Saturday, March 24, 2007

Probably my last post on circumcision, for a while a least...

Following my two posts on male circumcision I have received a fair amount of feedback from which I have learned some new things. The commentators have pointed out where I have been wrong about things and they have also provided some great links that I would like to share with my readers here.

After my first entry on the subject I received one comment from anonymous with a link to a blog which is entirely dedicated to male circumcision. Here you can among other things, see pictures of the surgical procedure, and read about the similarities between male and female circumcision. I always thought that female circumcision was quite a bit worse, but it seems that this is not necessarily the case...

When I wrote my second entry I also received some very nice feedback. The first comment really makes the general point well. Beanie's Appa, who wrote the comment has got his own blog which you will find here. This is what he wrote (I agree completely with what he says).

"Wonderful post. Thank you for your words of wisdom. I'm one of those men who was cut as a baby, but I wish they hadn't done that to me. For me, there's no choice. My parents and the doctor took that from me. But for someone who wasn't cut at birth and wishes he was, he can do that stupid thing any time he feels like it."

A few days later I received a comment from TLC tugger who is in the business of helping circumcised men get back their foreskin, an honorable business indeed. You can listen to his podcast here. Apparently it is possible to restore your foreskin following circumcision using TLC's product, which amazingly does not require surgical interventions. (I am wondering whether this approach will give you back some of your sensitivity to the foreskin). TLC, having restored his own foreskin also pointed out that sex is a great deal more pleasant with the foreskin. Furthermore, TLC pointed out that only very rarely (1 case in 10,000) is there a medical reason for doing circumcision. For most problems, there are less invasive techniques available. For instance, if you have a tight foreskin, you can simply stretch it using a balloon. I am actually quite confused about peoples' readiness to pick up the knife whenever there is a problem with the penis. Surgical procedures are usually avoided until there are no other options, and for good reasons...

Concerning the supposedly positive health effects associated with male circumcision I read somewhere (I cannot remember where I read this) that the correlation between circumcision and a lower incidence of HIV would not occur even if we circumcised all males in Africa. The reason why not is really quite obvious (at least if you have ever been to an African hospital, which I have). A lot of people in Africa get HIV because a procedure is not done in sterile environments, that is, they are infected with the virus during the procedure. Furthermore, many circumcisions in Africa are not even done at a hospital. Sometimes the procedure is done with dirty and not so sharp knives (see picture), out in the nature. Man I would not want to be that baby... Maybe more sterile environments could be achieved, but I suspect that in Africa today a mass circumcision campaign would have greater costs than benefits.

Finally, just earlier today I received an email from Frank. He gave me a table with STD (sexually transmitted diseases) statistics for circumcised and non-circumcised men respectively. I found the original study in which it is shown that there are no significant differences (differences that are unlikely to be caused by chance alone) in the occurrence of sexually transmitted diseases for circumcised and non-circumcised men. In other words, to circumcise a baby will not reduce the overall risk of STDs in the future. In the study they conclude that parents should be informed about the costs and benefits associated with circumcision prior to the intervention. I agree.

Of course I am still very interested in what all of you have to say, both people who agree as well as my critics, so keep sending me comments...

19 comments:

Beanie's Appa said...

Hi Anders, thanks for mentioning me in your post.

One thing to note about the foreskin restoration methods like TLCTugger's is that you would only get the skin back, not the original nerve endings and inner mucous membrane lining or any other structures associated with the foreskin. That being said, the sensitivity should still increase (even if not to 100% natural) because the glans (head) of the penis gets its protective covering back. The head should be smooth, but in circumcised guys it gets rough, dry, and desensitized from years upon years of rubbing against their clothing. After getting a new covering from foreskin restoration, the glans can go back into its natural state.

I've been meaning to buy some of TLCTugger's products, I've used another method which seems to have stalled giving me a nice bit of slack. I used to have skin so tight that during my teen years the skin would sometimes break (and I thought it was normal growing pains!) and my erections have an unnatural curve. That's something most parents don't realize when weighing the pros and cons of circumcision - that the doctor has no idea how big the baby will grow - the doctor can easily cut too much skin, causing problems that don't manifest themselves until puberty and adulthood, and so don't get counted in studies or cost/benefit analysis regarding infant circumcision. In papers that measure the incidents of circumcision complications, I would show up as a baby that was fine, but when I realized my circumcision was my problem, I was pretty pissed off - not fine!

One thing I think America needs more of is men from non-cutting cultures like yourself showing our circumcisers your point of view.

rasmussenanders said...

