Skepticism Against Non-Neutrality

This is a follow-up to my previous post, Media, Culture, and Half-Truths.

As I blogged that post, the media in other areas were already aflame with skepticism.  To recap from my previous post, the US CDC is considering a recommendation that medical providers should discuss the benefits of circumcision and offer it to parents and any uncircumcised male teenager and young adult (particularly those in a higher sexual risk group).  This is part of the US CDC's plan to help further reduce the incidence of HIV/AIDS.

And as I blogged in my previous post, this thread of logic is misplaced and damaging.  I even posted a comment on the US CDC's Regulations.gov site.  It's open for commenting between Dec 2 and Jan 16.  The vast majority of the comments on that site are negative towards the new recommendations.  Here's an article that reflects that:

Washington Post: Americans push back against CDC recommendation on circumcision

There is also a nice and succinct article on an Oxford ethics blog, A fatal irony: Why the "circumcision solution" to the AIDS epidemic in Africa may increase transmission of HIV, by Brian D. Earp in 2012.  It basically summarizes my thoughts from my previous post (but more eloquently written).

Again, this is not a new topic of debate.  The US CDC first began considering this back in 2009, but had delayed making notable public announcements until now.  As evidenced by an article in the Huffington Post, Male Circumcision and the HIV/AIDS Myth, by Dr. Ali Rizvi.

Heck, this topic has been covered (albeit tongue-in-cheek) by Queerty!  For example:

• If Circumcision Haves Risk of Spreading HIV, Should All Baby Boys Get Cut?
• So Circumcision Won't Help American Men Stop Spreading HIV?
• Even If Circumcision Helps Prevent HIV Transmission, Good Luck Finding American Guys It Could Benefit
• For Gay Men, Cutting Off Your Foreskin Not As Good As Condoms To Keep The HIV At Bay
• What's All This About The Government Wanting American Teenagers To Get Circumcised?

And to reference my previous post, the media can write about a single topic in two ways.  Queerty is clearly on the opposite side of the articles posted in my previous post.

So anyway, read the links if you desire.  They're there.  I'm a broken record on this topic.  No more on this until the US CDC finalizes its recommendation, one way or the other.  But for the love of democracy, please comment on the Regulations.gov link above if you have an opinion you'd like to share!

Media, Culture, and Half-Truths

This is nothing new.  Just warning you now, this is going to be an epically long post.  I've read about this before and I've discussed it before on this blog.  But this topic resurfaces rather frequently.  I see headlines such as:

Reuters "Male circumcision benefits outweigh risks, US CDC says"

The Verge "Benefits of circumcision outweigh the risks, US CDC says"

Yahoo "CDC: Circumcision benefits outweigh risks"

LA Times "Circumcision cited as defense against HIV in proposed CDC guidelines"

NY Times "Circumcision Guidelines Target Teenagers"

TIME "Feds Say Circumcision Best for Boys"

This is a controversial topic.  There is intense debate among physicians and even residents.  It's a subject that's almost taboo to talk about.  So let's talk about a few things: Media, Culture, and Half-Truths.

Media

I took a course in scientific journalism and media in undergrad, and I walked away from that class appalled.  So much so that I was literally unable to even look at a news article about a scientific or health topic without feeling an intense pang of rage for almost half a year.  Here are some things to know:

The media skews towards catchy headlines.  Sure "Male circumcision benefits outweigh risks, US CDC says" sounds pretty neutral.  But then you have the headlines "Circumcision Guidelines Target Teenagers" and "Feds Say Circumcision Best for Boys," and suddenly those pop out.

The media also has an agenda.  You are supposedly supposed to present both sides of an article (where there are 2 sides to present), but it's almost always skewed and thus almost never balanced.  Take the NY Times article, "Circumcision Guidelines Target Teenagers."  It dedicates a measly 2 paragraphs at the very end on counter-arguments, which although valid, reads as an afterthought.  Take the TIMES article, "Feds Say Circumcision Best for Boys."  There is no mention of any counter-argument.  None.  The LA Times article, "Circumcision cited as defense against HIV in proposed CDC guidelines" is actually the most balanced of the bunch.

The media doesn't understand statistics.  Now, statistics is a difficult concept for even many medical experts to grasp.  So to be fair, the media has no chance.  When presented with numbers, the media will always take the largest numbers presented.  Again, because it's catchy.  For example here, the recurrent phrase that goes "circumcision reduces a man's chances of getting HIV by 50-60%" sounds like a huge deal!  But context is necessary.  That number reported is what's called "relative risk reduction."  What matters to an individual is the "absolute risk reduction."  For instance, let's say the average uncircumcised man's risk of getting HIV is 1 in 1000 (or 0.001%).  So if he's circumcised, his risk goes down by 50-60%, thereby going from 1 in 1000 to 0.5 in 1000 (or 0.0005%).  Well, going from 0.001% to 0.0005% doesn't sound like much of a difference for that individual, and it isn't!  But both numbers could be true.  Going from 0.001% to 0.0005% is a 50% decrease - this is "relative risk reduction," but the "absolute risk reduction" is 0.0005%.  See why the media would choose to report 50% over 0.0005%?  (Note: the average man's risk of getting HIV in the US is WAY smaller than 1 in 1000).

Culture

Culture is such a pervasive and unconscious thing that few people even realize it comes into play.  The US, given his history of higher rates of circumcision, has a cultural bias towards that procedure.  Whereas comparable Western countries (Canada, Europe, Australia) don't have this cultural bias.  This is how everyone can look at the exact same studies, the exact same medical literature, and come out with polar opposite conclusions and recommendations.

Here's an excellent article rebutting the latest AAP (American Academy of Pediatrics) guideline update on this topic: "Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on Male Circumcision." 

People think of medicine and science as containing immutable truths.  Yet in reality the exact opposite is true.  We must constantly challenge and question old scientific truths in order to get ever closer to the Platonic Truths.

Half-Truths

Now on to the merits of what's been discussed/argued for in the articles.  The best quote I could find comes from the LA Times article: 

"Dr. Thomas Newman, a professor of epidemiology and biostatistics at UC San Francisco, says he believes that the medical benefits of circumcision outweigh the risks but that both are small."

