Monthly Archives: August 2013

Circumcision by Deborah Tolmach Sugerman, the usual crap

Another day, another circumcision post.

Today’s post by Deborah Tolmach Sugermen, MSW, with the JAMA (Journal of American Medicine Association) Network, starts, as they always do, reminding us that the procedure goes back thousands of years in time (in this case, to “prehistoric times“).

The article then says that “People worldwide continue to circumcise their sons for hygienic, cultural, and religious reasons“. The hygienic reasons are quite debatable, as it is generally accepted that “uncircumcised boys can learn how to clean beneath the foreskin once the foreskin becomes retractable” (after all, it’s easier than brushing teeth and more fun). As for cultural and religious reasons, one could also argue that people worldwide continue to circumcise their daughters for cultural and religious reasons (and those who do it argue that it’s not mutilation when they prick the hood of the clitoris to draw some blood, a procedure the AAP admitted is “less extensive than the newborn male circumcision commonly performed in the West” in their now retracted Policy Statement on “Ritual Genital Cutting of Minors”), and yet the law in the United States leaves no cultural or religious exceptions for non-therapeutic procedures on a female minor’s genitals.

Deborah then writes that “Circumcision in infancy is very safe“, which is in contrast with the AAP’s assertion that “The true incidence of complications after newborn circumcision is unknown“. She then states that “When it is performed by a trained professional under sterile conditions, few babies have complications“. I would challenge this statement given that some complications, such as the development of adhesions, buried penis and meatal stenosis, have little to do with the way the procedure is performed. But perhaps we are running into what the AAP considers “differing definitions of “complication” and differing standards for determining the timing of when a complication has occurred (i.e., early or late)“.

Parents should be told about these possible post-operative complications (which are not even mentioned in Deborah’s article), since they can result in the need for further “revision” surgeries, particularly when the AAP warned about a 119% increase on revision surgeries from 2004 to 2009.

She then states that “There are no long-term studies of the health benefits of children who have been circumcised” – which is particularly striking given that the practice of “medical” circumcision in the United States goes back to 1870, plenty of time for such studies to have been done. In lack of those studies, it could be easily argued that circumcision should be left to be a personal decision of the person, since it’s not demonstrated that circumcision improves the health of the children.

Following this, Deborah mentions the African studies on HIV, and uses this to support the idea that “male circumcision provides substantial medical benefits“. By contrast, Andrew Freedman, member of the AAP Task Force that wrote the 2012 Policy Statement on Circumcision, has publicly called circumcision a procedure with “modest benefits and modest risks“, which shows something that has been known for years, that those interested in promoting circumcision will “dismiss the harm and exaggerate alleged benefits“.

She then moves on to explain the benefits. Reduction of UTIs (no mention that after the first year, boys have less risk of UTIs than girls regardless of their circumcision status), risk reduction of HIV (no mention that this is only considered to be so for heterosexual transmission from female to male, not for male to male, not for male to female and not through non-sexual paths such as blood transfusions, and that the total risk reduction attributed to circumcision is 1.8% of the already small risk of transmission from female to male, and no mention of condoms and safe sex as better alternatives to HIV prevention), and of course, penile cancer (no mention that penile cancer is a very rare disease that occurs in old age, mostly related to phimosis during adulthood and to HPV, and that according to the AAP’s own Technical Report on circumcision “The clinical value of the modest risk reduction from circumcision for a rare cancer is difficult to measure against the potential for complications from the procedure” as 909 to 322,000 circumcisions would be needed to prevent one penile cancer event, at a cost of 2 to 644 complications ranging from mild to severe).

She then goes to explain that “Male circumcision does not appear to affect sexual function, sensitivity, or sexual satisfaction“, a statement that has been the subject of an intense information war, with circumcision promoters such as Brian Morris rabidly attacking or willfully dismissing the studies that contradict this view, such as Sorrells (2007), Frisch (2011), Bronselaer (2013), histological studies explaining the anatomy of the foreskin such as Taylor (1996-1999), or Tim Hammond’s preliminary poll of men circumcised in infancy or childhood.

The author then says that the AAP recommends that “Doctors talk to parents about the health risks and benefits” (one would hope doctors would be more forthcoming on the actual risks and complications than Deborah, a Master of Social Work who is potentially biased for religious reasons – as it’s simple to find that she is a member of the Adath Jeshurum Congregation- has just been) and that “Parents weigh this information together with their religious, ethical, and cultural beliefs and practices“.

This final statement deserves a little bit more of attention.

Circumcision is a surgery. It’s the excision (amputation) of normal healthy genital tissue with sexual functions (the article doesn’t mention that the foreskin is normal sensitive genital tissue or that it has sexual functions).

In most cases this is done for “religious and cultural reasons” (including Deborah’s religion).