Thank you again for your comments. As a neuroscientist I would have been extremely surprised if Tuggers product would bring back nerve endings. I did suspect though that some sensitivity would return for the reason you explained in your comment.

Is there really no way a doctor can tell how much a particular penis will grow (perhaps ask the father about his size or something). If there is no certain way to do this, then there is indeed a big problem which has gotten way to little attention.

Thanks again for your input!

Beanie's Appa said...

Well, among my uncut friends who I've seen in the nude, there is one who's foreskin is very long and hangs down off the head, coming to a point, and there is one who's foreskin is very short, about half of the head of his penis is always exposed.

I imagine it's just simply in puberty, the skin of the penis, and internal parts might grow at different rates for different people. If I were not cut, I guess I would have had one of the short ones. So if a doctor cuts all babies the same length, then ones like me would certainly have problems.

Joshua Amos said...

Your initial comments on circumcision indicated a lack of knowledge of the subject. In a series of posts you have embraced the anti-circumcision activist position which pervades the web. A very vocal minority. Why has there been no comment on the three recent RCT's (randomized controlled trails) which reported a 60% reduction in heterosexual HIV infection female-to-male? See the WHO news release: http://www.who.int/hiv/mediacentre/news68/en/index.html
And then onto the WHO recommendations with regard to male circumcision:
Recommendations :
1.1 Male circumcision should now be recognized as an efficacious intervention for HIV prevention.
1.2 Promoting male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men.
http://www.who.int/hiv/mediacentre/MCrecommendations_en.pdf
So as the scientific case for male circumcision builds one can expect that there will continue to be those who wish to promote the retention of the foreskin for other reasons and at all costs, perhaps psycho sexual?
Cheers Joshua

rasmussenanders said...

Thank you for your comment Joshua. I have not had time to answer until now.

In my initial post on circumcision I stated my belief that circumcision does offer some protection against HIV. I also wrote that based on how the studies have been conducted it was very likely that the effect have been overestimated. Note that I have never asserted that it has no effect, quite the contrary in fact.

If circumcision had no side effects and no dangers associated with it, I would have nothing against a mass circumcision campaign, however, this is simply not the case. I think that removing 50% of the nerve endings in the penis, thus taking away the victims chance of ever getting an optimal sex life, is just too high a price to pay when we can achive the same goals through massive condom campaigns. Furhtermore, circumcision is a rather invasive surgery and it is therefore associated with many risks, even more so when it is conducted in a dirty environment

WHO in their statement also write that they don't think that people should be forced to do circumcision. I don't know exactly what they mean by this. If they are saying that we should only circumcise those over 18 who wants to be circumcised, then that is fine with me I think. Circumcising babies is not ok...

I do recognize that I belong to a minority here, but that is really not a valid argument in the debate, wouldn't you agree?

Joshua Amos said...

Hi Anders,

I have always found it useful to separate science from opinion when it comes to the circumcision debate.

The science is clear that there are significant health benefits accruing through male circumcision. here we are talking about only one, being the protective effect against female-to-male HIV infection.

The results have been impressive for those interested in slowing the HIV/AIDS pandemic and devastating to those from anti-circumcision fringe groups.

Adding to the findings of the three RCTs, which confirmed previous findings one, must factor in age at circumcision study carried out in the same area of Uganda as the RCT.

See:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10199231

That study finds the highest protective effect is achieved when the circumcision is carried out before the age of 12.

So indications are that in order to achieve that maximum protective effect male circumcision should be carried out before the age of 12.

Now it would be argued that as a public health issue the decision to have their sons circumcised would fall into the same category as parental decisions to immunize their children.

One would expect that as with anti-immunization fringe groups the anti-circumcision groups would also argue until they are blue in the face to present their case. It is not expected that the latter will have any greater success than the former.

(your opinion dealt with in a second comment)

Joshua Amos said...

Dealing with your opinion on the matter, you said:

"If circumcision had no side effects and no dangers associated with it, I would have nothing against a mass circumcision campaign, however, this is simply not the case. I think that removing 50% of the nerve endings in the penis, thus taking away the victims chance of ever getting an optimal sex life, is just too high a price to pay when we can achive the same goals through massive condom campaigns. Furhtermore, circumcision is a rather invasive surgery and it is therefore associated with many risks, even more so when it is conducted in a dirty environment"

Read the studies about the complications they experienced and accept that it is a non issue if the guidelines are followed.

Massive condom campaigns alone have failed. Circumcision adds an additional means of slowing the pandemic. There are many branches on the tree of prevention, male circumcision is just one.

Not all nerve endings are 'equal'. You surely know this? Maybe I can leave it to you to do a little research into these nerve endings and their specific function? We need to be accurate about these matters don't you think?

rasmussenanders said...

