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Prostate cancer section

Because neither the American Cancer Society nor the policy statements on circumcision by national professional medical organizations mention a relationship between circumcision and prostate cancer, this article gives undue weight to a minority point of view both by the length of the section and its position in the article. -- DanBlackham (talk) 17:07, 25 October 2008 (UTC)

I'm not sure that I follow your argument, Dan. I don't think that we can interpret absence of mention in sources in such a way; this seems to be original research.

In late September I shortened this section considerably, more recently McCredie's study (which found higher risk of prostate symptoms in circumcised men) was added. I see no particular reason why this section must appear so early in the article, however, and wouldn't be opposed to moving it to a later point in the text. Jakew (talk) 17:38, 25 October 2008 (UTC)

Welcome, DanBlackham. Well, another way to put it might be that if major medical organization policy statements haven't mentioned it, then it may be appropriate for us to give it less weight by moving it later in the article. Since some of the "problems" in the section are cancer, I suggest having it right after the penile cancer section; and since penile cancer is "rare" and prostate problems have (according to DanBlackham) not been mentioned in med policy statements, I suggest moving both to (just?) after the HIV section, which is notable because of attention from the WHO. Perhaps a more extensive re-ordering of all the sections would be a good idea, possibly putting the HIV section first. I don't have a good feel for the relative notability of each section so I'm not sure what order would be best. ☺ Coppertwig (talk) 17:49, 25 October 2008 (UTC)

Coppertwig, thank you for the welcome. I am puzzled by your comment "according to DanBlackham". It would be easy to verify that the Royal Australasian College of Physicians, British Medical Association, Canadian Paediatric Society, American Medical Association, and American Academy of Pediatrics do not mention prostate cancer in their circumcision policy statements. Outside of Misplaced Pages, I have only seen prostate cancer mentioned in relation to circumcision by a small group of pro-circumcision advocates. If you know of an overview article on circumcision by a neutral, reliable source that mentions prostate cancer, please post a reference. -- DanBlackham (talk) 00:27, 26 October 2008 (UTC)

If the American Cancer Society or the national medical organizations mentioned prostate cancer and circumcision, it would indicate that the medical profession gives weight to the studies cited in this article. However because they do not even mention prostate cancer and circumcision, it is a good indication that this article gives undue weight the point of view of a tiny minority. Misplaced Pages policy states: "NPOV says that the article should fairly represent all significant viewpoints that have been published by a reliable source, and should do so in proportion to the prominence of each." and "Views that are held by a tiny minority should not be represented except in articles devoted to those views." -- DanBlackham (talk) 00:27, 26 October 2008 (UTC)

Herpes and NPOV

I agree with this edit, but I think it needs to be taken further. Apparently a few paragraphs from a specific POV were added recently in these edits by Pikipiki. At least, the language needs to be changed to be a more impartial tone per WP:NPOV. I might or might not have time to fully or partially do this. ☺Coppertwig (talk) 02:17, 1 March 2009 (UTC)

I've looked briefly at the material, and my conclusion is that it needs to be trimmed down. A lot. The amount of coverage given to this issue is disproportionate. In the very first paragraph it is stated that metzizah b'peh is practiced by "a minority" of mohels. That is to say, of the circumcisions performed worldwide, a fraction (about 1%?) are performed as part of the Jewish faith, and of those, a minority involve metzizah b'peh. Why, then, does coverage of this issue constitute more than half of the "immediate complications" subsection?

If I have time I'll try to condense this material. Jakew (talk) 09:58, 1 March 2009 (UTC)

One reason for some concentration on this practice is because of its danger to the infants involved. It is important that this is not suppressed. Michael Glass (talk) 09:42, 4 March 2009 (UTC)

Potential disadvantages

The article kinda gives the impression that once the foreskin is off without complications, everything is better. There is a section for potential complications and one for potential benefits, but none for potential disadvantages. I'm no doctor and haven't had the oppertunity to expirience the difference of circumcision first hand, but there has to be some drawbacks. Frostbites or increased damage when you are little and the evil toilet lid slams down on your weewee, at least. I know I've also seen some texts somewhere talk about less sensetivity and incresesd difficulty when masturbating, but I don't have any sources. There are a few rows in the 'Delayed Complications' section but nothing that suggests that these or anything could be a permanent disadvantage. I'm going to go out on a limb and create a 'Potential disadvantages' section with a request for citations. There just has to be something!

