean the opposite, :rolleyes: , I wasn't trying to imply that patient autonomy was some absolute. I was speculating that my nursing background did make it more likely for me to empathize with multiple values influencing the specific decision to circumcise. But maybe it is more my individual experiences than my professional background. Either way, nurses are socialized to accept patient's values and work with them as part of the nursing role.

Point of information: I'm not a physician yet. I appreciate the brevet rank, though. :cool:

You keep claiming this, and yet clearly, three different people are getting a different message. Is it not possible to state that there are differences between the professions of medicine and nursing without implying that one of them is intrinsically better? I know you will respond that you were doing no such thing. But that's how it's coming across.It's absurd to think I'm claiming one is better. My primary care provider is a physician, not a nurse practitioners. Not that I don't have the utmost respect for nurse practitioners, but I know or can research as much as they know medically. I expect and trust my physician knows a lot more medicine than I know. I'm saying that each has a contribution, but each has a different educational and professional experience.

I have. I've seen nurses who are openly scornful about patients not listening to them, even when it's something as simple as when they should get out of bed. Doesn't mean a darn thing about nurses in general. Your constant use of absolutes ("I have never seen a nurse do this") and implication of rare exceptions (Not all doctors are like this") is what is leading to the appearance that you *are* generalizing about "all doctors".There are poor nurses out there just as there are poor doctors. The specific role of the nurse is to deal with this kind of patient problem. The absolute is true in the profession of nursing, reality is by no means absolutely ideal.

If that is, as you say, not what you mean, then please stop bringing it up to bolster your position on this specific topic. I agree with Katana that you are clearly extremely knowledgable and you know your subject well; I have no doubt that your patients are well served by you. You are doing yourself and those who might learn from you a disservice by injecting your argument with what is obviously being interpreted as, if not a personal attack, then a professional one.No Dr Hawk, (and you do have MD after hawkeye so that's why I used the shorthand), in your defensive position, you are reading things into my posts which are not in them. I can't help you there.

Yes, let's, shall we? Only let's deal with my actual position. My position is that based on the medical evidence, I do not believe circumcision is warranted for every male child. Therefore, since I am considering it as a medical procedure, I don't intend to perform them routinely. As fls has pointed out, most parents are not primarily concerned with the risk of infection (whether of HIV, which seemed to be the predominant example early in the thread, or of UTIs, which have taken over lately) when considering circumcision. If a parent is concerned about UTI, then that is a medical question and a situation in which I would consider the procedure.Then why is it, do you think, that seasoned professionals in the AAP and AAFP have come to a different conclusion?

Your characterization of "willing to allow" and "respecting" other choices is specious. I do think that societal and cultural issues have weight, but I think that my input into them is far less than my input into a medical question. I don't even know what you think you mean by this. By 'respecting' a choice, you mean I should wholeheartedly support it and act on it just because it's the parents' decision? Sorry, but if I don't agree with it, I can't. I assure you I would never roll my eyes and say, "Well, if you MUST do it...." You seem to be assuming a level of judgmentalism on my part. It isn't like that. I really don't think circumcision is harmful. I think it's unncessary. That is different from "how dare you consider mutilating your child". Which, given the direction of some posts in this thread, I do see where that was coming from, but...don't ascribe that tone to me, because I have never and would never use it.Same question, how do you support your decision to go against two different physician organizations who, by consensus, do find the UTI risk reduction warrants consideration for circumcision of an otherwise healthy infant? At least one of which reversed an earlier position against circumcisions?

And as far as respect vs allow, you have yet to address the parent's legitimacy weighing infection risk reduction above the harm from loss of the foreskin. My issue is with your judgment that such a parent value doesn't rise to the level of "medically indicated". It bothers me you would say that to parents who might have lost a previous child to infection.

[JJM 777]

But some of them really do think that they are conferring a medical benefit. Equating them with rapists and child-abusers does not strike me as a good way to open a dialogue.

Look, I get the frustration.
There may have been remotely some dim sense in the allegory, though.

Some time ago I read the interview of a Russian woman who spent five years in Sweden as the victim of human trafficking, forced to do you know what profession.

Knowing that there are tens if not hundreds of thousands of young women in this situation across the western and eastern world, we might ask why the customers -- millions of quite ordinary men of the mainstream society -- participate in the business by buying the services.

This interviewed Russian ex-victim said that many of her "customers" seemed to earnestly believe that they were doing a favour to her, giving her the chance to earn money.

