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Keratin and Langerhans cells

The material on keratin and Langerhans cells got deleted somehow. I'd like to put it back in. I think it's important because it explains a possible reason why circumcision might help protect against a number of diseases (in the case of keratin) and HIV in particular (in the case of Langerhans cells). Otherwise we're only presenting dry statistics. We can now cite a secondary source for this theory: the WHO document. I suggest the following: "According to the WHO, the layer of keratin on the inner surface of the foreskin is thinner than on the shaft of the penis, which may make it easier for pathogens to enter, and cells targetted by HIV are also closer to the surface on the inner foreskin." (p. 13.) Coppertwig (talk) 01:48, 26 October 2008 (UTC)

Should this be in Medical analysis of circumcision instead, Coppertwig? Perhaps Jakew could also weigh in. Blackworm (talk) 06:50, 27 October 2008 (UTC)

PLEASE PLEASE PLEASE LOOK AT NON-ANGLOPHONE SOURCES THAT IDENTIFY THE NECESSARY IMMUNE FUNCTION OF LANGERHANS CELLS THAT ABSORB AND KILL HIV. CIRCUMRAPE REMOVES A VITAL PART OF THE IMMUNE SYSTEM.Brit Pariah (talk) 06:19, 13 November 2008 (UTC)

It would be helpful if you would give us references to particular sources. If you can read them, maybe you could give us quotes and translate the quotes into English for us. I can only read a few languages.

Maybe Langerhans cells kill some HIV; but I think Langerhans cells are also invaded by HIV, and the HIV live and grow in those cells. So the situation is complex. ☺Coppertwig(talk) 03:10, 15 November 2008 (UTC)

Miscellaneous comments

I've made a number of small edits to the article. Here are some other possible changes for discussion:

Arbitrary subsection 1

• Article size: When editing the page, a note at the top says, "This page is 140 kilobytes long. It may be appropriate to split this article into smaller, more specific articles. See Misplaced Pages:Article size."
• In the procedures section it says "The device is then placed (this sometimes requires a dorsal slit) and remains there until bleeding has stopped." I think "bleeding has stopped" is the wrong phrase. In the source it says "hemostasis". I think in this context it means that blood flow to the tissue has stopped. I suggest changing it to "until blood flow has stopped"; or if we're not sure what it means, then changing it to "hemostasis" as in the source.
• I suggest deleting this part from the "cultures and religion" section, since it's material more relevant in the "prevalence" section: "Circumcision is most prevalent in the Muslim world, parts of South East Asia, Africa, the United States, The Philippines, Israel, and South Korea. It is relatively rare in Europe, Latin America, parts of Southern Africa, and most of Asia and Oceania."
• This doesn't sound NPOV to me: "While endorsing circumcision for males, scholars note that it is not a requirement for converting to Islam": all scholars endorse circumcision? Should it say "Islamic scholars" or something? ☺Coppertwig(talk) 00:32, 2 November 2008 (UTC)

Arbitrary subsection 2

• Re "Obstetricians used anaesthesia significantly less often (25%)": I skimmed the study and found the 25% figure mentioned twice, but I didn't find it saying anywhere that this result was statistically significant. Is anyone else more familiar with this study able to pinpoint where it says that? Otherwise perhaps we need to change the wording. I suspect it may be wrong, because it's wrong in another way: it was 25% of obstetricians who responded to the survey, not 25% of obstetricians (in the whole world) as the article seemed to say (I'm just changing it).
• Re "A 2006 follow-up study revealed that the percentage of programs that taught circumcision and also taught administration of topical or local anesthetic had increased to 97%." Is this really what the source says, or does it say that of those that taught circumcision, 97% also taught anesthetic?
• Pain section: Isn't there a source somewhere stating that in addition to pain relief during the operation, pain relief during healing over the following few days should also be used? If so, that should be added; if the opinions that it's relatively painless are included then the opinions of pain-relief advocates should also be included. The section heading might need to be changed to just "Pain and pain relief" rather than "Pain and pain relief during circumcision". If changing a section heading, it's a good idea to insert <span id="Pain and pain relief during circumcision" />
• "a causal relationship between lack of circumcision and HIV," I suggest changing to "a causal relationship between circumcision and reduced rate of HIV acquisition"; it sounds more logical and NPOV to me It's harder to visualize how a non-act can cause something, and "lack of circumcision" makes it sound as if circumcision is the norm.☺Coppertwig(talk) 00:32, 2 November 2008 (UTC)