There are several cases in which death has resulted following circumcision. It is only few cases, but it happens. Also, because there is no way of accurately predicting the size of the penis when the person grows up, the circumcision is often done in at the wrong levels, a rather common complication. In other words, complications do result from circumcision (see my references in previous posts).

There are a half a dussin or so different types of nerve endings all over the skin, some sense temperature, some sense touch and pressure etc. Together they result in a particular sensation that we experience. It is not like the foreskin only contains unimportant nerve endings because all nerve endings are important. The foreskin is one of the most sensitive parts of the entire penis.

Would you advocate removing the breast of women in order to save them from breast cancer?

Joshua Amos said...

In answer to the scaremongering over the risks of circumcision, I post the following study:
http://tinyurl.com/2mleqv

It is not usual for a neuroscientist to give such a general explanation of the function of nerves. Anders the anti-circumcision argument is about sexual function and nothing else. You as a neuroscientist should be aware that the fine touch receptors 'switch off' if subjected to continuous stimulation and that 'fine touch' as defined in neurology is not what plays any role in insertive sex. This therefore is a carefully constructed myth by anti-circumcision fanatics.

Try this test. Apply your fingertips to yours lips in the lightest stroking motion. It tingles, it is pleasant. Now increase the pressure of the contact between the fingertips and the lips. What happens? The tingling goes away and there is now longer any pleasant sensation. The tingling sensation goes away before the approximate pressure as experienced during intercourse is reached and a deceitfull myth is exposed.

Two of the recent RCTs relating to male circumcision and HIV infection found that 98.5% and 99.5% were 'very satisfied' with the result of their circumcisions. Now if the foreskin had meant so much to them why did they agree to get circumcised at all?

rasmussenanders said...

Once again I would recommend that you take a look at my previous references. See the article titled "Foreskin Sexual Function/Circumcision Sexual Dysfunction" which can be found at:

http://www.cirp.org/library/sex_function/

The foreskin is important, there is just no doubt about that. So what we are talking about is a tradeoff. One could go into a lot of details about how the different receptors work, however, the sole fact that there are so many receptors in the foreskin signals that it is indeed an important part of the penis, otherwise why waste the extremely valuable brain capacity on that?

I also took a close look at what WHO are actually saying in their report. Their recomendations are for mature men, not for babies. This seems like a paradox considering the studies you showed me earlier, but in any case, WHO, thankfully, do not think it is ok to perform this surgery on babies who have had no chance to make up their own mind.

Also, I would just want to point out that a 1% risk of complications (the figure is slightly higher) is actually a significant risk. I would never perform a laser eye surgery say if there was a one percent chance of complications (which is why I haven't done one).

PS: You never answered my question about removing the breast of women. Are you in favour of that?

Joshua Amos said...

Anders said: "Once again I would recommend that you take a look at my previous references. See the article titled "Foreskin Sexual Function/Circumcision Sexual Dysfunction""

And in so doing you direct me to an opinion piece posted on an anti-circumcision website. Naughty.

Knowing that an anti-circumcision opinion piece will not be convincing Anders goes on to say:

"The foreskin is important, there is just no doubt about that."

Anders you have to support opinion with fact. You obviously don't have facts at your disposal so you once again generalize on the role and function of the nerves in the foreskin.

Anders, I say again that it is unheard of for a neuroscientist to be vague about the role and function of nerves. You are being vague about the role and function of the nerves in the foreskin. Why?

We need to hear which nerves respond and contribute to contact during sexual intercourse and foreplay beyond any stimulation by a feather. In the interests of science and your intellectual integrity I challenge you get into some detail on this matter.

If male circumcision has health benefits, which it undoubtedly has, then why would the age at circumcision be an issue at all? Try your logic on the issue of immunization. Should parents be retrained from having their children immunized until the kids are old enough to decide for themselves?

Anders not satisfied to allow the scare tactic of complications to pass stated:

"Also, I would just want to point out that a 1% risk of complications (the figure is slightly higher) is actually a significant risk."

A risk of what? Slow healing? Minor post operative bleeding? Minor infection?

Anders in the name of your personal honor you should really distance yourself from the scaremongering of the anti-circumcision fringe elements.

Anders lamented that I did not address the issue of prophylactic breast removal.

Anders, the female breasts have a proven biological purpose value unlike the foreskin.

rasmussenanders said...

The link I posted does reach the conclusion that the foreskin is important for many different things. You may have missed that there are no less than 67 references, many of which have been published in respected journals. Are you claiming that they are all biased?