In the same mindless sense, millions of Africans earnestly believe that they are doing a favour to their daughters by getting them circumcized.

Many also earnestly believe that amputation of the foreskin is a favour to their baby boy.

This discussion will never end I guess, but at this point it would be interesting to hear the voice of the amputees themselves: any statistics available about the thoughts and feelings of circumcized men generally?

I guess most of them are quite perfectly happy with their lives.

[Skeptic Ginger]

The only reason to use the term amputation (http://en.wikipedia.org/wiki/Amputation), JJM 777 is to make an emotional appeal. If you had a medical case, you wouldn't need an emotional appeal.

Where is the research showing more than a small percentage of men are mourning the loss of their foreskins?

[Abooga]

From your source, skeptigirl:

"In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment."

Is it not talking about circumcision or FGM? Seems like we CAN use the term amputation fairly.

The only reason you saw an emotional appeal when you read the term amputation, skeptigirl, is because of your emotional response. If you had no emotional response to it, you wouldn't have a problem with the term amputationl

[E.J.Armstrong]

Ask yourself if the practice even works, then ask yourself if it's barbaric or not. It doesn't. It is.

(Geez, EJ, something you and I agree on! :eek: )

Ivor brought up and interesting point: we have changed over the years. And while slavery, rape, and child abuse continue, their status within advanced societies has changed. You cannot buy or sell people legally, you cannot rape a woman legally, you cannot beat your child legally. we have come to understand that people have rights to and of themselves. Why is the issue of circumcision any different? Unless you're doing it for a specific medical reason, it simply should not be done.
I am glad we have some common ground.

[fls]

I completely agree with you. I will give you another example though, where nursing intervention is called for and not many doctors recognize it. It also, however, is specific to my experience.

I have been seeing workers for blood exposures for ~18 years, (17 on my own and 1 as a hospital employee health practitioner). It's rare that these exposures lead to infection, and I certainly know the medical protocols and provide the needed medical care. However, exposure to blood really has as big an emotional reaction as any medical need. Some workers are petrified, some worried about their family, and some not so much. I'd say 90% of the intervention is taking care of the emotional reaction and 10% is medical intervention. In addition, the drugs used for HIV risk are really risky in themselves. One protease inhibitor, no longer used, caused one worker's liver failure which necessitated a liver transplant.

For exposures, I'm very conservative with medical interventions and liberal treating the emotional response. I also see many workers who already went to the ED so I see what the Docs have already done. I use many more nursing skills than most physicians who tend to offer the medical interventions with these patients and really don't address the emotional issues much at all. Reassurance if not done right, often comes across as downplaying the risk the worker feels.

So do you think physicians are given an education which says, the PEP drugs in such a situation are often not needed, but addressing the exposed worker's fears is the most important intervention? Keep in mind also, this is often an ED Dr. There are a couple hospitals in this area who still refuse to do the worker's baseline HIV test, opting instead to refer the worker to a PMD the next day. Their reason? Our state law requires pre and post test HIV counseling and they didn't want to take on that task.

I think most medical care involves a mix of medical and nursing skills. I recognize that easily as someone with a nursing education which focused on nursing diagnoses and interventions. (Nursing got little credit for such skills until we figured out you had to name them and describe them.) I'd be very interested to know how much focus is given in med schools today covering those "nursing diagnoses" and whether any med school ever refers to them as "nursing orders".

I think that when doctors are taught to consider patients' emotional states, need for information, values, fears, etc. when caring for their patients, these considerations are not referred to as "nursing diagnoses". I also think that when comparing the actions of nurses and physicians working the ED vs. those working in a specialty clinic, time and priorities will lead to a difference in how those issues are handled regardless of profession. I agree that you may find that nurses are on average more nurturing than physicians, although I recognize that it's also possible that this perception is due to bias. I realize that you choose to compare disparate, rather than similar situations because you wish to emphasize differences. But that makes it unclear when those differences are due to the profession instead of the situation or other factors.

Linda

[fls]

This discussion will never end I guess, but at this point it would be interesting to hear the voice of the amputees themselves: any statistics available about the thoughts and feelings of circumcized men generally?

Could the fact that many boys are circumcised because their father is circumcised be considered a reflection of their thoughts and feelings? Most men are not in a position of dependency (unless you consider the threat of no fellatio excessively coercive ;)), unlike the women in cultures where FGM is prevalent.

