Re: I Guess I'll Post It . . .

First of all, I'm kind of amazed and shocked at the number of comments I did receive on my last post. I kind of assumed no one really cared because it's fairly technical and has a message that people may not agree with or don't care one way or the other. Now, before I continue with this post, I'd like to mention two things:

1. Everything, even "fact," is potentially open to interpretation. It's very difficult to present anything in such a way as to minimize the number of permutations that it can be read and interpreted. I can look at one study and its data and still remain skeptical, whereas another person (equally or more qualified) can read the same study and data and be convinced of its accuracy beyond any shadow of a doubt. I always endeavor to write my more . . . technical posts very carefully, and there should be nothing to read "between the lines." I try to limit the number of ways my words can be interpreted (or misinterpreted). That said, I acknowledge that it can still happen despite my carefulness.

2. Anon MD, did you lie to me?! If you're an epidemiologist then you must surely be Anon MD, MPH at least (if not Anon MD, PhD or Anon MD, DrPH)!! This'll be interesting. :-P

Now, on to the rest of the post.
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This post is in response to Anon MD's comments on my last post. Always the "devil's advocate" to my posts, sometimes I wonder if he's (or she's) secretly trying to pimp me. But no matter, such comments are definitely welcomed and force me to think and refine my words, and that kind of makes my brain tingle. o_O Anon MD's comments (and my responses) are as follows:

"As an epidemiologist myself, I find your comment that the fact the studies were conducted in Africa negates their applicability to the United States. Do cigarette smoking studies in England only apply to England? Absolutely not. The fact is a randomized trial confirmed the impact of circumcision. At this point, given the size of the effect, I doubt any further trials, in the US or elsewhere, would be considered ethical. It's about time those opposing circumcision (and I won't read motives into their advocacy) acknowledge that the data suggesting circumcision is protective from HIV are compelling. After all, the data are pretty compelling."

A cigarette smoking study in England applies better to the US than parts of Africa, because England and the US are more similar to each other than England and (most of) Africa. That said, smoking studies have a long history spanning decades that is verified by similar studies done in various parts of the world. So it is very well-established, and it took many years of research to effect a change.

I admit I haven't read all the African RCT papers on this subject, but I have read the Bailey et al. paper in The Lancet (2007). It reported a 60% relative risk reduction but the absolute risk reduction is 2.1%, with 25 more HIV infections in the control group (uncircumcised). Furthermore, the paper's wording leads me to believe that the intervention group (circumcised) had a "delayed start," as they were instructed to refrain from all sexual activity for 30 days rather than specifically instructing "all participants" to refrain. The intervention group also had slightly higher loss-to-followup (not statistically significant). Lastly, it's impossible to blind the participants due to the very external and visible nature of the procedure, though this is a limitation of any study of such nature.

The data may be compelling but they don't seem as compelling in a clinical setting in the US, at least not to me. In an adult man at high risk from contracting HIV via heterosexual sex (or in a high-risk country), I can understand circumcision being a consideration. But I believe that the 2.1% absolute risk reduction becomes almost vanishingly small in a country like the US, where the HIV transmission patterns via sexual intercourse is still highest amongst men who have sex with men (MSM), which numerous studies have suggested circumcision has no significant effect.

"You'll also find that many, if not most. of the things you do as a physician are backed by far less data indicating their efficacy than the data on circumcision and HIV infection. Do you plan to not practice the standard of care even if there's data to support its use? Or if the data only come from Europe, Japan, Africa, etc? I doubt it. After all, there's precious little data to show that coronary care units are efficacious, but they used in almost all cases of heart attack. If there were a trial showing the efficacy of coronary care units in Uganda, say, would you be as skeptical about the use of coronary care units in the US?"

Yes, many things in medicine don't have evidence-based medicine to back it up. It's scary that patients are even willing to put their lives in our hands with so little science to support us. That's why medicine is an art and not a science.

The issue here is that I was responding to an article advocating that US pediatricians push for routine neonatal circumcision to reduce HIV infections in a low-risk country where sexual transmission is still primarily via MSM, not an article advocating voluntary adult circumcision to specifically reduce the chances of contracting HIV via heterosexual sex in a high-risk country where condom use is abysmally low. It is one thing, ethically, to circumcise an infant who is unable to consent; it's quite another to circumcise a competent and consenting adult.

It is my personal philosophy that all surgical procedures only be performed when necessary and alternatives have either failed or don't exist. Furthermore, whenever possible, a conservative treatment plan should be preferred unless the patient him/herself desires something more radical/aggressive. I clearly won't be a great surgeon, emergency physician, or oncologist, and you may very well disagree with me. But it stands that there is no medical need to recommend/push for routine neonatal circumcision in the US. It hasn't significantly impacted STD rates in the past, and it's highly unlikely to do so in the future.