Arbitrary subsection 3

• Millet et al study says among other things: " Male circumcision had a protective association with HIV in studies of MSM conducted before the introduction of highly active antiretroviral therapy (odds ratio, 0.47; 95% confidence interval, 0.32-0.69; k = 3)." Our article citing it: "A meta-analysis of data from fifteen observational studies of men who have sex with men found insufficient evidence of a protective effect of circumcision; the authors recommended further investigation." doesn't seem an accurate summary to me. How about "A meta-analysis of data from fifteen observational studies of men who have sex with men found insufficient evidence of a protective effect of circumcision in the pooled data, but indications of a protective effect from data before the introduction of highly active anti-retroviral therapy; the authors recommended further investigation."
• I suggest shortening the HPV section. I'm not aware of any reason to give it that much weight in comparison to HIV and other infections.
• "In a cross-sectional study of 398 patients, Fakjian et al. reported that balanitis was diagnosed in 12.5% of uncircumcised men and 2.3% of circumcised men." I'm not sure if I have easy access to this study. Is the study claiming that 12.5% of the men who were not circumcised among the 398 patients they studied had a diagnosis of balanitis, or are they claiming that 12.5% of the general population of men who are not circumcised have diagnoses of balanitis? (worldwide?) The way it's stated in the article sounds like the latter to me, but the number of significant digits is unbelievable in that case, so I suspect the study means the former, in which case we need to reword it, perhaps by inserting "the" before "uncircumcised" and again before "circumcised".
• The first mention of urinary tract infections is in the Complications from circumcision section, and seems to imply that circumcision may lead to a higher rate of UTIs. Several sections later is the Urinary tract infections section, which seems to imply strongly that circumcision lowers the rate of UTIs. Perhaps these two sections could be moved closer together, or the sections could each mention the other ("see also"), or something else done to help resolve this apparent discrepancy. ☺Coppertwig(talk) 00:32, 2 November 2008 (UTC)

Good points, Coppertwig. I agree with your proposals regarding Millett and Fakjian.

Regarding HPV, I would certainly agree with shortening the material. I don't think it's necessary to directly discuss the HPV primary sources in this article, given that we already discuss two meta-analyses (Van Howe & Castellsague). We could probably just include these. As you mention in another subsection, the size of the article is becoming slightly problematic, and trimming the material would help in this respect. It might be a good idea to examine what other parts of the article can be simplified, too.

I think that the UTI material is potentially confusing, but the underlying problem is that the entire paragraph beginning "Meatal stenosis (a narrowing of the urethral opening)..." is too long and detailed. The final sentence (which mentions UTIs) is about conditions potentially caused by meatal stenosis, which seems an absurd amount of detail since that isn't the subject of this article. I don't think we go into this much detail about any other proposed risk or benefit. It would make sense to remove this paragraph and instead add the words "meatal stenosis" to the paragraph beginning, "Other complications include..." Jakew (talk) 16:10, 2 November 2008 (UTC)

Arbitrary subsection 4

• "Two studies have reported that the rate of penile cancer is 3 to 22 times higher in men who were not circumcised." This seems to imply "higher than the rates mentioned in the previous sentence", which is probably not what is meant.
• "Neonatal circumcision is not considered medically necessary and is therefore categorised as non-therapeutic." Really? In all cases? Hard to believe. Citation needed.
• US policy: As I think Jakew may have pointed out, the last sentence of the 1st paragraph and the 1st sentence of the 2nd paragraph are mutually redundant.
• AMA: I suggest replacing "The American Medical Association does not recommend non-therapeutic circumcision and supports the AAP's 1999 circumcision policy statement." with "The American Medical Association supports the AAP's 1999 circumcision policy statement, which states that while there is evidence for potential benefits, "data are not sufficient to recommend routine neonatal circumcision.""☺Coppertwig(talk) 00:32, 2 November 2008 (UTC)

Re the penile cancer statement, it does need rephrasing. Another problem is that, as written, it implies that exactly two studies have investigated the issue (in fact, several have done so; see medical analysis of circumcision for citations). I would suggest something like "Researchers have reported that the risk of penile cancer is greater in uncircumcised men than in circumcised men; estimates of the relative risk include 3 and 22."