This is the closest thing to the truth out there.  Let's look at the arguments on the table:

Pro:

• Circumcision reduces HIV risk by 50-60%.  Well that effect is quite small on an individual level, as illustrated above.  Plus, condoms reduces HIV risk by 90-97% when used correctly.  That "additional" 50-60% is rather meaningless.  Furthermore, circumcision offers zero benefit for those most at risk of getting HIV in the US (men who have sex with men, IV drug users).
• Circumcision reduces HPV and other STI's.  Maybe true.  But we now have a vaccine for HPV that's 98-100% effective.  And again, condoms.
• Circumcision reduces UTI's in boys during the first year of life.  This is actually true, however, the risk of getting a UTI is rather small to begin with.  In a healthy uncircumcised baby boy, the risk of getting a UTI is 1 in 100.  In a healthy circumcised baby boy, the risk of getting a UTI is 1 in 1000.  In girls older than 1 year of age, the risk of getting a UTI is like 5-7 in 100.  And how do we treat UTI's?  With antibiotics.  That said, there is a role for circumcision in a baby boy who gets recurrent UTI's (and usually there is some other anatomic problem as well).

Cons:

• Risk of complications.  I love how they kind of lumped all complications together, and then say that it's about 1% if the procedure is done before 1 year of age, 9% if done between 1-9 years of age, and 5% if older than that.  I don't know about you, but a 5-9% complications rate is pretty high.  And what are these complications?
• Infection and inflammation are a common one.  As with any invasive procedure, there is always a risk of infection.  And think for a moment, this baby's penis is healing while he's in diapers, exposed to urine and poop.  That can't be pleasant.
• Bleeding is another common one.  Well, this could be life-threatening if a baby has a bleeding disorder (like hemophilia).  I'm sure the majority of the time no one does blood tests before the procedure to confirm that a baby does not have a bleeding disorder, and often times a family history can only get you so far.
• Other risks not mentioned?  Adhesions, meatal stenosis, and accidental amputation are ones that probably should be mentioned.
• Adhesions: baby's bodies heal very well.  Sometimes parts of where the foreskin is removed will reattach itself to the glans (penis head).  This can cause not only cosmetic issues, but also functional issues.  Sometimes those adhesions are so tight that erections can be uncomfortable.
• Meatal stenosis: when the opening of the urethra (pee hole) is too small to allow urine to pass.  This problem exclusively happens in circumcised babies and requires surgical correction.  The end of the penis is not meant to interact with the outside world before puberty, and so exposure causes inflammation, which causes swelling, which causes a small hole to get smaller.
• Accidental amputations: yes, very rare, but very very tragic when it happens.  A handful of cases happen each year and it's impossible to remove this risk entirely.  It may be a 1 in a million risk, but if that 1 in a million is you or your baby, and it wasn't medically necessary, you would probably be pissed off.
• Also none of the articles mention studies that support the foreskin being a very innervated area of the body.  Whether those nerves play a role in sexual sensitivity and enjoyment is a topic of debate in and of itself, but logically it would make sense that more nerves = more sensation.

So you see, the full discussion is more nuanced.  And when I counsel parents on this topic, I present it as I do above.  Thankfully the area that I'm doing residency in has a low circumcision rate, so this rarely comes up.  But it does once every few months.  Most parents who do opt for the procedure are not undecided - it's like parents who're against vaccines, their minds are made up no matter what you say.  So I counsel towards less intervention, at least insofar as this topic goes.

Thoughts?  I know I'm biased, but again, no one has a truly neutral stance on this topic.  Which makes it difficult to fully "trust" the CDC's recommendations (or anyone's opinion, for that matter) on the subject.

Redefining the Republicans?

As we all know, President Obama won re-election and Democrats solidified their majority in the Senate, with the House of Representatives still Republican dominant.  And as much as I dislike politics, I couldn't help but read some post-election commentaries, such as this, "Christian Right Fails to Sway Voters on Issues."

The current Republican party is so far to their end of the extreme it's no wonder that they failed to win the election.  This got me thinking.  What is meant by "conservative" and what is meant by "traditional?"  These in and of themselves aren't sinister terms that should be tabooed.  Indeed, many people may consider themselves conservative or traditional but still be alienated by the current gestalt of the Republicans.

Economics

I've read that Republicans tend to favor market forces and believe in individual responsibility.  These are things that many people can rally behind.  They are less in favor of government hand-outs and give-me's, and as such are likely to be more restrictive on social safety nets for the poor or disenfranchised.  Still people can rally behind that notion when they believe they shouldn't "rely" on the government to pull themselves up or have seen others abuse the system.

Taxes
Republicans generally are in favor of less taxes on (preferably) everyone, but the current Republicans want tax cuts for the wealthy to a fault. Wealth is really a matter of perspective.  How much does one need to live comfortably?  How much does one need to enjoy life?  Yes, money is hard-earned, but taxes exist for a reason and without them, many things in society would simply cease to function.

Health Care
Republicans are united against "Obamacare."  Fine, I get that.  It's not a perfect bill.  But if you're going to attempt to repeal it, you better have a viable alternative ready to go as soon as it's gone, because the status quo isn't benefiting anyone.  Is health care a right?  Is it a basic right?  A civil right?  Is it a privilege?  Is access to health care a right?  These are philosophical questions that our society must determine.

Abortion
Alright, Republicans are generally anti-abortion.  Fine.  But I take issue when they say they're "pro-life."  They are not pro-life.  If you're going to oppose abortion, you better set up a support system for the children and mothers whose lives are affected.  If you're going to oppose abortion, you must make it okay for a single mom without a high school degree to give birth.  This takes investment, time, infrastructure, and of course money.  If you're truly pro-life, you'd campaign to have all kids vaccinated.  You'd campaign to have every child be in programs such as Head Start and Birth to Three.  You'd campaign to help single parents find jobs or tax credits for education.  You'd campaign to offer prenatal care at Planned Parenthood, not cut its funding across the board.  This is truly pro-life.  But it all costs money, and where does that come from?  Taxes.

Family
Republicans are pro-family.  But really, aren't we all?  Their problem is that they haven't kept up with what a "family" can be these days.  Yes, a family may be the nuclear family of parents and children.  But it can also be an extended family, where one lives with aunts, uncles, and/or grandparents too.  It can be a single parent home.  It can be a gay or lesbian couple.  All studies suggest that it matters less what kind of structure the family consists of, and more the love and care provided by that family.