ETA: The men who participated in one of the African RCT's (http://www.thelancet.com/journals/lancet/article/PIIS0140673607603122/fulltext) were surveyed about their satisfaction:

"1274 (99·5%) individuals were “very satisfied” and six (0·5%) were “somewhat satisfied” with their circumcision; one person was “somewhat dissatisfied”, and none were “very dissatisfied”."

Linda

[Ivor the Engineer]

What are you talking about? You have to have a good hypothesis and pass medical ethics committees before some clinical trial of FGM for HIV prevention. This is just getting idiotic, Ivor.

What's you hypothesis and where is your supporting evidence?

What? Cosmetic? By whose standards?

It is clear that you either refuse or are unable to understand the way I see the isue of routine infant circumcision in the developed world. However, I do understand your point of view, even though I think it is one-dimensional and rather narrow. This is something we shall just have to agree to disagree on.

[fls]

And at the risk of having you conclude if I say something I must really mean the opposite, :rolleyes: , I wasn't trying to imply that patient autonomy was some absolute. I was speculating that my nursing background did make it more likely for me to empathize with multiple values influencing the specific decision to circumcise. But maybe it is more my individual experiences than my professional background. Either way, nurses are socialized to accept patient's values and work with them as part of the nursing role.

When considering whether HawkeyeMD is unreasonably defensive, you may want to take into consideration that there is an implied "and doctors aren't" at the end of that last sentence (regardless of what you meant). You rush in to defend your profession when you see statements that misrepresent it. I don't think it is unreasonable to expect her to do the same.

Linda

[Ivor the Engineer]

Could the fact that many boys are circumcised because their father is circumcised be considered a reflection of their thoughts and feelings? Most men are not in a position of dependency (unless you consider the threat of no fellatio excessively coercive ;)), unlike the women in cultures where FGM is prevalent.

Linda

Yet more intellectualizing.

I could strap on a pair of prism glasses such that the world is upside down. Eventually my brain would adapt and it would be "normal", until I took the glasses off again.

[E.J.Armstrong]

The only reason to use the term amputation (http://en.wikipedia.org/wiki/Amputation), JJM 777 is to make an emotional appeal. If you had a medical case, you wouldn't need an emotional appeal.

Where is the research showing more than a small percentage of men are mourning the loss of their foreskins?

Euphemism is the last refuge of those who are not prepared to accept the reality of what they are proposing.

Non-medical circumcision of male babies is amputation. See http://www.informedconsent.org/circumcision.html. A part that does not need to be amputated has been amputated.

As the amputation is not necessary on medical grounds it is being done for the cosmetic preferences of the parent. That can be accurately described as genital mutilation of a defenceless infant.

From Wikipedia "Mutilation or maiming is an act or physical injury that degrades the appearance or function of the (human) body, usually without causing death.' Foreskin amputation degrades the appearance and many say function of an important part of the human anatomy.

An infant cannot defend itself from nor give permission to the amputation.

To paraphrase a famous english person 'unconsented amputation by any other name is still unconsented amputation' no matter how much it is wished otherwise.

[Ivor the Engineer]

From your source, skeptigirl:

"In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment."

Is it not talking about circumcision or FGM? Seems like we CAN use the term amputation fairly.

The only reason you saw an emotional appeal when you read the term amputation, skeptigirl, is because of your emotional response. If you had no emotional response to it, you wouldn't have a problem with the term amputationl

I think you've hit the nail on the head, Abooga. The reason for the incessant intellectualizing is a way to avoid having to feel.

Let's face it, to acknowledge that the tiny benefit provided by routine infant circumcision in the developed world at the ethical cost of the violation of the child's human rights is not justifiable must be quite emotion-provoking realization to come to. Hence they appear to have significant psychological defenses to prevent this from happening.

They prefer to ignore the ethics and focus on the tiny benefit to avoid having to feel and provide ridiculous reasons why every other form of (legal) child mutilation that goes on round the world which they consider wrong is different to their chosen variety.

[Emperor]

I have been lurking in the shadows and have read through and followed this entire thread, and I feel that now is a good time to emerge and offer input on this issue from a perspective that was only briefly touched upon -- Foreskin Restoration.

