Talk:Medical analysis of circumcision/Archive 8

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Definition of "relative risk"

Welcome back, Jake! You added "Published meta-analyses, using data from the RCTs, have estimated the summary relative risk at 0.42..." To me, the wikilink to "relative risk" doesn't sufficiently clarify what's meant here. I suppose you mean that the rate of HIV infection in circumcised men divided by the rate in uncircumcised men was estimated at 0.42. If so, I would insert in parentheses something like "(rate of HIV infection in circumcised divided by rate in uncircumcised men)". Coppertwig (talk) 22:50, 22 September 2008 (UTC)

Thank you, Coppertwig! That seems a reasonable addition to make. I'm slightly concerned that it is a little ORish, but explaining a term doesn't seem to have any NPOV implications, so that concern is minimal. Jakew (talk) 15:58, 23 September 2008 (UTC)

The case of the mysterious Arda study

I've deleted a link to a study apparently authored by Arda et al. The link was to an article at CIRP, and appears to be a legitimate study published by BJU International, entitled "Toxic neonatal methaemoglobinaemia after prilocaine administration for circumcision". However, when trying to find a better link for the article, I ran into some problems:

1. PubMed has no record of the study.
2. Google Scholar has no record of the study.
3. Searching BJU International's website revealed no evidence of the study's existence.
4. According to the CIRP page, the study appeared in volume 85, number 9, page 1. BJU International's page for that issue reveals no record of the study, and indicates that pages for that issue were numbered from 1007 to 1153.

For these reasons, I'm not confident that the study was ever published, and have therefore removed the link to the CIRP page. Jakew (talk) 19:23, 23 September 2008 (UTC)

Brennerman and Freud

Brennerman is from 1921 and Freud is from 1947. Are there truly no later studies for this? Secondly, Freud disagrees with Brennerman and says that the ulceration appears in noncircumcised children as well, although to a lesser degree. If anything, Brennerman needs to be dropped and Freud used as the later study. Lastly, can we get a better url? CIRP is performing its classic POV highlighting job again . -- Avi (talk) 19:35, 23 September 2008 (UTC)

There's a brief mention of meatal ulceration in the abstract of a 1995 literature review.[1] I don't have the full text, unfortunately.

Although it's desirable, I don't think it's necessary to provide a link at all. After all, we're already providing a citation, so the link only serves as a convenience link. If the link is problematic, for example if editorial comments and/or highlighting have been made, then it may be better to omit the link. If a reader chooses to do so, (s)he can find easily find CIRP's reprint of the article via a search engine. Jakew (talk) 14:13, 24 September 2008 (UTC)

Non-mention of prostate cancer

I think this sentence could be considered original research: "Neither the American Cancer Society nor the professional medical organizations' policy statements on circumcision cited here mention a relationship between circumcision and prostate cancer." It's also somewhat non-interesting as non-information. I therefore support deleting it. ☺ Coppertwig (talk) 12:35, 24 September 2008 (UTC)

Yes, it seems to be original research, which is why it was deleted. Conceivably, a source might somewhere exist saying something like "prostate cancer is not mentioned in statements about circumcision by the ACS and medical organisations X, Y, and Z". If such a source exists, I see no reason why it shouldn't be cited. However, I think it very unlikely that a source would say "...by the ACS and medical organisations cited in Wikipedia's article, Medical analysis of circumcision". Jakew (talk) 12:48, 24 September 2008 (UTC)

Delete 'smegma and cancer' section

It seems to me that the 'smegma and cancer' section (which was previously part of another, unrelated section) doesn't really belong in this article. Although it's interesting, it doesn't directly relate to circumcision; at best, it's background information for the penile & cervical cancer sections (it has been proposed as a mechanism for negative associations with these cancers). I propose to merge any information not already present in smegma into that article, and then delete the section. Any comments on that proposal? Jakew (talk) 16:48, 24 September 2008 (UTC)

I am ok deleting it. You mean you are going to merge the info into the sections right? That's fine.—Preceding unsigned comment added by Tremello22 (talk • contribs) 17:12, September 24, 2008 (UTC)

I think Jake means delete the information from this article completely, and put the information into the smegma article instead (not into sections of this article). I probably support that. Do the refs for the smegma section mention circumcision? Do other sources cite those refs in the context of circumcision? Does any source state that studies about smegma are relevant to circumcision? If not, it probably doesn't belong here, per WP:SYN. ☺ Coppertwig (talk) 02:13, 25 September 2008 (UTC)