LGBT
Republicans are against LGBT rights at large, but particularly gay marriage.  It doesn't hold much water with me from a legal perspective.  There is a difference between a civil marriage and a religious marriage.  Churches and other places of worship may refuse to consecrate a gay marriage, but that doesn't mean that the state should refuse as well.  In America where we profess to be open, accepting, and tolerant of all religions - where we believe in separation of church and state - where is all that here?  The same arguments made against gay marriage is exactly the same arguments made against interracial marriage several decades ago.

Minorities
The Republican party has a dearth of minority representation, and it has so far made little to no attempt to attract minorities.  It's really a shame.  Many African-Americans, Asian-Americans, and Latino-Americans likely agree with the Republican's economic stances and their sentiments about family.  Yet the Republicans have managed to alienate all of these groups.  Immigration reform, if done well, would begin to sway some Asians and particularly Latinos to the Republicans.

Environment
Republicans should be truer to the word "conservative" when it comes to environment.  The US has one of the greatest natural resources on the planet, and while it's something that we should tap into, it's also something that we should protect and cherish.  Investment into alternative energy would definitely open up job opportunities and drive innovation.

Education
There's a distinctly anti-education sentiment in the Republican party these days.  I do believe everyone should have the opportunity to attend college/university if so inclined.  I do believe we should invest in recruiting more people to become teachers, and to hold schools accountable (to a degree, this a very complex topic sufficient for its own post).  Teachers and their unions shouldn't be made out to be the bad guys.  It's not easy being a teacher.  If the Republicans don't do something to advance education, the US will continue to slide further and further behind.

Anyway, this post is long enough.  The point I wanted to make is that the Republican party, at its core and true to its moderate members, is not a bad thing.  But they've drifted so far from where they should be that they've become hypocritical.  Perhaps this election has kicked their butts sufficiently to see that what they're doing isn't working and will never work.

And this is a nice article to end on, "The Great Experiment."

Treatise on a Cultural Truth

The Truth by ~-nightm4r3- on deviantART

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:

LA Times: As circumcision declines, health costs will go up, study says

AFP News: Fewer circumcisions could cost the US billions: study

TIME: If circumcision rates keep falling, health costs and infections will spike

CNN: Decline in circumcisions could cost billions

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?

Utilizing the European Centers for Disease Prevention and Control (ECDC) and the US Centers for Disease Prevention and Control (CDC) data, we can see the following:

Chlamydia:

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)

Gonorrhea:

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)

HIV:

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:

Our Bodies, Our Choice: Circumcision is Not a Joke

Why Do We Still Circumcise Boys?

Why I Didn't Circumcision My Sons

The First Lady with Grace

I just got done watching the first night of the 2012 National Democratic Convention.  I was floored by Michelle Obama's speech bringing the first night to a close.  I'm also rather floored that it's already posted in its entirety on YouTube for you all to replay.

I believe it connected with many Americans in a very personal way.  It highlighted the struggles to improve one's station in life and that though it may not be realized in one's own life, it can happen through one's children or one's children's children.  It's not dissimilar to the story of my own family, immigrating from Hong Kong in search of a better life.  How my mom's family lived together in one apartment and I was cared for by all family members when I was born.  How my parents, grandparents, and uncles began on food stamps.  How my family worked its butt off to allow me, my brothers, and my cousins to be where we are today.

She tactfully touched upon all the social issues that President Obama has in some way championed - women's rights, healthcare reform, gay rights and marriage, and support for veterans.  She humanized him in a way that only she would be able to do.  She gracefully didn't lampoon the Republicans, something very refreshing to see.  It's easy to see why she's the most popular woman in the US.

I do agree with the news commentator on the TV - the Democrats have the social issues in hand, lock and step, but they need to refocus a good portion of the remaining nights of the Convention on the economic issues.  True, the economy has recovered and is growing, albeit slowly.  But they still need to bring that to the forefront.

When the Courts Intervene

These days the news are filled with stories of various laws, bills, and practices brought before the Courts system.  It must be difficult to be a judge, to sit in a position of logic when so many of the arguments brought forth are ones of emotion.  And when it may at first appear that the Courts overstep their boundaries, the reaction can be explosive.

In Germany, a curious ruling was made by a Cologne court: German Ruling Against Circumcising Boys Draws Criticism.  Of course Jews and Muslims are up in arms over this, believing the court overstepped its jurisdiction and invaded religious space.  The court basically ruled (paraphrased) that the child has the fundamental right to bodily integrity and must be able to consent to the procedure if it's not done for medically indicated reasons.  It sounds logical enough.

Now the vast majority of circumcisions are done in infancy or early childhood, when the child cannot of course consent.  By Jewish tradition it happens on the 8th day of life.  Muslim tradition, as I understand it, varies a bit - it could be in infancy or all the way in adolescence (when the child would be able to consent).

So the argument come back, does the child's fundamental right to bodily integrity trump the parents' rights to parent?  To dictate the child's religion?  This is a gray zone, to be sure, and I'm not sure why male circumcision gets such a pass (from a logical standpoint).  Courts have ruled previously that a parent may not tattoo their child.  Courts have ruled that female circumcision (aka female genital cutting/mutilation or FGM) is illegal.  Are those necessarily drastically different?  Tattooing inflicts a permanent mark on the child, but doesn't remove any part of his/her body.  Female circumcision exists on a spectrum - the most "benign" being a simple prick to draw blood from the clitoral hood (or removal of the clitoral hood) to practices way more extreme.

One medical body considered allowing physicians to perform the most benign on the FGM spectrum (pricking the clitoral hood to draw a few drops of blood, symbolically of female circumcision) to assuage parents who come from a culture that practices that, and to ensure they don't take their baby girls to a practitioner who'd do something way more extreme.  That consideration was met with a furious backlash and promptly retracted.  But we're allowed to do more than that to baby boys.  I mean, really now?

For the purposes of this post I'm ignoring the potential medical benefits/risks of male circumcision because the research on that waffles all the time, and whatever potential medical benefits that may be gained are easily achieved with other means (e.g. using a condom, good hygiene, etc).  But these procedures, because they are surgical in nature, do come with very real risks.  In an old Jewish tradition (fortunately not practiced by most - I think - Jews these days), the mohel sucks the blood away from the circumcision wound with his mouth.  This is obviously not sanitary and is against all medical standards.  How 11 New York City Babies Contracted Herpes Through Circumcision.  That's one of the complications of that particular practice.  Now in normal healthy older children and adults, herpes is annoying but nothing more really.  In babies, because their immune systems are next to none, a herpes infection can be deadly.