To begin with, I am a 31 year old American male who underwent RIC (Routine Infant Circumcision) as a newborn. From briefly speaking with my parents on the issue not too long ago, I understand that they were not asked about it and it was done automatically without their knowledge or consent. I never really thought much about it growing up, and only began to thing about it after getting married to my wife of now over 10 years.

Being from Mexico originally, she grew up in an environment where RIC was not performed (to my knowledge), and always viewed the intact penis as normal. I have the honor of being her first and only sexual partner, and years ago she expressed to me how attracted she was to the sight of intact penii and how erotic she found them to be. Over time, and especially over the last few months, I thought heavily about what it would be like to have a foreskin, and upon doing some online research came across a few sites and forums dedicated to foreskin restoration.

After reading about the differences and benefits of restoring, from both articles and input from various forum users, I decided to pursue restoration of my own foreskin. I am now using one of the devices on the "market" (not really a market, but I digress) and we both look forward to the results. It is, unfortunately, a lengthy process (a dedicated 2-3 years or more), but I believe it will be well worth it in the end.

Now, to hopefully shed some light on the issue of cut vs. intact, I shall address various points brought up in this thread...


First of all, on the subject of what exactly is lost with most circumcisions, and other unfavorable issues that "arise" (no pun intended.... well, maybe a little pun) from this:

- It is not simply a "little flap of skin" that is lost. In general, the total skin area missing from a fully grown adult who was subjected to RIC is about the size of a 3x5 index card. This removed area of skin does in fact contain many thousands of nerves that enhance sexual pleasure.

- The Frenulum, which "anchors" the foreskin in place and is extremely erogenous. Now, many people do have part or almost all of the frenulum remaining after Circ (I have just about all of mine, thank goodness), however it does usually sustain quite a bit of damage.

- The "ridged band", which helps to hold the foreskin closed and is said to be almost as sensitive and erogenous as the frenulum.

- Inner foreskin/mucosa - This varies greatly between circs, some are left with very little, and yet others (like myself) are left with a good amount. But this tissue is very sensitive and erogenous.

- Keratenization of the Glans and remaining inner foreskin - Since the glans and inner skin is no longer covered and protected, it changes from a moist internal membrane to a "dried-out" keratenized organ. This happens because of the body trying to protect the glans and skin, and the result is a loss of sensation due to the keratenization.

I know many people in this thread have said that "they're plenty sensitive enough" and they don't believe they've lost anything, but it is true that a normal, moist, unkeratenized glans is more sensitive and responsive than its circumcised counterpart. I know a study was posted earlier regarding "sensitivity tests" between cut and intact males, however I will address this point further in a bit...

Unfavorable issues that are commonly experienced include:

- Extremely tight shaft skin due to a very tight Circ, sometimes so extreme that it results in tearing during erection/sexual activity.

- The scrotum being drawn up during erection due to a tight Circ

- Hair on the shaft, causing discomfort for the partner.

- Curves, twists, and a loss in maximum length and girth due to the missing skin and tightness of cut.


Now, on the subject of pleasure and sensitivity:

- As I said above, a normal Glans is more receptive and sensitive to pleasure and other stimuli than a keratenized one. The layer of keratenization does inhibit the nerves to some degree. Regardless of the afforementioned study, this can be verified by those people who have restored some or all of their foreskin, because one of the benifits of foreskin restoration is the de-keratenization of the glans and its return to the normal, moist state of being an internal membrane! With this, they experience a very large increase in sensitivity, resulting in more pleasure, better and stronger orgasms, and overall better enjoyment of sex. As an FYI, the glans will eventually dekeratenize when it is covered all of the time again. The body is pretty smart sometimes! =)

- Regarding pleasure from the skin itself, one of the biggest things that is taken during circumcision is what is known as "gliding action". This is what occurs as the foreskin (skin-tube) moves up the shaft and over the glans during sexual activity. This is something that increases pleasure for not only the man, but the woman as well. Many women have an issue with painful intercourse, or needing a never-ending supply of lube, or pain after intercourse. This is what generally happens with circumcised partners. Many of these same women, upon having sex with an intact male, see all of these problems disappear completely! Lube also becomes a thing of the past for the most part, because the gliding action of the foreskin allows the shaft of the penis to move in and out of the vagina through the skin itself, rather than sliding agaist the vaginal walls, virtually eliminating the friction that requires lubricant to solve. Many women also report a greater "tenderness" and sense of "closeness" with their intact partners as their partners no longer have to "jackhammer" them to acheive climax.