The refs do mention circumcision, but it is very much background. At least some of them are also cited in other sources. For example, Schoen (The relationship between circumcision and cancer of the penis. CA Cancer J Clin 1991; 41: 306-9) cites Plaut & Kohn-Speyer when discussing possible mechanisms. I don't think that it's technically synthesis to include this material, but on the other hand it is at best indirectly related to circumcision (the hypothesis being that circumcision is directly related to penile cancer because circumcision reduces the incidence of smegma, and smegma is carcinogenic). The relationship between this material and smegma is direct and self-evident, and it seems to me that that would be a better place for the material. There's no reason why we can't add a sentence or two of the form "As a possible mechanism, Schoen cites ..." to this article, but I see little point in including in-depth material in two different places. It makes more sense to include it in the most relevant place, and summarise elsewhere. Jakew (talk) 13:22, 26 September 2008 (UTC)

I agree: as with the disposition of the foreskin, a brief mention of the relationship of smegma can be included, with a link to more in-depth analysis elsewhere: that sounds fine. ☺ Coppertwig (talk) 00:42, 29 September 2008 (UTC)

Describing authors

I support this edit by Tremello, which deletes "an anti-circumcision campaigner". To ensure NPOV I think it's probably easiest to simply name authors, without describing them; it might be hard to come up with NPOV descriptions. ☺ Coppertwig (talk) 00:40, 26 September 2008 (UTC)

I concur. AlphaEta 01:18, 26 September 2008 (UTC)

I agree as well. Poisoning the well about a person is never appropriate. However, I would say that regarding the CIRP links, it remains appropriate to point out their POV, as they use HTML highlighting themselves to poison the well or highlight data that supports their perspective. I am certain that Van Howe, when he published his paper, did not submit it full of yellow highlighting, bolded statements, and underscores. Thus in the notes, if a link is to a CIRP version, and not the original paper, a warning is not inappropriate. -- Avi (talk) 02:06, 26 September 2008 (UTC)

I concur. Readers might not understand that the highlighting is not in the original document or that we're intending to cite the original document, not the CIRP version. ☺ Coppertwig (talk) 02:15, 26 September 2008 (UTC)

Title of section after complications

To use the phrase "possible medical benefits" isn't very neutral if you ask me. You seem to imply that because we have outlined the complications then to even it out we should add your opinion that it possibly confers medical benefit. I disagree with that. Tremello22 (talk) 15:48, 23 September 2008 (UTC)

The subsections themselves discuss the potential benefits. Further, as analysis includes results of all kinds, should we decide on "Analysis" as a heading, then we have to combine the two sections (complications and benefits) so as to maintain neutrality. -- Avi (talk) 15:52, 23 September 2008 (UTC)

Are you seriously suggesting, with a straight face, that it is unreasonable to describe a possible lowering of cancer rates as a "possible benefit?" Maybe we could title the section "Doubleplusunbad effects"? Nandesuka (talk) 15:53, 23 September 2008 (UTC)

Yes because the American cancer society have said that circumcision should not be used as a means to lower cancer rates. This is because there is no evidence to suggest it does. Tremello22 (talk) 15:56, 23 September 2008 (UTC)

Tremollo, that does not mean that it not a benefit, it means that it is not a suggested mode of prevention in and if itself. To deny that if one is circumcised for other reasons that it does not confer possible benefits is somewhat illogical. -- Avi (talk) 15:59, 23 September 2008 (UTC)

Tremello22, I think you need to re-read the ACS statement. The ACS do not say that they do not recommend circumcision because there is no evidence that it is protective. In fact, they say quite the reverse: "Circumcision seems to protect against penile cancer when it is done shortly after birth. Men who were circumcised as babies have less than half the chance of getting penile cancer than those who were not. The reasons for this are not entirely clear, but may be related to other known risk factors. For example, men who are circumcised cannot develop a condition called phimosis. Men with phimosis have an increased risk of penile cancer (see below). Also, circumcised men seem to be less likely to be infected with HPV, even after adjusting for differences in sexual behavior."[2]