Re the unsourced "Neonatal circumcision..." sentence, the entire paragraph is somewhat problematic. Consider the previous sentence, which is also unsourced: "Most guidelines make a distinction between therapeutic and non-therapeutic circumcision." Do they? I think we should consider deleting this paragraph, replacing it with some kind of sourced overview. One possibility - while not ideal - is to use the AMA's statement: "Recent policy statements issued by professional societies representing Australian, Canadian, and American pediatricians do not recommend routine circumcision of male newborns."

Re the US policies section, specifically that of the AMA, I would note that this material has been changed slightly. However, since we've described the policy of the AAP in the previous paragraph, it seems rather unnecessary to restate it. Wouldn't it make more sense to simply state that the AMA supports the AAP's statement? It seems to me that we could expand discussion of the AAP in the first paragraph, and still use fewer words overall. Jakew (talk) 16:46, 2 November 2008 (UTC)

Yes and no Jake. On one hand we could remove the first part of the sentence "The American Medical Association does not recommend non-therapeutic circumcision and supports the AAP's 1999 circumcision policy statement." and leave the AMA's support of the AAP statement, but in this case redundancy strengthens the statement's position because another major is supporting it. The reader may only be interested in one particular organizations stance and not forced to read others for conclusion. Garycompugeek (talk) 17:20, 2 November 2008 (UTC)

Coppertwig, what is the rationale behind your suggestion? It seems that it needlessly makes the sentence longer, and only by repeating information already presented. It also makes it sound like the AAP only believes there are benefits, just not enough of them to recommend it; when the phrase they use elsewhere in their conclusion is "there are potential benefits and risks," seemingly indicating that a weighing of such benefits and risks had them arrive at their finding that the data on its benefits is insufficient to recommend it. Blackworm (talk) 22:36, 3 December 2008 (UTC)

I'm trying to make it more accurate. "The American Medical Association does not recommend non-therapeutic circumcision" sounds as if it could be interpreted to mean they recommend against it. I don't think they say anything along the lines of "We do not recommend non-therapeutic circumcision". Making a statement about what is missing from a source seems to me to be OR. Can you think of other suggested wordings? ☺Coppertwig(talk) 23:21, 3 December 2008 (UTC)

The source is crystal clear Coppertwig. They do not recommend non-therapeutic circumcision and supports the AAP's 1999 circumcision policy statement which does not recommend circumcision. Garycompugeek (talk) 23:33, 3 December 2008 (UTC)

It seems to me that it follows that if they state (or agree) that the data are insufficient to recommend circumcision, then they do not recommend male circumcision. The problem I think you're talking about is how "not recommending" is often (but not always) used to mean "recommend against" -- however we do not know which meaning the AAP/AMA intend here (hypothetically it's possible that they do in fact recommend against it, but are intentionally or unintentionally unclear on that, for example). Thus, due to this lack of clarity in meaning, it is best to summarize their statement with minimal editorializing. How about: "The American Medical Association agree with the AAP that data are insufficient to recommend non-therapeutic circumcision." That seems to be very close to the source, short, and leaves open whether they are neutral to the procedure or (perhaps secretly or vaguely) recommend against it. Blackworm (talk) 06:30, 4 December 2008 (UTC)

I agree with Coppertwig. Saying "does not recommend non-therapeutic circumcision" is apparently OR, and without the context provided in the original document it may potentially mislead. Their actual policy statement is somewhat more complex and subtle than that. The AMA themselves express it by reference to the AAP's policy ("The AMA supports the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics..."). Once again, it seems that the sensible approach is to simply state that the AMA supports the AAP's policy statement, which is after all discussed in the preceding paragraph. Certainly the current explanation of the AAP's policy is inadequate, and suffers from the same problems that Coppertwig highlighted, but to my mind it seems that the solution is to solve this problem once, in the appropriate place, not to try to express what is largely the same information twice, in two consecutive paragraphs. Jakew (talk) 10:36, 4 December 2008 (UTC)

Let's quote their actual policy statement then, as I suggest. How about replacing the AAP and AMA paragraphs with:

The American Academy of Pediatrics (1999) stated: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child." The AAP recommends that if parents choose to circumcise, analgesia should be used to reduce pain associated with circumcision. It states that circumcision should only be performed on newborns who are stable and healthy.

