Tuesday, January 13, 2009

"So what?" I Hear You Say

That was something my pathophysiology professor said when he started lecturing on something he thought we thought was unrelated to whatever we were being lectured on. It was followed by "Eh hreh, I hear you say" when he explained how it was, in reality, related.

So I figure I'd address the poll I put up ages ago (and ended seemingly ages ago as well) and hit that "So what? I hear you say" wall. I'm not sure I'll get to the "Eh hreh, I hear you say" epiphany. We'll see.

The question was: "Dear reader, where are you from, and are you cut/uncut/a girl?"

The results were:
  • 29 US - cut
  • 13 US - uncut
  • 0 US - girl
  • 6 non-US - cut
  • 21 non-US - uncut
  • 3 non-US - girl
So, percentage-wise for male responders: about 69% of US guys are cut, 31% of US guys are uncut, 22% of non-US guys are cut, and 78% of non-US guys are uncut.

This isn't actually that far off from "actual real world" proportions of the two figures. I think I've read something like, about 75% of all guys in the US are currently cut (my numbers are skewed, likely due to younger readers who're less likely to be cut) whereas only about 20-30% of all guys in the world are cut. It is interesting to see that the two numbers are almost the same but flipped.
I may get majorly flamed for what I'm about to say, but to challengers I say "bring it."

A few weeks ago I read an article that made my blood boil. In a nutshell, the article asserts that circumcision rates in the US are too low, that Medicaid in states that no longer cover the procedure should cover it again, and that it's a valuable public health tool. Current national circumcision rates (with tons of regional variation) is at about 56% for guys being born right now, and it continues to decline overall. "So what?" I hear you say.

The article was very poorly written and could lead to misinformed decisions. There is NO real reason why non-therapeutic circumcision (circumcision that isn't medically necessary) should be covered by health insurance. At all. Almost all circumcisions (in the US and globally) are chosen electively and thus non-therapeutic. Now, I'm not a doctor (yet) or an epidemiologist, but I think I've enough "training" to argue my point reasonably well. I'm arguing that circumcision is medically unnecessary as well as an unnecessary cost from a medical/public health perspective, at least as it applies to the US.

Note: I'm not arguing whether cut or uncut is "better" on aesthetic, personal, ethical, legal, or socio-religious grounds. Some of those are largely un-arguable, at least from any truly logical perspective.

In a brief overview, the reasons are as follows:

1. The assertion that circumcision may reduce the risk of getting HIV by 50-60% in heterosexual men is misleading and overstated, even if it's true. In the Bailey et al. paper, 25 uncircumcised men who became HIV-positive accounted for the 60% statistic (22 cut and 47 uncut men got HIV out of a sample population of 1391 and 1393, cut and uncut respectively); the risk to an individual is 2.1% higher for uncut guys in the Bailey et al. paper. In addition, the studies that arrived at that figure has been bombarded with valid (and invalid, lol) criticisms challenging its methodology, external validity (and thus generability), and application to public health. Additionally, the results of these studies haven't been replicated anywhere outside Africa and there are studies that suggest circumcision status makes no difference in reducing the risk of getting HIV in gay/bi men.

2. The assertion that circumcision reduces the risk of getting any STD is completely unfounded. For every study that says it does, there's a study that says it makes no difference. Condom use and monogamy trumps circumcision at every turn.

3. The above two assertions do not reflect trends in other Western developed countries where circumcision prevalance and rates are much lower, and also where HIV and STD rates are also much lower. It's probably because they use condoms more and actually practice safe sex; gee, how about that. Furthermore, no medical body in the world (not even in the US) supports routine non-therapeutic circumcision on medical grounds.

4. The assertion that circumcision lowers the chances of getting a UTI (urinary tract infection) in the first year of life is overstated. While this may be true, the risk of a UTI in uncircumcised infants is 1% at most, and much lower infants who're breastfed. Additionally, females have a much higher risk of UTIs throughout life (at 5-7% or something), yet there's no "intervention" on their behalf.

5. Circumcision is not without risks, just as with any surgical procedure. In most cases the complications are minor (infection and excessive bleeding) but gone unchecked could become life-threatening. Severe complications have been well-documented, included deaths. Unfortunately, there have been a lack of studies into the rates of complications arising from circumcision, so the true number is unknown but conservatively estimated at 0.5-2% in the US (conservative = at least). Also, in several studies, the complications of circumcision weren't reported as being a result of the procedure, so the rate may be higher than the estimate just given (some say closer to between 2-10%). Treating complications is terribly cost-ineffective.