And when public health officials try to intervene to limit/stop these practices, religious backlash is again furious as they claim they can self-regulate.  Clearly not always.  Circumcision, as my ob/gyn attending once said, has a "narrow therapeutic window."  It's not a difficult procedure to perform, but when you mess up, you mess up big time and you can destroy that kid's life.  That's not a burden I'd like to carry.

If at this point you may think I'm bashing religion, I assure you I'm not.  But when a religion requires modification to a person's body, particularly to a person who cannot consent, there are at least standards that must be met.  I'm in full support of medical/public health/legal bodies regulating such practices to ensure minimal harm.  The Cologne court in Germany may have gone too far, but the issue they bring up is valid: does the parents' rights trump the child's right to bodily integrity?  What if the child grew up and wish he (or she) wasn't circumcised?  What consolation is there then?

On my ob/gyn rotation I met a young first-time mother who asked me, as she was in the last stages of labor, whether her son would get circumcised right after birth.  I tried my best to mask my shock.  I said that the baby must first be observed for at least 12+ hours to ensure he's healthy enough.  I told her if she wished it to be done, it'd happen the following morning.  She asked me again if it'd be done right after he was born.  I reiterated myself.  Her friend suggested she could just leave him uncircumcised, that there's nothing wrong with that - I agreed and said most of the world's men are uncircumcised and the vast majority of them have no health problems because of it.  She considered this for a full 3 seconds before asking me that question again.  I changed the topic, exchanged some polite words, and left.  This mother, in my opinion, shouldn't have had the right to make that snap decision for her son without full consideration of the potential risks/benefits.

Thoughts?  Should logic rule over emotion and tradition?  Did that German court go too far, or simply conform to laws regarding other somewhat similar practices?  Whose rights should respected first?

Here's one last article, food for thought: Circumcision's Deadly Fault Line: Rationality vs. the Metzitzah B'Peh.

Thoughts?

So I read from time to time, as I'm wont to do. Today I came across this article:

No surprise for bisexual men: report indicates they exist

Lol, the title amused me. Of course bisexual men (and women) exist! The only way the title could've been better is if it had the words "Well, duh" somewhere in it. Some may be offended that it took a study like this to "prove" or "validate" our existence, but I'm rather amused. The study does have some limits, as all studies do. It basically assess those who're "perfectly" bisexual rather than people who self-identify as bisexual but may have a skewed attraction towards either men or women.

Thoughts?

Circumcise or don't? Quandary for parents
Fairly balanced article for something that inherently has a lot of bias. A fellow med student friend (at another med school) and I briefly discussed the article/topic. He's of a neutral opinion and would follow whatever medical recommendation would be at the time of his future son's birth (assuming he'll have a son). My opinion is basically the same as any other surgical procedure - if it isn't medically necessary right now or in the near future, then don't do it. 99% of the time, circumcision is not medically warranted (that is, there's something so wrong with the foreskin that circumcision is the only option). I then asked him if, in the future, the medical recommendation is as "neutral" as it is now, then what'd he do? He said that he tends towards conservative treatment, and hence would likely leave his son uncircumcised unless there were some very clear benefits that outweigh the risks (there aren't, as of current medical literature).

Thoughts?

Why medicine actively and legally stifles innovation
This was a particularly interesting article. The author certainly utilized a unique health care delivery model. Definitely worth a read. I find the idea of such innovation to kind of operate outside "the system" refreshing. It's a funny thing - they tell us (the med students) to think about every possible diagnosis in the differential for a patient's disease. Then the physicians proceed to systematically dismantle almost every suggestion we come up with except the most likely/obvious ones. I can't say they're wrong in doing so because if you keep asking a med student for something "outside the box," you're going to eventually hear ridiculously rare diseases that very few people ever get and very few physicians ever see. I don't question their knowledge and clinical judgment over mine, because it's obvious that they know far more than I do (almost more than I can possibly imagine myself ever knowing!). What I do question is the system at large that seems to repeatedly fail patients and ends up producing jaded physicians. There must be some way to rectify the system and this article was one step in that direction.

Thoughts?

Gender-free?

A person's sex is biological, primarily determined by XX or XY. A person's gender is largely a social construct, or what being of one sex or the other "means."

This may be old news, but it's interesting nonetheless. A couple in Canada decided to withhold their newborn's gender from the world and him/herself. The idea is to let the child discover his/her own gender and decide for him/herself. It's an interesting "experiment," to say the least, and one that has drawn a lot of controversy.

Personally, I think the child will be all right. S/he will figure out gender, as it's been shown that a child's concept of gender is innate and becomes cemented by the time they're 4 or so. A child "knows" if they're a girl or boy. But what does it "mean?" That can be challenged.

I'm not sure I agree with the way the parents are withholding the child's gender from the child and the world. I think they'd be better off treating the child in such away to avoid gendered stereotypes. Because, honestly, gender stereotypes (to me) seem to be getting less distinct and less important. But maybe that's just me. There's a related article on masculinity that's an interesting read.

---TANGENT---
On a completely different note, I came across this recently:


Oh to have a body half as good as that, lol. Yeah, it's totally unrealistic for the vast majority of us to ever have a body remotely like that. And I can accept that. Doesn't mean I/we can't try to get halfway there (which, honestly, is more than good enough). :-P

Btw, Chris Fawcett is HOT. It's mostly his eyes to me, and less his body.
---END TANGENT---

Agent of Change

change the world by ~moshimoshimoo on deviantART

Have you ever had the feeling that you're on a journey to seek out your purpose in life? That there's something you can do to change the world, in whatever small way you can? That something out there needs to change?

It's a feeling that's been growing in me recently. I read articles about things like the Embrace baby warmer for premature infants, designed by a group of engineering students at Stanford, or about the gay teen in AZ changing things for LGBT youths posted over at You Could Have It So Much Better, and I kinda wonder what I've been up to these last few years. Sometimes I feel like I should've accomplished more by now.

But then I realize that I should step back and take things into perspective. What is the kind of difference and change I want to make? What have I done? What can I do? What might the future hold? Time, energy, and effort are all limited resources. So with some perspective, a few things come to mind.