Religion and culture are not medical indications for surgery.

Circumcision is “elective” surgery, that does not treat a condition, disease or abnormality. But the patient, a minor, is not given the chance to “elect” or “refuse” the procedure.

In a recent article in the Journal of Medical Ethics, Robert Van Howe and Steven Svoboda declare that “When physicians decide whether to do a procedure, they must, and normally do, exclude from their medical decisions non-medical factors regarding the parents’ culture. Contrary to what the AAP suggests, doctors are not cultural brokers. Their duty is promoting and protecting the health of their patients, not following practices lacking a solid ethical and medical foundation.

But Tolmach Sugerman makes no mention of this ethical issue.

Why Deborah? Why?

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South Africa: 4 year olds child dies after hospital circumcision

Johannesburg – “They killed my child.” These were the pained words of a Germiston father whose son had to be taken off life support on Wednesday evening after he was declared brain dead by two surgeons following a medical circumcision operation a week ago.

Reggie Mokalapa, 39, took his four-year-old son, Gugulethu, to Medicross Germiston for what doctors had assured him would be a “less than two-hour” procedure last Tuesday.

On Sunday, monitors showed that Gugulethu’s brain was not responding, and on Monday he was declared brain dead.

On Wednesday, a second doctor confirmed that Gugulethu was brain dead and the family elected for doctors to take him off life support.

“We are always advised to circumcise our children young, and we did this so that he’d be okay in future. Unfortunately, we took him to a slaughterhouse,” said Mokalapa.
 
 
 
 
Rest in Peace, Gugulethu.
 
Please, let’s stop cutting minors.
 
WHO, PEFPAR, Bill and Melinda Gates Foundation, UNAIDS, please stop cutting minors.

Does Male Circumcision Affect Sexual Function, Sensitivity, or Satisfaction?- No Morris, it doesn’t work that way

So, a new day and the news already report a new study. “Sydney researchers find that contrary to perception circumcision actually increases sexual satisfaction“. That Sydney researchers would seem to have nothing else to do but to research circumcision seems strange, until you find the same old name: Same old Professor Brian Morris, author of circinfo.net the most rabid fanatic pro-circumcision site on the web, and who is not a sexologist or a urologist, but a molecular biologist. Oh, also founder of the Circumcision Foundation of Australia and author of the book “In favour of circumcision“. Do we need to point any more bias?

But enough with Morris, let’s cut to the meat and potatoes and take a look at the abstract. The article is being published on the Journal of Sexual Medicine (how he gets publishers is something we can’t really understand).

And what is this “new” research, one would ask? Well, it’s nothing but a recycle of the same old papers. In his own words, “A systematic review of published articles retrieved using keyword searches of the PubMed, EMBASE, and Cochrane databases was performed.

From this, 2,675 publications are identified (several of them authored by Morris himself, no doubt), and they are “rated” on their quality level, to conclude that “The highest-quality studies suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation, or satisfaction.“. The problem is, what is the criteria for this rating? Which were the “low quality” studies and what did they reveal?

But, at this point we are not even really discussing the meat and potatoes of the subject, are we? Because, how can we evaluate sexual function, sensitivity, sensation and satisfaction, if we don’t start by defining what those are and how to measure them? Guess what, Morris didn’t.

For being a biologist, Morris willingly overlooks the question of what is sexual function, and skips the topic by going to statistics. Do you see anything wrong there?

Histological studies such as those by John R. Taylor (published in the British Journal of Urology) are evidently ignored, and most likely Sorrells’ “Fine-touch pressure thresholds in the adult penis” (also published in BJU) is most likely rated with low quality, given that Morris (and his friend Jake Waskett, a computer programmer) took it upon himself to criticize that paper by distorting, eliminating and reprocessing the data, as pointed out by Hugh Young. In fact in the Daily Telegraph’s article, Morris is quoted saying “There are no legitimate studies which have found a lack of sensitivity”. Sorry Morris, just because you don’t like the findings of Sorrells et al. doesn’t mean that it’s not legitimate. You can’t remove 20,000 soft-touch receptors from an organ and claim that there is no difference in sensitivity.

Circumcision promoters prefer to ignore Sorrells study while paying attention to Payne et al’s “Sensation and sexual arousal in circumcised and uncircumcised men” which was based on a similar methodology with a fatal flaw: Payne didn’t take sensitivity measures for the foreskin, only for the glans, thus ignoring the main difference between the circumcised and the uncircumcised penis in what can only be called “researcher’s bias” or “researcher’s prejudice”.

Anyway, the question of what constitutes sexual function is not even asked by Morris. Of course that would have to get him to explain about frenulum, ridged band, gliding function (described by Lakshman in the Indian Journal of Surgery in 1980), etc, things that he really doesn’t care to talk about… because he doesn’t have them.