I should also point out that even if the ACS were adamant that circumcision was not protective, that would be evidence that the benefit is disputed. It would not indicate that the benefit is impossible. A title such as "benefits of circumcision" would imply that the benefits definitely exist. Describing them as "possible" acknowledges that some are disputed. Jakew (talk) 16:25, 23 September 2008 (UTC)

Avi I am fine with your suggestion of combining the 2 under one heading. Tremello22 (talk) 15:57, 23 September 2008 (UTC)

Avi other studies have found no link either. Anyway I've combined complications under the medical analysis since you think it isn't neutral as it was. —Preceding unsigned comment added by Tremello22 (talk • contribs)

Refactorization

Per Tremollo's initial start, I have re-ordered the article. Sections which describe potential complications of circumcision are in the first section. Sections that specifically discussed circucision being implicating in reducing complications, severity, or frequency of verious illnesses/diseases are in the second section. The sections on Phimosis, Paraphimosis, and Hygiene did not fit well in either section, so remained on their own. -- Avi (talk) 16:30, 23 September 2008 (UTC)

I don't think you understood my objections. My objection is that by using that heading you imply that there is more evidence to suggest a benefit than there is to suggest there is no benefit. Just because the studies showing no benefit haven't been written here doesn't mean there aren't any. the reason they aren't here is because they have been left out purposefully. I think the layout of the article is fine now. Tremello22 (talk) 16:44, 23 September 2008 (UTC)

Perhaps I did not, and we're both pushing up against 3RR, however unintended, so we should continue the discussion here. My objections to the way you have it, is that the way it is now, it seems to be hiding the benefits and trumpeting the complications. The subsections are clear that there may be benefits, just as there may be complications. Therefore both should be introduced the same way, in my opinion. -- Avi (talk) 16:53, 23 September 2008 (UTC)

How are the complications given more weight and being trumpeted up? I think you are coming into this discussion from a non-neutral point of view. The layout even reflects the view of the medical associations. There may be benefits but they haven't been conclusively proven yet.Tremello22 (talk) 16:54, 23 September 2008 (UTC)

We all have individual biasses. The trick is to try to avoid writing those biasses into the article. Editors with different biasses working together can write a better article. ☺ Coppertwig (talk) 12:36, 25 September 2008 (UTC)

I think some medical associations would disagree with that statement (that there "may be benefits but they haven't been conclusively proven yet") For example, consider the WHO's statement about the association with HIV being "proven beyond reasonable doubt". Regardless, Avi has a good point. The reader is presented with "possible complications" as a heading, but "possible benefits" seem to be missing. And this is difficult to justify. Although there is no dispute about the existence of some complications, others are more controversial. For example, the meatal stenosis, breastfeeding, and emotional consequences are all disputed. By your (Tremello22) own argument, the heading "possible complications" should not therefore be used. But I think that argument is erroneous. Regardless of how likely you, Avi, or myself may personally think it is, it is possible that these are complications, and possible that penile cancer, etc, are benefits. Indeed, by saying "there may be benefits", you seem to be agreeing with that.

A further problem, which I've tried to correct on several occasions, is the "Further medical analysis" section heading. This is a meaningless heading in the context of this article, which is - after all - about medical analysis. If you're unhappy with "Relationship to specific conditions", please suggest an alternative that actually means something. Jakew (talk) 23:33, 23 September 2008 (UTC)

The WHO aren't a medical organisation. We are primarily talking about routine infant circumcision here and all medical associations agree that the risks of circumcision outweigh the benefits. Here is how most of these conditions have come to be linked with circumcision - some guy who is pro-circ dreams up the reason - studies are conducted by the pro-circ people and then what do you know - it shows some protective benefit. OK, I see you are not happy with the title "medical analysis", therefoere i propose "analysis in regards to specific conditions" My aim is to keep it as neutral as possible and not imply something - you should take a read of WP:AVOID, specifically WP:WTA#Article_structures_that_can_imply_a_point_of_view Tremello22 (talk) 15:33, 24 September 2008 (UTC)

Tremollo, the same case could be made for anything by Van Howe, in that he will dream up an anti-circ reason and then do the research. Intimating reasons for various researchers' motivations is WP:OR and forbidden. Published research is permissible, as you well know, so let us proceed reasonably without letting our respective personal points of view overly color our dialogue. -- Avi (talk) 15:39, 24 September 2008 (UTC)