--Nakerlund (talk) 03:37, 22 March 2009 (UTC)

Your edit cited no sources, and was so vaguely put that it was almost meaningless. While I'm sure that your intentions were good, I don't think that the article benefits. For these reasons, I'm reverting. I suggest finding (and preferably discussing) sources before editing the article. Incidentally, the alleged sexual effects you mention are discussed in sexual effects of circumcision. Jakew (talk) 09:52, 22 March 2009 (UTC)

Very well, Jakew, I respect your seniority. My bad q: It was my hope that someone who is familiar with the subject could continue what I started. It seemed obvious that an article with a long list of advantages also needs some mentioning of disadvantages. The 'Sexual effects of circumcision' article you linked provides a more balanced picture, but it attacks the subject from a sexual point of view rather than a medical. Also, it lists potential effects rather than andvantages and disadvantages. Perhaps that is a better way of doing it, and instead of adding a disadvantages section, the advantages section should be renamed to 'Potential medical effects' or something similar. Since you didn't love my contribution, I hope you can suggest an alternative...or explain more clearly why I'm wrong, at least. --Nakerlund (talk) 11:03, 22 March 2009 (UTC)

I think that you and I must have a different understanding of the section entitled "Potential complications", Nakerlund. Since a "complication" is (loosely speaking) a negative consequence of (in this case) a surgical procedure, the "potential benefits" section seems balanced by the "potential complications" section. For this reason, I don't think that a "potential disadvantages" section is needed. Furthermore, I think that creating such a section would introduce ambiguity over where material belongs (for example, is the hypothesis that circumcision may cause psychological harm a complication or a disadvantage?), and also risks making the article's coverage too negative towards circumcision.

If we have "potential complications", then we should not rename "potential benefits" to "potential medical effects", because this would introduce unequal treatment of evidence: if someone proposes a harmful effect, we call it a "potential complication", whereas if someone proposes a beneficial effect, we merely call it a "potential effect".

But perhaps this broad sense of "complications" is unintuitive, and a cause of confusion. We might consider renaming the "potential complications" section, perhaps to something like "potential adverse effects". Jakew (talk) 13:40, 22 March 2009 (UTC)

I think you hit the nail on the head in your last paragraph, Jakew. Complications indicates something going wrong with the procedure itself, which may have short or long term effects. It did not register with me as a balance to potential benefits for that reason. I imagine the line between long term complication and directly adverse effects grows very thin, and I can see the point of having them in the same section.

Psychological harm could be both from the procedure itself, and from the lack of foreskin. The later would be an adverse effect and not directly a complication.

Perhaps a good way to maintain neutrality and to focus more on medical benefits and potential drawbacks, would be to split complications regarding the procedure itself off into its own article. Complications are by definition never good, and I don't see why such an article would need balancing from 'positive benefits' to remain neutral. My point is that it does not need the context of the rest of this article, and this article would also be easier to keep neutral without it. Those are the cleverst thoughts on the subject that I can come up with at the moment, but I don't know what other related articles there are or how such a split would fit into the rest of wikipedia. I'm hoping you can tell what is appropriate, Jakew :) --Nakerlund (talk) 16:02, 22 March 2009 (UTC)

I think Jakew's suggestion of renaming the section to "potential adverse effects" is a good idea. That way it can include any long-term effects as well as immediate complications.

This article is currently the 44th longest page on Misplaced Pages: Special:LongPages. The Benefits section is over half the length, bytewise. It probably wouldn't be a good idea NPOV-wise to have an article just about the benefits or just about the adverse effects. However, we could split off an article about "medical effects of circumcision" containing the adverse effects, benefits and "costs and benefits" sections (leaving summarized forms of those sections in this article per WP:SUMMARY). That article would still be too long, I think; so instead, we could divide it up somehow: "short-term medical effects of circumcision" and "long-term medical effects of circumcision"; or "circumcision and infectious disease" (including both short-term infections as complications and long-term risk factors) and "circumcision and cancer" and, um, "physical effects of circumcision" or possibly "non-infectious medical effects of circumcision" although I'm not sure if you can have a valid topic that specifically excludes one aspect. It might be worth having an article on just "circumcision and HIV". Or we could just shorten this article. ☺Coppertwig (talk) 20:23, 22 March 2009 (UTC)