6. Most problems with the foreskin are easily (and cheaply) resolved by non-surgical means. Circumcision is just an added cost to the health care system (and money in someone's pockets). US physicians are poorly trained to handle foreskin problems, and have tended to "default" to circumcision.

7. Circumcision is painful to infants and until very recently (within the last decade), analgesics/anestheics were rarely used. Those painkillers are also an additional cost to the health care system.

So that's that in a nutshell. I had begun to write a full detailed elaboration on each of the points, but then realized it'd end up taking me until tomorrow morning (if not into next week, there's that much to be said on this topic), before I finished. Questions, clarifications, etc welcomed via comments or email.


Fiction Writer said...

I'm cut and glad I am, just because I'm used to it. I'm sure I'd be just as happy with being uncut. If I were to ever have a kid, it'd be really hard to have him circumcised because I just don't think it'd be my place.

I also prefer cut guys, but again, I think it's socially grounded - 90% of the dicks I see are cut. When this is different, it won't be the expectation and it won't change the outlook of any potential girls (or guys?) of any kid of mine or anyone else's.

Anonymous said...

I like uncut. Therefore, that is the way all guys should be. ^_^

Aek said...

Fiction Writer: You point out a common reason for parents to have their sons cut, but it's still medically unnecessary. I have my opinions (that I'm sure you can easily guess at) but I won't overtly express them in this post, as that would "contaminate" my point. :)

I am glad that you would step out of your comfort zone for your hypothetical future son and not have him cut. I agree with your sentiment there. I'm not entirely sure what you meant in your last sentence though. o.O

James: Haha, that's your view. You force me to add the caveat that there ARE medical reasons to get cut, but it rarely gets to that point (medically). To do it without immediate need is unnecessary and a burden on the US health care system (as was the point of my post).

Steevo said...

i think cut is genital mutilation!

victor said...

ok, sorry to be posting so late in the game here. i had to do some research on this, but the whole circumcision thing came about because of a physician back in the 1870s named John Harvey Kellogg (yeah, the guy responsible for corn flakes) recommended it to prevent boys from masturbating and causing themselves to become insane, paralysed, and often ending up dead because of this horrible action. here's a link.
this was the norm until 1949, when a doctor in britain discovered that this was bogus, and
since then, almost every country, with the notable exception of the united states has stopped circumcising boys. yay for us.

Aek said...

victor: Hi! Comments always welcome. :)

I've actually heard all that before, and it's really quite disturbing for me. I believe Dr. Kellogg also supported doing the procedure without any kind of painkillers, so as to "ingrain" the memory of pain into the minds of the children to make them more chaste. I've also heard that circumcision is a "cure/treatment looking for a disease." And for its entire "medical" history, this seems to be more or less true.

When will the US learn? Times are changing, though some people are glorifying the HIV/AIDS related research on it, which is blown WAY out-of-proportion to what is realistic. Sigh.

samuel said...

I appreciate the small point you made about breastfeeding. It's amazing that the US has such issues with breastfeeding when in fact it is one the single most beneficial things most mothers could possibly do for their infant children.

There is some sort of irony in the different views of circumcision and breastfeeding. In the case of circumcision many people have it done to their children for the most ridiculous of reasons such as wanting the child to resemble the father. At the same time people can get so enraged over the chance that they might see the merest hint of the side of a boob while a mother naturally feeds her small child.

Aek said...

samuel: Yeah . . . I hear you don't get such things in Europe. Another thing of note is how ridiculous violence in games is okay, but throw in a little sex/nudity and it's a huge no no. In Europe (again, so I hear) this is reversed.

Makes one think what the true feelings of a culture are. Aesthetics vs. function? Violence vs. sex? Ridiculous reason for the lose.

Doomed But Cheerful! said...

Circumcision - genital mutilation - child abuse - patriachic control - call it what you will, if it's a procedure without medical need, it should be outlawed, and medical practitioners struck off that do it without good reason.
If you ever saw an Australian aboriginal circumcision (using shell, or old razor blade) you would have no compunction but to agree with me.
I am cut - and wish I weren't.
My children are as they were born.