First, short-term are the various things I'm doing through student organizations. Patient Education was on the verge of being axed from the free clinic. T_T However, since we changed the flow of the program 3-4 weeks ago, the managers have agreed to let the program survive another year. Phew! Hopefully we'll be able to reach out to more uninsured patients at more than one free clinic in the city, and educate them on how to take control of their own health. Also, basically reviving the LGBT group to a semblance of a group from practically nothing is no simple feat.

Second, in the near future, my friend - who I've known since kindergarten - is starting a non-profit. He has asked me to be one of his board members. The central idea of his non-profit is simple (aren't all great ideas simple?): to provide kids with someone who will move with the kid through grades 1-5 and provide guidance, encouragement, and help. I'm incredibly proud and honored to be considered to help him with this endeavor! I could go on and on about the merits of his idea, but perhaps in another post.

Third, in the far(ther) future, my friend AG-F and I will make our video game project a reality. Over a year ago, we had drafted the concept of a video game to educate kids (and adults) on genetics. Now AG-F works practically across the hall from the professor for whose class we wrote the project for. Evidently we made a big impression as he keeps talking about it now! So yes, we promised each other that one day we will finish what we started as just a class assignment.

And so, I think in each of our own small (or big) ways, we can become agents of change. For the better or for the worse, that's up to us to decide. As Gandhi said:

"Be the change you wish to see in the world."

---TANGENT---
In case you haven't heard the news (as if it's possible miss something this big), DADT was repealed!! About time. A lot of human resources were wasted in the military as a result of this silly legislation. Listen to one soldier's account here, it almost moved me to tears. I don't think when that was recorded months ago, that he thought a repeal would happen within the year.
---END TANGENT---

It Gets Better

I came across the It Gets Better Project yesterday. It was started by Dan Savage in the wake of the much-publicized recent LGBT youth suicides, and it basically collects video stories from people on YouTube telling LGBT teens that "it gets better."

Although I don't have a message to share, per se, there are a few I'd like to share (and I've quoted some of the lines they said that I could relate to). The first 2 are from the It Gets Better Project and the last one is a very emotional and moving vid.


"It gets better . . . well to be honest, I still have to believe that in myself. But I think it's gonna get better. And sometimes it feels like you're the absolute only person left in the world to care for yourself and even then you don't want to care for yourself. But, something you've gotta remember is that somebody out there needs you as much as you need somebody."


"I struggled a lot in high school with mostly myself, I suppose; I didn't have a lot of problem getting picked on, but I knew it wasn't acceptable or really smiled upon. So I struggled with feelings of guilt and shame and all that stuff that is very unpleasant and hard when you feel alone . . . and it's rough."

"My favorite memory is watching the sun rise on a mountaintop with this boy I was in love with and it was amazing, and if I didn't make it through high school I wouldn't've been able to do that. . . . Thank God that I'm human and able to experience this." Something about this bit really got to me.



So this post is for any of you readers out there who're having a difficult time. This is for you bloggers/ex-bloggers. This is for me. This is for us.

I Guess I'll Post It . . .

First of all, thanks to all the people who commented on my last post. I'm glad you took the time to say something. :-) For the record, I've no intention of leaving the blogosphere any time soon.

Now I've been debating about posting the following since last night. I don't think it's really meaningful of me to post it as I doubt I'll change any minds here, but I'm going to post it anyway after talking to a couple other bloggers online. So I guess I'll post it . . .

You see, I get the AMA (American Medical Association) Morning Rounds - basically, their daily newsletter emails. Yesterday I read an article that really bugged me. So I wrote a rather involved comment in response to it, only to find out that I have to be a subscriber for my comment to be seen. Thanks a lot Wall Street Journal. -_-

Anyway, here's the "blog-friendly" version:
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The article:
Should Pediatricians Recommend Routine Circumcision?

My would-be comment:
"I'm rather appalled at the bias in this article, particularly from such a reputable reporting source as the WSJ.

As a former MPH (Master's in Public Health) student in epidemiology, and currently a medical student, I don't understand how people in the field can truly translate those studies to the US population. The results of those African studies haven't been replicated in the US and observational studies can be risky to base policy on.

In fact, a study sometime in 2007 found no significant protective factor between circumcision and US men. Read here.

Furthermore, a 2008 New Zealand study on birth cohorts (groups followed since birth) of circumcised and uncircumcised men found no significant difference in protecting against STIs. Read here.

Do we discredit such studies? One done in the US and the other done in New Zealand, a country whose demographics are much closer to that of the US than Africa?

And the American Cancer Society reaffirmed in 2009 that "Most experts agree that circumcision should not be recommended solely as a way to prevent penile cancer." Read here.

Also, healthy infants do die every year from circumcisions, even in Western developed countries like the US and the UK. Infants are so vulnerable to bleeding and infection immediately after birth, why would we risk their health during that time? Even if such deaths are rare, they do happen. But when they do, one must wonder, "Would this child have lived a full, healthy, and perfectly normal life had he not undergone that surgery?" The answer is most likely "Yes."

State details safety lapse at Beth Israel
Baby bled to death after circumcision, inquest said
Four year old in hospital due to messed up circumcision

Lastly, why isn't the US looking and comparing against policies from other more similar countries such as Canada, the UK, and Australia to see what their policies are and the health outcomes of their male children? Medicine isn't country-specific, and people are people everywhere you go. Social, cultural, and economic situations vary - but that makes it all the more important to compare with a population that's more similar (e.g. Canada) than dissimilar (e.g. Africa).

Statement by the British Medical Association (BMA)
Statement by the College of Physicians and Surgeons of British Columbia
Statement by the Royal Australian College of Physicians (RACP)

There are many many points I haven't even touched on, but the above should be an alarm to caution in approaching this controversial issue. I fully support the AAP's current position on the matter, neutral though it is. Until a study done in the US with a US population to definitively show that circumcision works better than, say, condoms and safe sex programs at reducing STD rates, I will remain a skeptic. Until a study like that done in Africa can be replicated in the US with just as high an efficacy, I will remain a skeptic. The former is ridiculous and the latter is unethical. So I will just say that there's no such thing as prophylactic surgery on infants and children, especially without their consent (an issue I haven't even touched on)."
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So think about it and feel free to comment, or even challenge and flame me (if you dare, lol). But I suspect the above words largely fall on deaf ears (or blind eyes, I suppose) of those who don't care one way or the other anyhow, or are set in their opinions.