It was not my intention to suggest that the article should be spit into one for advantages and one for disadvantages. I meant that complications(as in the surgeon slipping or the wound festring) of the circumcision procedure itself should be split off. Not that the complications section should be split off. But regardless, your idea of spitting off "circumcision and HIV" is even better to get the article shortened length-wise. And Jakew's proposal down below seems terrific to me. I don't think my original point of imbalance is relevant anymore, and at least not until the proposed changes have been made. --Nakerlund (talk) 16:00, 23 March 2009 (UTC)

A separate "Circumcision and HIV" article

(unindenting) Your suggestion that we spin out some material is a good one, Coppertwig.

My preference would be to have a reasonably "flat" structure, without subdividing into "infectious disease", "cancer", etc. Looking at the article, the biggest section by far is that for HIV/AIDS. Due to the emphasis in the literature, I'd expect this topic to receive quite a lot of weight, but I think this much is excessive, and as I've remarked previously, the section is a bit of a mess.

I'd therefore suggest that we spin out the HIV section into a new article, "circumcision and HIV". As a summary, I'd suggest the following material (extracted from the existing text):

Van Howe conducted a meta-analysis in 1999 and found circumcised men at a greater risk for HIV infection. He further speculated that circumcision may be responsible for the increased number of partners, and therefore, the increased risk. Van Howe's work was reviewed by O'Farrell and Egger (2000) who said Van Howe used an inappropriate method for combining studies, stating that re-analysis of the same data revealed that the presence of the foreskin was associated with increased risk of HIV infection (fixed effects OR 1.43, 95%CI 1.32 to 1.54; random effects OR 1.67, 1.25 to 2.24). Moses et al. (1999) also criticised Van Howe's paper, stating that his results were a case of "Simpson's paradox, which is a type of confounding that can occur in epidemiological analyses when data from different strata with widely divergent exposure levels are combined, resulting in a combined measure of association that is not consistent with the results for each of the individual strata." They concluded that, contrary to Van Howe's assertion, the evidence that lack of circumcision increases the risk of HIV "appears compelling".

Weiss, Quigley and Hayes carried a meta-analysis on circumcision and HIV in 2000 and found as follows: "Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised."

Siegried et al. (2003) surveyed 35 observational studies relating to HIV and circumcision: 16 conducted in the general population and 19 in high-risk populations.

We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV.

In 2005, Siegfried et al. published a review including in which 37 observational studies were included. Most studies indicated an association between lack of circumcision and increased risk of HIV, but the quality of evidence was judged insufficient to warrant implementation of circumcision as a public health measure. The authors stated that the results of the three randomised controlled trials then underway would therefore provide essential evidence about the effects of circumcision as an HIV intervention.

A 2008 meta-analysis of 15 observational studies, including 53,567 gay and bisexual men from the United States, Britain, Canada, Australia, India, Taiwan, Peru and the Netherlands (52% circumcised), found that the rate of HIV infection was non-significantly lower among men who were circumcised compared with those who were uncircumcised. For men who engaged primarily in insertive anal sex, a protective effect was observed, but it too was not statistically significant. Observational studies included in the meta-analysis that were conducted prior to the introduction of highly active antiretroviral therapy in 1996 demonstrated a statistically significant protective effect for circumcised MSM against HIV infection.

Three randomised control trials were commissioned to investigate whether circumcision could lower the rate of HIV contraction.

On Wednesday, March 28, 2007, the World Health Organisation (WHO) and UNAIDS issued joint recommendations concerning male circumcision and HIV/AIDS. These recommendations are:

• Male circumcision should now be recognized as an efficacious intervention for HIV prevention.
• Promoting male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men.

Published meta-analyses, using data from the RCTs, have estimated the summary relative risk at 0.42 (95% CI 0.31-0.57), 0.44 (0.33-0.60) and 0.43 (0.32-0.59). (rate of HIV infection in circumcised divided by rate in uncircumcised men). Weiss et al. report that meta-analysis of "as-treated" figures from RCTs reveals a stronger protective effect (0.35; 95% CI 0.24-0.54) than if "intention-to-treat" figures are used. Byakika-Tusiime also estimated a summary relative risk of 0.39 (0.27-0.56) for observational studies, and 0.42 (0.33-0.53) overall (including both observational and RCT data). Weiss et al. report that the estimated relative risk using RCT data was "identical" to that found in observational studies (0.42). Byakika-Tusiime states that available evidence satisfies six of Hill's criteria, and concludes that the results of her analysis "provide unequivocal evidence that circumcision plays a causal role in reducing the risk of HIV infection among men." Mills et al. conclude that circumcision is an "effective strategy for reducing new male HIV infections", but caution that consistently safe sexual practices will be required to maintain the protective effect at the population level. Weiss et al. conclude that the evidence from the trials is conclusive, but that challenges to implementation remain, and will need to be faced.

