Wednesday, September 5, 2012

Treatise on a Cultural Truth

I wish to begin a discourse, a treatise, on a cultural truth.  That what we believe is true, correct, and accurate may not hold true across all peoples.  Given the same data and knowledge, we may reach very different conclusions - each with its own merits.  Warning: this post is rather long.

Early last week, the American Academy of Pediatrics (AAP) revised their position on infant male circumcision, stating:
"New scientific evidence shows the health benefits of newborn male circumcision outweigh the risks of the procedure, but the benefits are not great enough to recommend routine circumcision for all newborn boys."
It is a shift from the AAP's neutral stance that had been reaffirmed since 1999.  The statement was revised by a committee that had reviewed the medical literature on the subject for the past decade.  This is in stark contrast to a German court in Cologne that essentially banned non-medically indicated circumcision, and you can read my thoughts in my post here.  To me this contrast highlights one of the age-old questions: "What is truth?"  Is truth objective or subjective?  Is it an immutable reality or something malleable to our perspectives?

The BBC News wrote a nicely balanced article, Circumcision, the ultimate parenting dilemma, comparing and contrasting how the US and Europe have approached this topic, looking at the same medical literature, and coming to polar conclusions.  Whereas the AAP has move more "pro-circumcision," the Royal Dutch Medical Association maintains its neutrality (if not slightly "anti-circumcision") stance.  At the end of the day, despite the science and the medicine, it would appear that the decision is decided upon a cultural truth.

Around the same time as the AAP's new guidelines, Dr. Tobian et al. - the same Dr. Tobian of Johns Hopkins who conducted one of the African trials that linked circumcision status to lower HIV infection rate - released an article titled: "Costs and Effectiveness of Neonatal Male Circumcision."  Instantly news stations ate up that press release, with news titles such as:

All worded rather strongly with words such as "will go up" or "will spike," suggesting an objective immutable truth to the study.  So what did the study report?  It says that if the US infant male circumcision rate continues to fall and fell to 10% (the approximate rate in Europe), the following could occur:

Lifetime health care costs per man: increase by $407
Lifetime health care costs per woman: increase by $43
Net expenditure for the US health care system per year: increase by $505 million, reflecting an increase of $313 per male circumcision not done
Net expenditure for the US health care system over 10 years: increase by over $4.4 billion

Lifetime prevalence of HIV for men: increase by 12.2%
Lifetime prevalence of HPV for men: increase by 29.1%
Lifetime prevalence of HSV-2 for men: increase by 19.8%
Lifetime prevalence of Infant urinary tract infections (UTIs) for men: increase by 211.8%

Lifetime prevalence of bacterial vaginosis for women: increase by 51.2%
Lifetime prevalence of trichomoniasis for women: increase by 51.2%
Lifetime prevalence of HPV for women: 12.9-18.3%

Those are big numbers, fighting numbers.  But they are potentially misleading numbers.  First of all the calculations based off of prevalence is, in my opinion, disingenuous.  Prevalence is the total number of people in the population with the disease at a given time.  The incidence rate is the number of new people contracting the disease within a time period.  The prevalence for a disease such as HIV, HPV (genital warts or cervical/anal cancer), or HSV-2 (herpes) will always be higher than the incidence rate.  Why?  Because people are living longer with those diseases, and they're considered "chronic," so the prevalence will always increase even if the incidence rate falls.

Second, the study fails to compare/contrast incidence rates between the US and Europe.  It instead falls on relying on data from the African trails on HIV and other sexually transmitted infections (STIs).  When Tobian was interviewed and asked about comparing the US to Europe, the article states:
"It is too difficult a comparison because "we have very different racial and socioeconomic backgrounds and different transmission dynamics," he said."
Wait a second there.  Tobian et al. used data from Africa, where racial and socioeconomic backgrounds and transmission dynamics are clearly more different compared to the US than Europe compared to the US.  Didn't he just invalidate his study, in some sense?  So what is the comparison between the US and Europe?

Europe (overall): 143 cases per 100,000 people (2000) to 332 cases per 100,000 people (2009)
US: 405.3 cases per 100,000 people (2009) to 426 cases per 100,000 people (2010)

Europe (overall): 16.8 cases per 100,000 people (2000) to 11.7 cases per 100,000 people (2009)
US: 98.1 cases per 100,000 people (2009) to 100.8 cases per 100,000 people (2010)

Europe (overall): 6.6 cases per 100,000 (2004) to 7.8 cases per 100,000 (2010)
US: 16.3 cases per 100,000 (2010) - CDC's website wasn't too user-friendly for finding info

HPV and herpes aren't tracked as closely and are difficult to track because of a latent asymptomatic phase.  But the US CDC cases seem to be overall steadily trending up, though herpes appears to actually have had a steep decline in the past 2-3 years.

As you can see, the US has higher incidence rates of all STIs, including HIV, compared to Europe.  At first glance, most of the STI rates in the US are either stable or slowly trending up at a rather consistent pace since the 1960s or so.  As infant male circumcision rates have decreased since the 1980s, one would expect to see a quicker pace of increase starting in about 1995-2000 or so (when the first cohort of more uncircumcised males reached age 15 or so).

It's true that Tobian et al.'s study is true utilizing the data he used.  But with additional data, different data, I reached a different truth.  What I see is that:
  1. the rates of STIs in Europe (on the whole, individual countries vary) are lower than in the US - and we should figure out why before resorting to cutting off a part of the human body.
  2. the velocity of increase in rates of STIs in the US aren't speeding up as the years progress, which should theoretically correspond to a decrease in infant male circumcision rates over the last 30-40 years if Tobian's assertion is correct.
  3. despite an estimated 211.8% increase in male UTIs in Tobian et al.'s study, the rate of UTIs in baby boys is still at about 1% or less (a lower rate than for females at any age).
  4. despite an estimated increase in HPV among both men and women in Tobian et al.'s study, there is now a vaccine for HPV that he likely didn't factor in (a vaccine, might I add, that has been recently FDA-approved for use in men as well).
So we must sometimes evaluate what we deem as "truth."  Even if we look at the same object we may still see it differently.  Culture can shape our truths and to evaluate our truths we must sometimes not evaluate the data, the science, the medicine, but rather the culture with which those truths are framed.  Below are some well-written challenges against the culture truth of infant male circumcision in the US:


Uncutplus said...

Thanks for an excellent post on the recently released news about circumcision. The post is both well researched and well written, without bias.

Circumcision worldwide will be argued for years to come for both religious and cultural reasons. Thankfully, I was one of the fortunate ones who was not mutilated at birth.

Readers of my blog will be linked to this excellent post! Thanks.

Anonymous said...

The AAP is full of bullshit.

If we gave every woman a radical mastectomy, we would also have lower rates of breast cancer.

In addition, did the AAP also consider the risks of circumcision itself? A botched circumcision can ruin someone's life. I'll take a higher risk of UTI anyday.

Aek said...

@Anonymous: The AAP is a credible organization with a lot of good, sound guidelines. The risks on a population scale is very small, but if you're the unfortunate one who is botched, that statistic is meaningless. The AAP didn't go as far as they could have, thankfully.