This Will Not End Well

I often browse The New York Times every few days because I generally hold their professional journalistic ability in high regard. However, every now and then, I come across an article that I greatly disagree with.

Earlier this week I came across the article South Africa Is Seen to Lag in HIV Fight. The title wasn't really news but the moment I began reading the it, the epidemiologist in me bristled with indignation. The article focused almost exclusively on the low rate of male circumcision in South Africa as a major factor for the nation's high HIV rate. It barely mentioned the importance of condoms (and combating the Pope's erroneous statements about condoms), access to HIV testing, access to HAART drugs, safe sex education and behavior, LGBT rights, women's rights, and mother-to-child transmission of HIV - all necessary and greatly lacking in South Africa (and verily, most sub-Saharan African countries). This will not end well.

The purpose of this post is singular: to dispel the belief that male circumcision will make a significant dent (if at all) in lowering HIV rates.

The argument for male circumcision hinges on 3 studies (all of which were ended early) that seemed to indicate that being circumcised might decrease a guy's risk of getting HIV by 50-60% from woman-to-male transmission. It should be important to note that this is a relative risk. On an individual scale, the absolute risk is closer to a 2% decrease according to the studies. It's simple math and statistics. A risk reduction from 4% to 2% has a relative risk decrease of 50%, but the absolute risk reduction is 2%. It's critically important to use the words "risk reduction" as opposed to "prevention" because circumcision does NOT prevent HIV/AIDS. I had already discussed this briefly before in a previous post here.

There have been many criticisms of those studies. All sexual encounters were self-reported. Female partners were not tracked. It isn't known if any of the men engaged in homosexual sex (will be important later). Hygienic practices weren't assessed, as good and proper genital hygiene does help lower the risk of contracting STDs. There is no solid biological/physiological reason why male circumcision would confer this risk reduction.

But let's assume male circumcision is the wonder bullet that some health officials have made it out to be. In one recent model, increasing access to antiretroviral drugs and increasing condom use will have a much greater impact on HIV rates than circumcision. In fact according to their model, increasing both antiretroviral drugs and condom use could reduce new HIV infections by 64% to 90% by 2025 and could reduce mortality by 10% to 34%. In contrast, focusing on increasing male circumcision would only reduce new HIV infections by 3% to 13% and reduce mortality by 2% to 4%. Of course there are several assumptions that must be held in this model, as in all models. But the difference is still quite striking. The article could be found at aidsmap.

If you read the aidsmap article, you'll notice that their model does not increase access to antiretroviral drugs, condom use, and male circumcision. Why? It probably boils down to cost. Funds are a limited resource - the more you focus funding on one thing, it necessitates that you must reduce funding elsewhere. South Africa does not have the health care infrastructure nor enough health professionals trained to circumcisions safely and under sterile conditions. It costs a lot of money to update the health care infrastructure and to train more health professionals. Now think how many antiretroviral drugs, condoms, and safe sex pamphlets and ads will that same amount of money buy? Two words: A LOT.

Even if male circumcision continues to be promoted, there are several foreseeable problems. The first is that if you tell guys that getting circumcised will reduce their risk of getting HIV, it's only a matter of time until people misinterpret being circumcised as preventing HIV. While these men are still counseled to use condoms, if they think they're protected against HIV they will use condoms less. (Note: proper condom use reduces the risk reduction conferred by male circumcision to negligible or near-zer0.) Furthermore, they may use their circumcised status to "negotiate" unsafe sex with women, posing a greater of HIV infection to women. Circumcision Is a Red Herring, a must-read article.

In addition, because clinics and hospitals are becoming overwhelmed by men wanting to get circumcised, it's only a matter of time until they seek traditional healers or witch doctors with little/no medical training to perform unsafe circumcisions. Each year in South Africa, several hundred teens and men are maimed and disfigured due to seeking circumcisions outside the formal health care system, and many also die as a result. Read more about it in an article here, but be warned: it's not for the faint of heart.

Lastly, several studies have concluded that circumcision makes no difference in reducing HIV rates where homosexual sex is concerned (article here). Anyone who thinks circumcision offers a risk reduction against HIV in gay sex is simply wrong. With this in mind, the number of gay/bi men in Africa have long been underestimated and the role of gay sex in HIV transmission in Africa has been ignored. Because homosexuality is illegal and punishable by death in several African countries, gay sex is kept secret and underground. Little/no safe sex info is targeted towards homosexuals and gay/bi individual often face discrimination and lack access to care. To maintain the appearance of normality, many male-male sex networks often overlap with male-female sex networks. This is how homophobia fuels Africa's AIDS crisis.

In summary, male circumcision is not an effective means of reducing new HIV infections. It's entirely possible that it may actually do more harm than good. Money going towards male circumcision should be directed to strengthening proven methods (e.g. condom use and safe sex education/behavior) and increasing access to retroviral drugs and HIV testing. Pregnant mothers should be tested for HIV and have access to antiretroviral drugs to reduce/prevent mother-to-child transmission of HIV. There should also be campaigns to promote women's rights and LGBT rights. A lot of money, and a lot of people, hinge on a single decision. I only fear that Africa (and perhaps health advocates) might be making the wrong one. This will not end well.

Another Giant Falls

Chrysler has already fallen into bankruptcy. GM is next, as it's expecting to announce bankruptcy tomorrow. And thus, another giant falls. Ford is hurting, anyone want to bet it's going to be next?

It's troubling to me that to help speed GM through and out of bankruptcy, the US government is offering GM $50 billion in exchange for a 72.5% stake in the company. In essence, the US government will own almost 3/4 of GM. I can't speak for anyone else, but I personally find it a bit unnerving for the US government to have such a strong hold over the largest auto company in the US. Apparently, polls show that a majority of people find this potentially worrisome. I'm not well-versed in the issue and especially not in the politics of it all, so I can't comment if this "government take-over" is/will be a good thing or not.

So many people will be hurt by GM's bankruptcy. It's not just UAW union workers and manufacturers, but also auto parts suppliers such as Delphi. When a major auto company like GM tanks, it drags a ton of other people and companies down with it. Many people I know personally - especially parents - will be impacted by this. The Midwest will hurt. Badly.