I know nothing about coronary care units, so I'll take your word for it until I learn about it. :-)

"Let's change the situation to AZT. When AZT was first available, there was less data to support its use than that for circumcision, and the data were from the US, nowhere else (and there's never been a randomized trial of AZT in Africa). AZT does nasty things to bone marrow and liver, so unlike circumcision, it has significant risks associated with its use. If you were a physician in Europe at that time, would you insist on European data before prescribing AZT for your AIDS patients? What about if you were in Africa? If you prefer, we can shift the discussion to chemotherapy for lung cancer or a variety of other conditions with prognoses similar to AIDS when AZT came out--and the risks to the patient are far greater than those of circumcision."

I believe the situation in my argument is not applicable to the AZT situation you mentioned. AZT is a treatment, not a prevention. And outlined in my belief above, in the case of HIV/AIDS or cancer, the alternative to treatment is death; so AZT (or chemotherapy for cancer) is the only route to go. I believe there were no other effective HIV drugs before AZT, so truly it was "something better than nothing." With prevention, there are often many tools available with limited funds to allocate.

The American Academy of Family Physicians (AAFP) - position reaffirmed in 2007 - cites a complication rate range of 0.1% to 35% for circumcision. I don't know about AZT, but 35% as a possible high end is really high (even if most of the complications are minor). Deaths were estimated to occur about 1 in every 500,000 operations.
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I hope my central argument is abundantly clear by now.

I am against routine neonatal circumcision in a country like the US where any potential positive effects are minimal at best. It's perfectly fine to offer circumcision as a possible prevention to a consenting adult at high risk of contracting HIV via heterosexual intercourse. But as far as the US is concerned, I believe that better safe sex behavior education can go much further.

Again, it's difficult to definitively say that there will not be a cure or vaccine for HIV in the next 15-20 years. So in that time, why not be conservative in this manner and leave infants as they were born? If one was circumcised as an infant and wishes he wasn't, tough luck and too late. But if a man needed/wished to be circumcised, he can always have it done. What would you say to the former individual?

---Edit 1---

"Yep, there's a MPH there, too. I'm not big on posting degrees. As for the absolute risk, you're correct, it's not that large. Then again, how large do you think the risk of lung cancer is? In absolute terms, it's not large either. That doesn't mean that one doesn't take measures to prevent it. As for a 60% risk reduction, having lived through the early years of the HIV epidemic, when the gay/bisexual viewed the advice to use condoms to prevent the spread of HIV as some sort of faschist (sp?) plot, I'll take whatever risk reduction I can get. There's a new generation of gay/bisexual men now coming into adulthood who, unfortunately, weren't even alive when HIV first struck, and many of whom one again view condoms as a heterosexual plot against them. If circumcision were to interrupt viral transmission even half as much as the African data suggest, wouldn't that be a sufficient reason to recommend circumcision in the US? Or are you willing to consign thousands who are unwilling to use condoms to becoming infected simply because of quibbles about data and concerns about the aesthetics of circumcision? I know I wouldn't. Who knows, the life that's saved may be your own."

I don't remember the absolute risk reduction for lung cancer (I assume you're talking about smokers vs. non-smokers). However, numerous studies have indicated that smoking has other detrimental health outcomes other than just lung cancer, some of which may have a higher absolute risk difference (I don't know, as I haven't looked into the numbers).

You give the example of the gay/bi male population. However, it's been repeatedly emphasized that those Africa RCT studies were only done on a male population who (as far as the researchers know) only engaged in heterosexual intercourse. And several studies (done in the US and Australia) have demonstrated no significant risk reduction in HIV rates in the gay/bi male population with regards to circumcision status. Therefore it can be assumed, for now, that circumcision confers no protective effect for MSM.

Again, I'm not opposed to an adult male who elects to get circumcised to reduce his personal risk of contracting HIV (or a health care provider recommending such an intervention for a high-risk individual, or practicing medicine in a high-risk population). That is their own personal autonomy that's to be decided between the individual and his physician.

What I do have a problem with is a blanket surgery to be pushed on all neonatal individuals of a given gender, just by the biological nature of their bodies. You may want to note that while there are mass male circumcision programs in Africa to (hopefully) reduce HIV rates, none of them are targeted to male neonates. No medical organization in the world is (or even thinking about) advocating routine neonatal circumcision, except in the US (if I'm wrong, prove me wrong with a source). What does this mean to you? Is the US somehow better/smarter/more aware than the rest of the world?

Now, there are limited funds in health care, so it must be allocated carefully. Hypothetically, let's say there's a pool of funds that go towards HIV prevention. Money going towards circumcision is necessarily taken away from money going towards condom promotion and safe sex education. In this scenario, circumcised men grow up and are less likely to use condoms because they've been told they're "protected." Meanwhile, uncircumcised men are stigmatized as being dirty, easier to infect, and are repeatedly told that they must use condoms because they're more vulnerable. What do you see as the long-term outcome? It's a very small step to from telling someone that he has a reduced risk of getting HIV because he's circumcised to that individual thinking he's "protected" from HIV and can get away with using condoms less frequently. It may already be beginning to happen in Africa, read this article.