Any thoughts? Jakew (talk) 10:24, 23 March 2009 (UTC)

Yes, I have 3 thoughts:

1. That's the shortened version?!
2. Go for it!
3. With nonsignificant results, don't say "found that the rate ... was ... among men who..." (which seems to imply a statement about the general population) nor "a protective effect was observed". You can say "is consistent with" causal thingies or trends in the general population, or you can make statements about the rate specifically within the study group, but based on nonsignificant results I wouldn't make statements about either causality or rates in the general population (except maybe to say "consistent with").

☺Coppertwig (talk) 11:26, 23 March 2009 (UTC)

Ok, I'll wait for a few hours to see whether there are any objections. If not, I will implement this (assuming nobody else has got there first!).

I realise that it is a fairly long summary. This was largely intentional, as if the section were too short it wouldn't give enough weight to something that has received a relatively huge amount of attention in the literature.

Re nonsignificant results, the above text is extracted from the article. I don't think I've changed it. If you think that wording needs to be made more accurate, then it would probably be best to edit the article before implementing WP:SUMMARY. Jakew (talk) 13:14, 23 March 2009 (UTC)

Implemented. Circumcision and HIV is no longer a redirect, but is now a page in its own right. I'm sure that the summary here would benefit from some tweaking, though... Jakew (talk) 16:36, 23 March 2009 (UTC)

Nicely done! I feel responcible in some small way for this turn of events and tried looking the changes through with a critical eye. But everything looks fine to me :) --Nakerlund (talk) 17:49, 23 March 2009 (UTC)

I didn't mean to imply it was too long. Good work. I'll try to remember to edit both versions later in the week. ☺Coppertwig (talk) 22:33, 23 March 2009 (UTC)

Thanks! It helped, of course, that you suggested such a good idea in the first place. Jakew (talk) 22:44, 23 March 2009 (UTC)

A better option would have been to summarise each section better. Instead of citing primary sources one after the other, we should agree on the consensus and then proceed from there. What has happened over time is that each side of the debate has added primary sources agreeing with their point of view. That is how the article has gotten so long.

A problem with your HIV summary section is that it makes no mention of studies criticising the RCT's. Plus it just leaps into a criticism of Van Howe's meta-analysis without any explanation or background for the general reader. Nor is there mention of any articles relating to circumcision in developed countries such as the USA or how that relates to routine infant circumcision. Tremello22 (talk) 11:52, 7 April 2009 (UTC)

I agree. What do you propose? Garycompugeek (talk) 13:51, 17 April 2009 (UTC)

The Mucous membrane Issue & Circumcision

Why is there no discussion or references in this article about the glans (head) of the penis being a natural mucous membrane? This is one of the main medical arguments against circumcision, because when the foreskin is sliced away the glans ceases to be a mucous membrane like it is in its natural uncircumcised state. Circumcision is quite simply the process of turning the glans from a (mostly) internal part of the body (a natural mucous membrane) in to a totally external part of the body (non-mucous membrane). This is bad because mucous membranes like the glans are supposed to be naturally moist, while a circumcised glans loses its ability to be moist because the foreskin has been sliced away and thus the retention of smegma and other natural secretions is lost, leading to gradual toughening of the skin of the glans. There are plenty of sources and references regarding this issue - so why is it not mentioned in this article? —Preceding unsigned comment added by 172.163.80.90 (talk • contribs)

Please see Talk:Sexual effects of circumcision#The Mucous membrane Issue .26 Circumcision, since you've asked exactly the same question there. Jakew (talk) 08:37, 17 April 2009 (UTC)

Coppertwig calls removal of the phrase "or benefits" from the BMA quote "reasonable"