These are scary and troubling times economically. For GM to lose $90 billion in the last several years, I have to wonder, how the hell did it get this bad?! It boggles my mind that we - someone - "allowed" it to come to this.

The "Gay Gene" Part II

This is Part II on the discussion of the genetics of sexuality. Part I is here.

Medical and psychological research literature have underwent major shifts in regards to homosexuality (and bisexuality). Once it was deemed as a psychiatric illness to be "fixed," and gays "converted" into straights. This thought prevailed until somewhat recently (in the US).

A recent NY Times article questioned the classical Masters & Johnson "gay conversions." It questioned the science and reality behind the studies, suggesting that the conversions may have been faked. These conversions may have been "at best composite case studies made into a single ideal narrative, and at worst they were fabricated."

Yet despite this and a shift away from homosexuality being a psychological "problem," some psychological therapists still attempt to "help" homosexuals and bisexuals become heterosexual. In this article, Gay 'cure' still sought by some therapists, it was found that 1/6 of UK therapists have attempted to "help" gay people become straight. It certainly doesn't help that another recent article, Some Gays Can Go Straight, Study Says, only seems to reinforce the notion that, if a gay really wants to try to become straight, it may be possible. I have not read the primary literature of the study, I do not know the design or the biases, and I'm certainly not versed in psychological or psychiatric research, thus I cannot personally comment on how valid the study may be. However, this is not the focus of this post - it is not my purpose to prove or disprove a study. I shall merely mention them as food for thought.

Down to the biology of it all. What does the literature say? What has the body of scientific knowledge determined about the "biology" of homosexuality? One thing is for certain: there is no single "gay gene." In fact, there are almost certainly many genes that influence sexuality. Furthermore, are there environmental factors that influence sexuality? Research hints that there might be. First things first.

Genetics and Sexual Orientation
Article 1: Genetics has a role in determining sexual orientation in men, further evidence
In my last post, I posited the simplification that a single gene governs a single trait. Science now knows this to be false for most (if not almost all) genes. A single gene may affect several traits, and a single trait may be affected by several genes. Scientists have looked for correlations to see what physical traits appear to be more common in gay men compared to straight men. What have they found?

Left-handedness tended to be more common in gay men (39% higher, as quoted here, thus about 14% of gays are left-handed compared to 10-11% of the general population). Notably, left-handers and gay men tended to have a larger corpus callosum. The corpus callosum connects the two hemispheres of the brain, allowing greater communication between the two halves of the brain. Each half controls the opposite half of the body (e.g. left hemisphere of the brain controls the right side of the body) and "specializes" in different kinds of thinking (e.g. language is in the left, music is in the right).

What does this suggest? Possibly that whatever genes affect sexuality also affect the brain and handedness preferences. Of course, it makes sense that genes affecting sexuality primarily act on the brain. But this is hardly fool-proof, as not all homosexuals (most aren't, in fact) left-handed, nor do all homosexuals have a larger corpus callosum. The genetics is incomplete here.

Genetic Regions Identified
Article 2: Genetics regions influencing male sexual orientation identified
A study by Mustanski has identified stretches of DNA on 3 chromosomes - 7, 8, and 10 - that may play a role in affecting sexuality. Quick note: in every cell in our body (excluding the germ cells - aka sperm and egg) we have 23 pairs of chromosomes. 22 pairs of chromosomes are somatic (non-sex chromosomes) and the 23rd pair is the XX or XY chromosome pair. This study has found that these 3 stretches of DNA on chromosomes 7, 8, and 10 were shared in about 60% of gay brothers in the study, compared to the expected 50% by random chance (assuming no genetic linkage).

This suggests that there is indeed something genetic to sexuality. Specific genes have not yet been identified within these 3 regions, as that's actually pretty difficult to do still. However, some words of caution: 60% is not that much greater than 50%. Thus the genetic effect observed here is still somewhat weak and alone cannot explain the whole story. Additionally, it also means that these genetic regions are not shared among gay brothers 40% of the time. What's going on here?

Genetics and Environment
Article 3: Genetics, environment shapes sexual behavior
This article suggests that both genetics and environment play a role in determining sexual orientation. In the study mentioned, about 3800 same-gender twin pairs were studied in Sweden.

The study found that genetics accounted for 35% of male homosexuality while non-shared environment accounted for the remaining 64% (I don't know what happened to that last 1%). Interestingly, genetics only accounted for 18% of female homosexuality while non-shared environment accounted for 64% and shared family environment accounted for 16%.

The study is, like any study, not without flaws and limitations. But it's certainly worth noting how genetics could account for so little of sexuality (still a significant portion, but certainly not all). How does one proceed in formulating a model of genetics and sexuality from here? Furthermore, the study population was pretty narrow (genetically speaking - all from Sweden), could this study be replicated in several other populations?

Bisexuality?
Article 4: Researchers revisit male bisexuality
For the vast majority of the articles above, bisexuality had been completely ignored. Only the dichotomous heterosexuality/homosexuality were more or less assessed. Part of the problem is certainly finding and identifying bisexual individuals.

This article brings back into the foreground the 6-point Kinsey scale, allowing a spectrum from "completely straight" to "completely gay." But how would a spectrum of sexuality like this fit into the results from the articles above, much less a genetic model?

So many unanswered questions. Clearly sexuality is determined by multiple genes. But what is the effect of each individual gene? How strongly do they contribute? And if genetics seemingly contributes so little (at 35% for men), then are people really "born gay?" Is there a way to modify the environmental factors, either willingly or not? Does the greater impact of environment mean that one can, in a sense, "choose" to be gay? I'm still going to say "no" to that last question.

And then there's Part III, where I attempt to present a somewhat plausible genetic model that accounts for environment . . .

This Reminds Me . . .

After GSI prep today, the professor had an interesting but short conversation with the head GSI as we were all walking out of the room.

Back-story: The head GSI was late to GSI prep today (and I'm usually the last one to make it to the meeting because I have to walk across campus). Her young daughter was having some "female problems" and wanted her mom (the head GSI) to bring her to the doctor's. Also, the Professor (who I'll call Professor C) is I think Eastern European . . . this'll be relevant later.

So here's the convo (I was on my way out the door and didn't catch how this convo ended):

Professor C: So how's your daughter?
Head GSI: Well, you know. She was having some girl problems, and wanted me to bring her to the doctor's, but once we got there she didn't want me around, and . . . yeah . . .
Professor C: Why is it that girls have these problems? How come boys never have these problems?
Head GSI: I don't know.
Professor C: Well, my boys are not circumcised, and my one job is to make sure they clean down there and that's it . . .