This heading change is poor. The content of the "possible complications" section also constitutes "analysis in regards to specific condition". Jakew (talk) 15:52, 24 September 2008 (UTC)

Tremello22, you seem to want to have your cake and eat it too. You're taking great pains to avoid describing possible benefits as such, but at the same time you want to have a section entitled "Possible complications of circumcision". Personally, I think it's logical to divide the article into "possible complications" and "possible benefits" (or "conditions which have been proposed as possible...", or however we put it). However, if you're adamant that we should avoid doing that for benefits, we have to do the same with complications. What we can't do is to treat the two sections of the article differently, as that is non-neutral. Jakew (talk) 16:17, 24 September 2008 (UTC)

How do you mean 2 sections of the article? There are 9 sections. Like I said before no benefits have been proven conclusively so the word analysis is appropriate. The complications have been proven. That is the difference. With regards putting the complications under the "Analysis in regards to specific conditions" heading. Are you sure - complications aren't really a specific condition. But if you want I will put it there. Tremello22 (talk) 18:41, 24 September 2008 (UTC)

(unindenting) I mean the two sections that contain the bulk of the article: currently, section 3 ("Possible complications of circumcision") and section 4 ("Analysis in regards to specific conditions").

Suppose we were to create a "rule" for deciding how to incorporate claims about the medical effects of circumcision. Judging by the present layout, the rule seems to be this:

• Does the claim allege that the effect is positive or negative?
  • If negative, call it "a possible complication of circumcision"
  • If positive, call it "analysis in regards to a specific conditions"

It would be difficult to argue that such a rule is neutral. While I respect your opinion (and those who agree with you) that no benefits have been proven conclusively, there are equally valid opinions (such as the WHO statement on HIV) that one or more benefits have been proven conclusively. Furthermore, as noted above, there is disagreement in reliable sources over whether some complications are, in fact, complications. We can't achieve NPOV by structuring the article around a single viewpoint; instead we must base the article on the claims that have been made in reliable sources.

So here are some alternative "rules":

• Does the claim allege that the effect is positive or negative?
  • If negative, call it "a possible complication of circumcision"
  • If positive, call it "a possible benefit of circumcision"

Or:

• If the claim alleges that condition X is related to circumcision, include it under the heading "X".

Jakew (talk) 18:59, 24 September 2008 (UTC)

Yes but the point is: depending on the source, the claim differs as to whether circumcision offers a protective benefit. The valid opinions of the WHO are mentioned in the appropriate section along with other opinions that disagree. What's the problem? I don't see it myself. Tremello22 (talk) 19:53, 24 September 2008 (UTC)

Similarly, as I noted previously, sources differ as to whether circumcision has a specific harmful effect. For example: "these physicians have incorrectly included meatal stenosis among complications of neonatal circumcision" (Wiswell TE. Circumcision questions. Pediatrics 1994;94:407-8). A second example: "There was no evidence of an association between neonatal circumcision status and breastfeeding outcomes, or between circumcision status and health and cognitive ability outcomes associated with breastfeeding, and the findings do not support the view that neonatal circumcision disrupts breastfeeding." (Fergusson DM, et al. Neonatal circumcision: effects on breastfeeding and outcomes associated with breastfeeding. J Paediatr Child Health. 2008 Jan;44(1-2):44-9). And a third example, quoted from the article: "Moses et al. (1998) state that "scientific evidence is lacking" for psychological and emotional harm, and cite a longitudinal study finding no difference in developmental and behavioural indices."

Yet in each case, these conditions are found under the "possible complications" heading. That seems remarkably inconsistent. Jakew (talk) 20:19, 24 September 2008 (UTC)

Good point, Jake. -- Avi (talk) 00:54, 25 September 2008 (UTC)

Tremello, you said "the complications have been proven". Surely not all complications have been proven. Are there any about which there is no controversy? Jake has a good point: including complications about which there is controversy as to whether they are complications in a section labelled "possible complications" would have to be balanced by treating benefits about which there is contoversy in a similar manner. I'm not sure we can conclude that there is controversy in RSs about the alleged HIV benefit after the RCTs: I haven't seen any refs questioning it after the RCTs as far as I remember. So perhaps for purposes of NPOV the HIV benefit can be considered proven. ☺ Coppertwig (talk) 02:20, 25 September 2008 (UTC)