I don't believe my views are consigning the thousands who refuse to use condoms to becoming infected. I will not stop anyone from desiring (or needing) to get circumcised himself. But the procedure does not, and personally I believe it should not, be carried out on minors without medical need or perhaps for religious reasons.

---Edit 2---

"Anon MD here. For Biki, there's an MPH and an MS, as well as a couple of other degrees. I'm surprised that matters so much to you.

As for the comments on the means of transmission, actually, in Africa, while there is a bit more male-female transmission of the virus, there is a lot of male-male transmission too. A lot of the latter are not included in anything close to a governmental document, since gay sex is illegal/heavily stigmatized in many African nations. After all, until 2 years ago, South Africa didn't even acknowledge HIV as the virus causing AIDS.

I must say that the only argument that's been put forward on this blog (and many others on this topic) is an asthetic one. No one has suggested the African studies were biased or that circumcision doesn't impact on risk of HIV transmission. The question--and it should be the only question--is whether the risks of circumcision outweigh the benefits. With all the comments given thus far, no one has put forward a viable claim that those risks do in fact outweigh the benefits. When I see/hear one of those arguments put forward, I'll comment on this topic again. In the meantime, I will refrain from further comment on this topic, and the comments are too reminiscent of the Reagan Administration's approach to HIV. Very passive. Oh, and by the way, for all the talk about condoms are a means of preventing spread of the virus (and I have no qualms with those data), take a look sometime at condom use rates among gay teens and young adults. THat's the thing about circumcision--one time, and it's there to reduce risk for life. However, if a gay teen or young adult isn't going to bother with condoms, then condoms don't do very much to reduce risk, do they?"

To address your first question, I believe both Biki and I were merely curious. If you misread that comment/question as anything more, on behalf of both of us I apologize.

For the rest of my response, I have to ask you: how carefully have you read my arguments? From your responses, I can only assume that you are quite busy (understandably) and don't have the time to read my rather lengthy and detailed responses beyond only skimming them.

Now, I hope you meant to say "female-male transmission" rather than "male-female transmission," as the study only specifically measured the former and I did not address the latter. As for male-male transmission, it's undeniable that it's occurring in Africa (just like anywhere else), but there's no data on it and it would be presumptuous to say that the African RCT studies were somehow able to measure/account for it. Again, as I've pointed out above, there have been several studies that suggest that circumcision offers no protection against contracting HIV to individuals who engage in MSM. I haven't seen one study that definitely says that circumcision (significantly) reduces HIV infection rates in the gay/bi population. If you find such a study, please let me know.

This may be an instance of misinterpretation of words, but I truly fail to see how my singular argument has been an aesthetic one (or rather that I've only had a single argument). I made no mention to aesthetics and as I prefaced this post, if I don't specifically and overtly write it, assume I'm not arguing it. Please cite sentences from my post that you felt have been argued from an aesthetic point-of-view, and I will rectify them.

As for the comment on whether anyone has suggested that the African RCT studies were biased, I believe there were a couple commenters who addressed that. Also, I did briefly mention that the patients in those studies weren't blinded (because it's impossible to do so, and this may have influenced the outcome). Furthermore, I've read that the participants in the study were all either willing or desiring to get circumcised anyway, so that seems to be potential selection bias right there - which could be a serious study design flaw. Again, I believe I've made myself clear that I don't believe circumcision will significantly impact risk of HIV transmission rates within countries such as the US.

I have also addressed the risks of circumcision in my posts (this one and last), albeit not fully. For example, meatal stenosis (I apologize for not pulling up a study) has been estimated to occur in as high as ~10% of circumcised infants. If left untreated, this can definitely become quite risky and even life-threatening. I have even read that some pediatric urologists almost specialize in correcting errors from circumcision. You may be interested to read one such account here. I can't imagine what kind of physical, emotional, and psychological pain those children and their families must endure.

As for your last point, I must reiterate that no studies have shown that circumcision makes any difference in male-male transmission of HIV. So foreskin status is irrelevant (given current data) for the gay/bi population. Your argument is insufficient. A gay teen/adult can always elect to get circumcised. I have never argued against that. But it need not be done in the neonatal/childhood period, where the individual can't consent to a medically unnecessary operation. Rather than presenting a false sense of security with circumcision, I still believe the money that would've went into funding that operation would be better utilized in condom promotion and (comprehensive) safe sex education. Has this not worked for Europe, Thailand, and now (I think) India?

I've responded to your questions point for point, when will you answer mine? :-P