I thought this was an interesting exchange. And it reminded me of several things I read while purusing the news on the internet. Oh yeah, for the record, the vast majority of Europe doesn't circumcise.

Some public health officials have latched on tightly to a new study that came out (and completely ignored an equally valid study refuting it published last year) and is pushing the AAP (American Academy of Pediatrics) to revise their currently neutral stance on circumcision in favor of the procedure. And they blame the economy and thus lack of Medicaid reimbursement in 16 states for the decline in circumcision rates. Article here (this is only an example, almost all other US news articles on this topic say the exact same thing).

It's clear that the link to the economy is ludicrous because rates have been declining for decades in the US before the current economic woes, and even before Medicaid decided to (rightfully) drop coverage of an unnecessary (and almost entirely) cosmetic procedure on infants. On this note, it's refreshing to see both a US article and a UK article countering this, or at least bringing it back into perspective.

The thing about most US articles on circumcision is that they always praise the potential benefits, but barely even pay lip service (if that) to the potential risks and harms. There have been recent incidences of complications in the US, but these stories haven't achieved the same level of press as the ones "praising" circumcision. From a cost-benefit perspective, how many infants must suffer complications, or even die, for it to outweigh potential benefits decades down the line - benefits that may be achieved with simply good hygiene and condoms? Can infant lives be put on a cost-benefit scale/analysis? Or would that be unethical? I wonder . . .

Here are the articles (not for the faint of heart):

Botched job
MRSA infection
Bled to death (bleeding is a "common" complication that, if not caught early, could become quite severe)

"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.
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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.

Election Wrap-up

I spent the evening watching the election last night, and consequently got no work done. Oh well. As people may (or may not) have noticed, I try to keep politics out of this blog because I don't much like politics. So just a few things:

1. I'm glad Obama won. I hope he'll be able to deliver the change he promises and the change that we so need as a country after 8 years of Bush. I have no doubt he'll be a competent and capable president, but I feel just a little bad as he's charged with cleaning up all that Bush messed up.

2. McCain is a great and respectable man. There was a time (at the very beginning of the campaign) that I might've considered voting for him. The closer it got to election time, the more that evaporated. Yet, he exhibited dignity and grace in his speech accepting his loss in the election.

3. California, we've been watching your Prop 8 here. Of all the states with that initiative on the ballot, we never expected it to turn out so close with "Yes on Prop 8" slightly ahead. Last I checked, not all the precincts were in, so there's still hope that "No on Prop 8" will win the day. I'm keeping my fingers crossed for you. If for no other reason to support "No on Prop 8," it's that if Prop 8 passes, it'd be a clear violation in my mind of the Separation of Church and State. And I hold that concept pretty sacred.

4. I am ecstatic to say that Prop 2 in my state passed (barely), which means "looser" restrictions on embryonic stem cell research. Prop 2 is actually a very specific and detailed proposition that has many limits on obtaining embryonic stem cells (see my past post here for more). So "looser" really means "at all" and with all the attendant restrictions at the state and federal levels.

Now, to go research for my term paper on pre-implantation genetic diagnosis (aka, embryo screening). And to study for my pathophysiology exam next Monday. I do love that class, lol.

Conclusions of Summer

It suddenly struck me that summer is beginning to draw to a close. It's been a fairly boring, yet stressful, summer. However things are starting to fall into place.

1. Today, in the mail, I got my acceptance letter to the Medical College of Wisconsin (MCW) . . . for the entering class of 2009. I guess I wasn't fated to go to med school this year. Oh well. Point is, I'm in! Hurray!! ::waves a little flag of victory::

2. This means that I indeed will continue with 1 year towards my Masters in Public Health (MPH) in Hospital & Molecular Epidemiology at my alma mater. It has a very strong school of public health, 5th in the nation I believe. Apparently the Epidemiology department only has like 75 incoming students (some of whom I know) and my sub-program is obviously much smaller than that. I'm kind of excited to have smaller and more interactive courses. Unfortunately most of my friends graduated with me and are now strewn across the world, but mostly somewhere across the US.

3. Thankfully I also found a roommate to live with me. He's a 30-year-old Japanese guy from Tokyo who will be an incoming grad student at the School of Public Policy this fall. I don't know if he's found an apartment for us yet and he hasn't returned my last email. I sent him another email earlier today. Yesterday I was made aware of another person who needs a roommate and an apartment. So if this Japanese guy doesn't respond to my emails in a timely manner, I may have to abandon him and go with the other guy. Now, I know this other guy, and he's kind of annoying so I think I'd prefer to live with the Japanese guy if possible. But I'm going to keep my options open about roommates and housing for the next week or so.

4. Yesterday a bunch of my friends from campus came to my city to have dinner. So I got to see JW-M and DJ-M (his roommate) one last time before they go home on the other side of the state. And next week JW-M will be heading to Beijing for a year, studying abroad. It was nice of them to come by, and it reminded me how much I missed and will miss them. I should write a post on JW-M as a roommate and as a friend . . .

5. Tomorrow I'll be going to my friend JR-M's cast & crew screening of his movie. I'm part of the crew, as I was the cellist for the soundtrack composed by our mutual friend, CM-M (in this post). Granted I won't know most of the people there, but hey, at least I get to hang out with some of my old friends who I haven't seen in a while. He gave me a relatively unedited DVD of his movie, but he'll have the full DVD (with director's cut and all) at this premiere.

6. This isn't really anything interesting, but I'm kind of a planning whore. Yes, I do get a little stressed when planning things, but I think I secretly enjoy it. I have pretty much my next 1-2 years planned out (coursework-wise) as an MPH and I'm starting to plan what I should bring with me to my new apartment (when I get one) as well as next summer's plans. Maybe next summer I'll finally be able to visit Beijing and other parts of China. At least JW-M will still be there, he can show me around! Yeah I'm lame, don't judge me.

7. My cousin's back in Chicago! Which means I got my room back and my privacy to enjoy certain activities. I'm doubly happy at reading another news article on a study supporting the health benefits of this particular activity. Oh yeah, my cousin was able to improve his ACT score from 21 to about 26-27 in the two weeks he was here. That's right, hardcore academic improvement.