So let’s be clear here.

If sexual function means simply being able to sustain an erection and ejaculate, then, in most cases there would be no difference… except perhaps at an older age (40, 50…) as keratinization of the glans progresses.

But if sexual function means that the penis works as it was intended to work:

  • The foreskin glides over the glans and allows the ridged band and the ridge of the corona to stimulate each other,
  • Pre-ejaculate collects in the subpreputial space for additional lubrication instead of falling down on a useless liquid thread,
  • The intact frenulum and ridged band perceive a lot of sensation and produce tingling sensations and help control the orgasmic threshold,
Then there is no doubt that removing the foreskin changes the function.
Some of the “high quality” studies would have been, no doubt, those by Kigozi et al, in Uganda (including circumcision promoter Ronald Gray) where the men that volunteered for circumcision as part of the “randomized trial” for HIV prevention, were followed up at 6, 12 and 24 months. Participants reported on “sexual satisfaction and function”. Of course at 24 months, keratinization wouldn’t have been enough to represent a good difference (some men circumcised during the neonatal stage report the effects of keratinization when they are past their 40 or 50 years – but I’m sure Morris would dismiss them as case-studies in the best case, or as being brainwashed by anticircumcision literature on the internet at worse).

But given that this is nothing but a “systematic review” of existing literature, then comes the question of what’s the relevance of this paper. Why did Morris even bothered looking for all these articles and writing a new paper based on no new research whatsoever?

Circumcision promoters have suffered some backslash in the recent years. In 2011 the International Journal of Epidemiology published Morten Frisch’s “Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark” which concluded that “Circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment.” In spite of the expected anonymity of reviewers, Morris outed himself as one of the reviewers, as the one reviewer opposing the publication of Frisch’s study, when he asked the members of his mailing list to write letters to the editor protesting the publication of the article. Quite unethical on his part.

In 2013 BJU published Bronselaer’s “Male circumcision decreases penile sensitivity as measured in a large cohort“, a study in Belgium, which concluded that “This study confirms the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning. Furthermore, this study shows that a higher percentage of circumcised men experience discomfort or pain and unusual sensations as compared with the uncircumcised population. Before circumcision without medical indication, adult men, and parents considering circumcision of their sons, should be informed of the importance of the foreskin in male sexuality“. Strangely for a study that suggest negative consequences of male circumcision, Reuters covered the study so it reached several global news outlets. In some of the media, particularly in American news sites, a critique by circumcision promoter Aaron Tobian (Johns Hopkins University college of Ronald Gray) was included in an attempt to “balance” the information (or reduce the impact of the study, we could say).

And this would be the reason why circumcision promoters needed some “new” publication to “find” that circumcision “does not affect -or actually increases- sexual satisfaction”, even if it means just recycling all the old articles, even the old and utterly debunked excuse of a “study” by Masters and Johnson from 1966 (here explained and refuted by Hugh Young).

So this is the issue. Awareness of the consequences of male circumcision has been growing. It was already reported in 1997-1999 by Tim Hammond. The past two years have seen two European articles denouncing the reported loss of sensitivity and sexual consequences of circumcision for European males and their partners. 2012 also saw the results of the Global Survey of Circumcision Harm. There is also growing awareness of the possibility of Non-Surgical Foreskin Restoration for men who feel harmed by their circumcision and wish to recover some of the function of their lost foreskin.

So obviously, circumcision promoters are not happy, especially when African men are not rushing to get circumcised as they expected them to. Aaron Tobian prepared the path for the AAP’s new Policy Statement on Circumcision by publishing his “findings” (actually a computer simulation applying premises from African data to the United States) that healthcare cost would increase if circumcision rates continue decreasing. Of course even if this was true, this unethical paper is only putting a price tag on a valuable part of the male genitalia, and most of the public could see through it. More was needed, so Professor Morris did what he knows how to do: review old information to produce new publications, while denying everything that doesn’t fit his model of the world.

Well, Professor Morris, it doesn’t work that way. You can’t deny the changes in function by simply refusing to discuss function. Good try though.

One thing we appreciate of Morris “study”, and it would be pointing us to his coauthor, Krieger JN. Professor John Krieger from the University of Washington. We’ll definitively be learning more about Krieger’s work, such as his previous 2008 study on “Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya“, which no doubt is one of the studies reviewed in this new publication, it’s not like Morris has been known for self-referencing his own publications, what’s the cost of sharing that trick with his coauthor?

One final thought is, why is it that European males report sexual difficulties related to their circumcision while African males don’t? And why is it that the perception of African males would be more relevant to English speaking countries than the perception of European males?

But let’s listen to Brian Morris for a moment, let his words give you an idea of his character. He would be quite amusing if he didn’t think he was being serious.