Coppertwig, re: this, please explain how, precisely, you believe removing "or benefits" and replacing it with "" from the following British Medical Association quote reproduced in Misplaced Pages, was "reasonable." The quote is: "The medical harms or benefits have not been unequivocally proven ." Put a different way, why, in your opinion, should Misplaced Pages have removed "and benefits" and replaced it with ellipses from that quote in the context of that edit? Blackworm (talk) 18:26, 26 July 2009 (UTC)

1. Van Howe, R.S. (1999). "Circumcision and HIV infection: review of the literature and meta-analysis". International Journal of STD's and AIDS. 10: 8–16. Retrieved 2008-09-23. Thirty-five articles and a number of abstracts have been published in the medical literature looking at the relationship between male circumcision and HIV infection. Study designs have included geographical analysis, studies of high-risk patients, partner studies and random population surveys. Most of the studies have been conducted in Africa. A meta-analysis was performed on the 29 published articles where data were available. When the raw data are combined, a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis (odds ratio (OR)=1.06, 95% confidence interval (CI)=1.01-1.12). Based on the studies published to date, recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa, or elsewhere, is scientifically unfounded. {{cite journal}}: Cite has empty unknown parameter: |coauthors= (help); Unknown parameter |month= ignored (help)
2. O'Farrell N, Egger M (2000). "Circumcision in men and the prevention of HIV infection: a 'meta-analysis' revisited". Int J STD AIDS. 11 (3): 137–42. PMID 10726934. The results from this re-analysis thus support the contention that male circumcision may offer protection against HIV infection, particularly in high-risk groups where genital ulcers and other STDs 'drive' the HIV epidemic. A systematic review is required to clarify this issue. Such a review should be based on an extensive search for relevant studies, published and unpublished, and should include a careful assessment of the design and methodological quality of studies. Much emphasis should be given to the exploration of possible sources of heterogeneity. In view of the continued high prevalence and incidence of HIV in many countries in sub-Saharan Africa, the question of whether circumcision could contribute to prevent infections is of great importance, and a sound systematic review of the available evidence should be performed without delay. {{cite journal}}: Unknown parameter |month= ignored (help)
3. Moses S, Nagelkerke NJ, Blanchard J (1999). "Analysis of the scientific literature on male circumcision and risk for HIV infection" (PDF). International journal of STD & AIDS. 10 (9): 626–8. PMID 10492434. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
4. Weiss, H.A. (2000). "Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis" (PDF). AIDS. 14 (15): 2361–70. PMID 11089625. Retrieved 2008-09-25. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
5. Siegfried N, Muller M, Volmink J; et al. (2003). "Male circumcision for prevention of heterosexual acquisition of HIV in men". Cochrane database of systematic reviews (Online) (3): CD003362. doi:10.1002/14651858.CD003362. PMID 12917962. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
6. Siegfried N, Muller M, Deeks J; et al. (2005). "HIV and male circumcision--a systematic review with assessment of the quality of studies". The Lancet infectious diseases. 5 (3): 165–73. doi:10.1016/S1473-3099(05)01309-5. PMID 15766651. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
7. ^ Millett GA, Flores SA, Marks G, Reed JB, Herbst JH (2008). "Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis". JAMA. 300 (14): 1674–84. doi:10.1001/jama.300.14.1674. PMID 18840841. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
8. "WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention". World Health Organisation. 2007. {{cite web}}: Unknown parameter |month= ignored (help)
9. "New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications" (PDF). World Health Organization. March 28, 2007. Retrieved 2007-08-13. {{cite journal}}: Check date values in: |date= (help); Cite journal requires |journal= (help)
10. ^ Weiss HA, Halperin D, Bailey RC, Hayes RJ, Schmid G, Hankins CA (2008). "Male circumcision for HIV prevention: from evidence to action?" (PDF). AIDS. 22 (5): 567–74. PMID 18316997. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
11. ^ Mills E, Cooper C, Anema A, Guyatt G (2008). "Male circumcision for the prevention of heterosexually acquired HIV infection: a meta-analysis of randomized trials involving 11,050 men". HIV Med. 9 (6): 332–5. doi:10.1111/j.1468-1293.2008.00596.x. PMID 18705758. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
12. ^ Byakika-Tusiime J (2008). "Circumcision and HIV Infection: Assessment of Causality". AIDS Behav. doi:10.1007/s10461-008-9453-6. PMID 18800244. {{cite journal}}: Unknown parameter |month= ignored (help)

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