The American Medical Association supports the AAP's 1999 circumcision policy statement with regard to non-therapeutic circumcision, which they define as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. They state that "policy statements issued by professional societies representing Australian, Canadian, and American pediatricians do not recommend routine circumcision of male newborns."

Blackworm (talk) 18:44, 4 December 2008 (UTC)

Sure that is accurate (can't get more accurate than quoting the source) Blackworm, but for simplification, I think people typically only want to know if X medical association recommends circumcision or not. Garycompugeek (talk) 20:53, 4 December 2008 (UTC)

It may be too long and put undue weight on U.S. organizations. Other than that, at the moment I don't see any problem with it. No strong objection. ☺Coppertwig(talk) 02:05, 5 December 2008 (UTC)

Likewise, I think it's ok, and I've implemented the change. Jakew (talk) 12:08, 5 December 2008 (UTC)

(sigh) I'm still not convinced it was necessary (considering article size and above arguments) but I have no strong objection to quoting the source directly. Garycompugeek (talk) 14:12, 5 December 2008 (UTC)

Arbitrary subsection 5

• "The medical harms or benefits of non-therapeutic circumcision have not been unequivocally proven": this statement seems non-NPOV to me, as well as not being supported by the given source, and, as Jakew pointed out, is not about U.S. policy. In addition, it's a news source; these tend not to be very reliable for medical information.
• I'm just noting this here for future reference: "The 1989 statement by the Academy reversed a long-standing opinion that medical indications for routine circumcision were lacking." from the AMA "Report 10 of the Council on Scientific Affairs (I-99):Neonatal Circumcision".
• The link to the American Urological Association website for document "Circumcision" doesn't work; I looked at their site map and got the impression they no longer have such a page.
• "Circumcision in the English-speaking world": why do we have such a section? Is this undue weight? Within the section, is too much weight given to U.S. information? I suggest shortening this section; the detailed information can be provided in a subpage (presumably History of male circumcision). Some of the material in this section might be more appropriate in the Prevalence of circumcision section.
• "Map published by the United Nations": Is this the same map as the one published by the United Nations, or has it been redrawn by Emilfaro? Who owns the copyright?

☺Coppertwig(talk) 00:32, 2 November 2008 (UTC)

I've fixed the link for the AUA's policy. It seems that they've reorganised their site recently: previously there was a page containing a number of policies (possibly all of their policies), whereas now they seem to have a page per policy.

Re the English-speaking world, the coverage certainly seems rather Anglo-centric. I'm not sure whether this is undue weight; it may simply reflect the coverage in available sources. I think there's a certain amount of overlap between the 'prevalence' and 'history' sections, especially with older prevalence data. It does seem as though too much weight is given to US info, and I would be in favour of shortening the material.

Re the map, the description is inaccurate. This isn't the same map, and describing it as such is misleading. It's also unnecessary to cite the sources used by the source we cite (and doing so misses the point of secondary sources, I think). I would suggest rephrasing to something like: "Map showing percentage of males who have been circumcised at country level. Based upon United Nations (WHO/UNAIDS) publication." Jakew (talk) 17:20, 2 November 2008 (UTC)

Pornographic photos of penises

Understanding that Misplaced Pages is not censored, I see no reason why we have to include real photos of a man's penis when we could just as easily show what the picture shows through sketches. Misplaced Pages, because of the vast amount of people who refer to it, should not cater to everyone's coarse desires. I would not want my wife or girlfriend looking at those pictures. We need to improve and be more respectful. — Preceding unsigned comment added by 140.180.51.212 (talk • contribs) 22:50, 16 November 2008 (UTC)

Maybe sketches would be OK, or maybe photographs are better; but at least we have to have either sketches or photographs, or else the information isn't being presented. So please don't remove the photographs without at least putting sketches in their place. ☺Coppertwig(talk) 23:18, 16 November 2008 (UTC)

Misplaced Pages is not censored. The photos are appropriate. Blackworm (talk) 22:22, 26 November 2008 (UTC)

Ethical Issues Image

Has anyone ever taken a close look at the image in the ethical issues section of the artical? Its not even a real protest. Its poster pasted in front of a man on the street.