Just as there are possible complications, there are possible benefits too. Feel free to make the wording parallel, and restore WP:NPOV. Jayjg ^(talk) 02:45, 25 September 2008 (UTC)

The things Jake mentioned are not under complications anymore since I put them under the more neutral heading "Psychological and emotional consequences". Meatal stenosis doesn't have its own heading either. To coppertwig - there have been criticisms over the validity of the RCT's and so it still isn't proven either way. Further still, you only mention HIV - what about all the other conditions - they would still be under the heading possible benefits. To Jayjg , it is neutral.Tremello22 (talk) 16:59, 25 September 2008 (UTC)

No, actually, it's not neutral to bury the possible benefits, but have special headings for possible complications. This has been explained to you already, and will have to be fixed. Jayjg ^(talk) 23:49, 25 September 2008 (UTC)

Actually, "meatal stenosis" is still included under "possible complications". A second problem is that "Psychological and emotional consequences" is not a sub-heading of "Analysis in regards to specific conditions".

As a general comment, it's not terribly productive to think in terms of "proven" or "unproven", since the question is whether sources disagree or not, not whether there is absolute proof (which would require us to make that assessment, and of course we can't do that). It's probably better to think in terms of "controversial" vs "uncontroversial", though I'm not convinced that even these are good criteria for the layout. Jakew (talk) 18:28, 25 September 2008 (UTC)

The difference is though that each complication isn't given its own heading. Also, Complications are directly caused by circumcision - whereas almost of these conditions are indirectly linked to circumcision and therefore should not be treated equally.

Your proposal of headings would mean that those conditions would be then strongly associated with a benefit to circumcision. Which would violate NPOV policies. Also the title heading "possible benefits" doesn't correlate with the subheadings - penile cancer isn't a benefit of circumcision, Human Papilloma Virus isn't a benefit of circumcision. See what I mean?

You say "the question is whether sources disagree or not", then why should we favour one side of the argument? Presumably the title would be "possible preventative benefits of circumcision in relation to specific conditions". How can you say with a straight face that that is neutral? You might as well say "circumcision prevents the following conditions:".

You say we can't make an assessment but let me remind you that it it is generally agreed by medical associations worldwide that this elective procedure carries risks of complications and that there isn't sufficient evidence to recommend it to newborns. This is evident by the fact that countries that used to do it have turned their back on RIC. In most places that don't do it, it is generally considered mutilation. Tremello22 (talk) 22:15, 25 September 2008 (UTC)

re. your other title suggestions below - What is the point in dividing the article into "Possible decreases in risks" and "possible increase in risks"? You would have to use a lot more judgment to judge which conditions go with which title and I thought it is , as you said, best to restrict as much as your own judgment as possible. Tremello22 (talk) 22:23, 25 September 2008 (UTC)

Ok, let me address your concerns one by one.

• "The difference is though that each complication isn't given its own heading". This is a discussion about the structure of the article, so obviously that needn't be the case for all time. Nothing is stopping us from breaking up the complications sections.
• "Also, Complications are directly caused by circumcision". The degree to which we can be certain of causality can vary. To take one extreme, we can be reasonably certain of a causal relationship between circumcision and bleeding, because the penis starts to bleed during circumcision, there's an obvious explanation for bleeding, and it is well-established that the body bleeds when cut, and of course penes are unlikely to start bleeding spontaneously, so the correlation is highly consistent. But to take another example, we can be less certain of a causal relationship between circumcision and failure of breastfeeding, because the evidence of correlation is inconsistent, the proposed mechanism speculative, and so on. As a general rule, there really no reason to treat what WP:RS call complications differently from what WP:RS call benefits.
• "Your proposal of headings would mean that those conditions would be then strongly associated with a benefit to circumcision. Which would violate NPOV policies". No, the proposed headings do not indicate a strong association, nor a proven association, just a possible one. Similarly, if I say "it is possible that Tremello22 is over six feet tall", it does not imply that this is likely. Nor does it imply that it is unlikely.
• "Also the title heading "possible benefits" doesn't correlate with the subheadings". Fair point. There are two obvious solutions. One is to use "conditions proposed as more likely to affect circumcised males" and "conditions proposed as less likely to affect circumcised males" as the parent headings. The other is to use "Reduced risk of HIV (etc)" as subheadings.
• "You say "the question is whether sources disagree or not", then why should we favour one side of the argument?" We don't favour one side, but the only reason why the subject is discussed in the first place is because it has been proposed that there is an association. If you think about it, there are an infinite number of things that probably aren't associated with circumcision: playing frisbee, writing poetry, and the common cold spring to mind. We don't discuss them because nobody has stated that they are unrelated, and nobody has stated that they're unrelated because the lack of relationships is, to be blunt, incredibly boring. Jakew (talk) 23:42, 25 September 2008 (UTC)