Concerning the risk, you should know (since you posted the link), that slow healing and post operative issues occured considerably more often than in 1% of the cases. The 99% was the number of how many were satisfied long term.

The reason that there is a difference between immunization and circumcision is that circumcision is much more invasive and has more complications. Not many people regret being immunized, but many people wish their parents had not circumcised them.

rasmussenanders said...

Concerning the nerves in the foreskin and their function, I have not studied what particular type of nerves that are in the foreskin.

The reason I have not gone into the issue further is that to me, the fact that we have a relatively large part of the somatosensory area in the brain devoted to the foreskin is conclusive evidence of its importance.

The link which I have posted gives many references to journals in which the errogenous function of the foreskin is investigated.

I would add that even if the foreskin responds most intesively to light touch this is also an important part of the sexual act, especially during foreplay. If you still think that it is absolutely essential to find out which particular receptors are in the foreskin and what type of stimuli they respond to, then sure I will get into that in depth, though it may take me some more time.

Joshua Amos said...

Anders said: "Concerning the nerves in the foreskin and their function, I have not studied what particular type of nerves that are in the foreskin"

If you had any knowledge of the particular type of nerves and their function in the foreskin you would have stated it. It seems that you have blindly accepted the myth of a sexual role for the foreskin by which you undermine your claim to be a scientist.

The obvious key to assessing any sexual function of the penis is during sexual arousal and not at any other time.

Read this study to educate yourself suitably.

http://tinyurl.com/3xfm8s

Joshua Amos said...

Anders said: "The reason that there is a difference between immunization and circumcision is that circumcision is much more invasive and has more complications."

Well I am not sure about that. Try a google search on "complications immunization" and see what comes up.

It is noted that you switch from concern over "giving the child a choice" to " the risk of complications" as the moment dictates.

There are "foreskin activists" and there are "immunization activists". Their arguments are very similar. Both acts they claim destroy something and should be left to the choice of the individuals concerned.

The principle is the same, if one should not be left to a parental decision then so also should not the other. Or do you believe the foreskin deserves special attention?

rasmussenanders said...

You may want to educate yourself as well before making definite claims:

Take a look at a preview of a coming article in the Brtish journal of Urology at:
http://www.doctorsopposingcircumcision.org/pdf/sorrells_2007.pdf

There are studies which claim there is no difference in sensitivity and there are studies which claim that there is a difference, why are you so sure that you are right?

I want to emphasise that the sexual pleasure that the foreskin brings is also merely one of its functions there are many others, see again (or take a look at one of the many studies cited on the page...): http://www.cirp.org/library/sex_function/

Some interesting information about the randomized experiments on which WHO base their conclusions is that all three were supervised by scientist known to be pro-circumcision. All three studies were ended prematurely, which would have concealed a plausible rise in HIV among the circumcised men. Therefore the conclusions are premature as well...

Joshua Amos said...

Anders said: "You may want to educate yourself as well before making definite claims."

He then goes on to quote a study organized and funded by the anti-circumcision organization NOCIRC with direct involvement and assistance from a fringe organization "Doctors Opposing Circumcision" and expects anyone, and I mean anyone, to take the findings of such a study seriously.

In desperation Anders goes on to cite claims from an anti-circumcision website to support claims of a sexual function for the foreskin.

And finally while providing no proof drops the innuendo that as the randomized controlled trials which found that male circumcision reduces the risk of heterosexual infection to the man by 60% were supervised by a "pro-circumcision" scientist the findings may be questionable.

Now get this. A study planned, funded and organized by anti-circumcision organizations should be taken seriously while other studies can be discounted on the mere suspicion that one of the participants may be pro-circumcision.

Not very good logic is it ... but as they say if your argument is not supported by the facts then you have to do whatever it takes to sell your point of view. Very sad.

rasmussenanders said...

The study I referenced to is about to be published in the british journal of urology, a highly respected, peer reviewed journal.

So go ahead and fool yourself all you want, but don't go and wave away every argument by claiming that it is biased (unlike all your own references of course).

The fact is that you have not once actually met any of the arguments. You have not had a single concrete complaint about how the studies were conducted, which is the way we normally do science...

rasmussenanders said...

Let me add that I do think that the studies which you have shown references to are interesting and I will take them into account in the future.

I am far from convinced that circumcision is a good HIV-prevention stragety, because I think that the foreskin has many important functions, and I am not only talking about pleasure.

Nevertheless, I think that your argumentation has become personal beyond the extent that I can tolerate here. You are accusing me of all kind of things, and you are not adding anything anymore. Therefore I will stop the comments on this post now, you are of course welcome to keep sending comments on other posts as long as they are objective.