Circumcised men feel plenty of pleasure (as I personally know), but intact men have the potential, and the "equipment" to feel much much more, as has been shown by the restoration community and as I have PERSONALLY experienced, even though I am only beginning the restoration process.

On the subject of cleanliness/cheese/smegma/etc:

- Everybody should be keeping their genitals clean, regardless whether you are cut, intact, male, or female! All an intact person needs to do is pull their foreskin back to clean properly, and it will never be a problem. Children whose foreskin has not naturally retracted on its own yet do not need to retract for cleaning, as no dirt will be getting/forming in there. NEVER MANUALLY RETRACT A BABIES/CHILDS FORESKIN, if it hasn't done so naturally yet, because yes, that specific event could open the door for infection.

- I cannot honestly understand how any woman could *ever* try to justify circumcision based on an intact man's potential for "uncleanliness", or criticize intact men based on that potential. Do you realize how absolutely disgusting you would get down there if you did not clean properly? All of the "cheese" that you thing is so gross about intact men is something you yourself will get if you do not clean!! Does that mean we should "circumcise" you by removing part of your labia to avoid "cheese buildup"? This is a pretty hypocritical stance for a female to take, IMHO.

- While I'm on cleanliness I might as well bring up infection risk, both to men and women. Now, Skeptigirl, you seem to be focusing on UTI as the biggest reason to circumcise. I know you have posted a boatload of studies throughout the thread, so if I missed it, I apologize in advance, but can you show me any studies or reports indicating that there is an epidemic of UTI issues with newborns/children in modernized countries that do not circumcise? Because honestly, I have never heard of UTI's being an issue across the pond or anywhere else for that matter. Also, some people mention Cervical cancer being higher in women whose partners were intact. This again is something I have never heard of... there doesn't seem to be a rash of women in non-circumcisional countries dying of this cancer. Regardless of *potential* for disease/infection by leaving newborns intact, there really doesn't seem to be an actual problem anywhere in the world. Please note that I am not speaking about HIV/AIDS in Africa, as I feel that is a different issue altogether.

On the subject of visual appeal:

- I know it has been stated in this thread already, but it bears repeating -- It really does seem to be based on what you grew up around, and what kind of society you live in. It's possible that the majority of American women find an intact penis to be "gross" and "ugly" and not erotic. However, head over to Europe and the exact same sentiment will be found regarding circumcised penii. Not even Europe, since as I had mentioned before, my Mexican wife finds intact penii much more appealing and erotic.

Now, to summarize:

The foreskin really does have a function, and serve a purpose. It allows for greater sexual pleasure for the male, and it also allows for greater sexual pleasure for the female partner, for the reasons described above. That is its function -- better and easier facilitation of sexual activity.

Foreskin restoration will not bring back some of what was lost, e.g. the Ridged Band. However, when restored, the penis will look virtually indistinguishable from a natural intact penis, it will return "gliding action", and it will return the Glans and Inner foreskin to its natural state as a moist membrane, all helping to increase sensitivity and pleasure greatly. Remember, this is not based on studies or tests between intact and cut males, this is based on the first-hand experience of those who are restoring/have restored (myself included).

In closing, as I grew up most of my life not really thinking about cut vs. intact all that much, it never really bothered me. After learning about the foreskin, foreskin restoration, and actually beginning the process myself, I do honestly feel like I was robbed and cheated out of something that I would have cherished greatly. I am not filled with anger and rage and looking to sue the pants off of the hospital I was born in, but I believe it is wrong, so very wrong, to perform this operation on an infant. I am not an anti-circ activist, but I will never subject any children I have to this.

For now, I am thrilled that I can restore my foreskin and get back much of what was taken. That is my focus. I will, however, do my part when necessary to help educate people on the topic of circumcision. Whether they will throw down their bias and listen, though, is strictly up to them.

I hope this (long long long) post has been helpful, or at least entertaining, and I look forward to any replies that I may receive.

[Abooga]

Awesome post Emperor! Good luck with your restoration!

Some will dismiss your post as "anecdotal evidence" and refer only to "proper" studies, but I think the pro-cut studies have to be taken with a grain of salt. I don´t have the time nor the expertise to evaluate those studies that point to positive autcomes of circumcision or deny the loss of sensitivity. But comparing the power of the religious lobbies (2 main religions!) to the almost inexistent "anti-cut" activists, and knowing that studies can be manipulated...