It's not like it is a big deal, but I think it needs to be acctual protesters. NOT a fake picture. Azcolvin429 (talk) 12:46, 26 November 2008 (UTC)

What leads you to believe the picture is fake? Blackworm (talk) 22:41, 26 November 2008 (UTC)

If you look close, the posters have been cut and pasted from something else. No one is even holding the poster, and you can see the holes where it would be tacked up on a wall. Its not like its that important, but the picture IS indeed "fake". Azcolvin429 (talk) 11:03, 27 November 2008 (UTC)

It seems one poster is leaning on something, and the other is being held by the man. The left poster is casting a shadow on the ground. Sorry but I remain unconvinced that the photo is fake. Blackworm (talk) 19:01, 27 November 2008 (UTC)

I see no evidence that the photo is fake. The man seems to be holding the poster on the right. The posters have bits of string or something protruding from the holes in the corners, and the bottom edges of the poster on the right are bent, apparently because the string is pulling on the poster to hold up its weight. The man is apparently holding whatever is attached to the corners of the poster. ☺Coppertwig(talk) 00:07, 28 November 2008 (UTC)

Ok, whatever. Im a digital photo editor, and I can tell the difference between real and fake. And it is fake. But who cares, it dosent matter. Azcolvin429 (talk) 07:54, 29 November 2008 (UTC)

Feel free to remove fake protest image and replace with a real protest image... Garycompugeek (talk) 20:05, 1 December 2008 (UTC)

What is it about the photo that tells you it's fake? ☺Coppertwig(talk) 01:06, 2 December 2008 (UTC)

I oppose (and reverted) this edit. At least two editors seem unconvinced that the image is a fake. Editors may also wish to view this image, this image, and this image, which seem to indicate that the photo is authentic. Blackworm (talk) 19:18, 3 December 2008 (UTC)

Recent edits to intact penis caption

I oppose this edit. The caption is an inappropriate place for the information, which besides seeming a bit glowing and unencyclopedic (one might even say "brochure-like," potentially violating Misplaced Pages's neutral point of view policy), is uncited. Also, the reasons given by the IP editor for the multiple reversions seem somewhat contradictory: can it be true both that "it is a common misconception that a circumcised penis and an uncircumcised penis are exactly the same when erect" and that "What is stated is common knowledge to the vast majority of the world's men and women?" In any case, if both those statements are each true to an extent, then surely reliable sources may be found that put any misconceptions to rest. Blackworm (talk) 07:41, 27 November 2008 (UTC)

I agree with Blackworm. See Misplaced Pages's verifiability policy. I note the above comment as a sign of neutrality on Blackworm's part. ☺Coppertwig(talk) 14:17, 27 November 2008 (UTC)

Pointing out the neutrality on an editor's part in a thread unrelated to that editor's neutrality seems to actually cast doubt on the editor's reputation for neutrality. I'd rather you not do that. Thanks. Blackworm (talk) 19:07, 27 November 2008 (UTC)

You're right. I apologize. Would you like me to delete that part of my comment? Or you may delete it, and optionally this comment can be deleted at the same time. ☺Coppertwig(talk) 23:46, 27 November 2008 (UTC)

List of organisations which either advocate or oppose circumcision in the introduction

I see the list of organisations which advocate circumcision in the introduction has three different organisations listed whereas the list of organisations which oppose circumcision has just one listed. What happened to keeping the intro neutral??? Usergreatpower (talk) 14:27, 5 December 2008 (UTC)

1. ^ Cite error: The named reference AAP1999 was invoked but never defined (see the help page).
2. "Report 10 of the Council on Scientific Affairs (I-99):Neonatal Circumcision". 1999 AMA Interim Meeting: Summaries and Recommendations of Council on Scientific Affairs Reports. American Medical Association. 1999. p. 17. Retrieved 2006-06-13. {{cite web}}: Unknown parameter |month= ignored (help)
3. Cite error: The named reference WHO-Info-2 was invoked but never defined (see the help page).

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