(unindent) Lets just go back to look at the complications. Yes bleeding is caused by circumcision. Then you try to win the argument by bringing up breastfeeding. In case you didn't notice, breastfeeding isn't in the complications section. Care to list anything else? The other complications such as loss of penis are directly caused by circumcision. So do you agree that if there has to be a slight NPOV unbalance (which you see, but I don't) then do you not think that it should go in favour of things we are actually certain about? But like I said, this is missing the main point: even if there was a debate over causality in the majority of these complications, the current structure isn't a problem because the complications are not given a subheading and so are not going to be attributed to a "complication of circumcision"(i.e. it isn't one of the anti-circ arguments - see what I mean about this page turning into a debate rather than an analysis) whereas if you had your way then circumcision would be attributed to benefiting these conditions. You argue that "possible benefits" or "conditions proposed as more likely to affect circumcised males" doesn't infer anything and you use a bad analogy about height. Someone's height is an innocuous thing - there is no debate to be had over someone's height, it isn't a sensitive issue and more importantly - it is easily provable. Lets just remember shall we, the title of this article is "Medical Analysis of circumcision" Now if this was a debate and it was the pro-circ's turn to step up to the debate podium and list off the list of benefits "lower risk of...etc" then I could understand the need for an argument-proposal style structure. But if it were that way then you would automatically be giving the pro-circ side the floor and therefore conferring an advantage.

re: your argument about Breastfeeding. It is currently in the "Psychological and emotional consequences" section. We can change the title of the "Psychological and emotional consequences" section if you would like. I am willing to admit that the word "consequences" carries a negative connotation. So would you like to propose a heading? There is no reason why that section need be an anti-circ section (if we look at things from that adversarial perspective, like you seem to be doing). As I say, there may be some people that get circumcised late in life that actually are happy about it. Maybe they like the new look or they had phimosis, or whatever. For them there is a psychological benefit. Or maybe there are Jews that would be emotionally or psychologically impacted if they didn't get circumcised. Maybe there could be 2 subheadings "positive" and "negative"? Tremello22 (talk) 19:29, 26 September 2008 (UTC)

Tremello22, let me explain the problem as clearly as I can. Here is the disputed part of the article structure:

• 3 Possible complications of circumcision
  • (conditions that have been proposed as complications of circumcision are included here)
• 4 Psychological and emotional consequences
• 5 Analysis in regards to specific conditions
  • (conditions that have been proposed as benefits of circumcision are included here)

Now, the problems with this structure are as follows:

Section 3 includes conditions such as meatal stenosis and painful erections, which are disputed. Please note that this isn't inherently a problem, as they have been proposed as complications and hence are "possible" complications. However, as I shall explain, the unequal treatment of evidence is a problem.

Section 4 includes psychological and emotional harm, as well as breastfeeding. You acknowledge that the heading is problematic, but my question is this: why is this section 4 and not 5.1? Isn't it "analysis in regards to specific conditions"? In fact, aren't both sections 3 and 4 "analysis in regards to specific conditions"? Of course they are.

And then we have the wonderfully named section 5, "Analysis in regards to specific conditions". What does this mean? Will any reader, just looking at the table of contents, have any idea? I don't. 'What', (s)he might well ask, 'is an "analysis in regards to a specific condition", and how does it differ from the preceding sections?'. And perhaps after (s)he finishes reading the article: 'why does this article try so desperately to distance itself from the very idea that there might be benefits, so much so that it uses a heading that's so vague that it is practically devoid of meaning, yet it doesn't try to distance itself at all from the merest suggestion of a harm?'

As I've shown, you can't say that complications are undisputed and benefits are disputed, because there are several complications which are disputed. And using such a division as the basis for structuring an article can easily create NPOV problems. To illustrate that, imagine if we were to divide complications into a section entitled 'possible complications' and another entitled something vague like 'analysis in regards to specific conditions that may or may not be complications'. Now imagine that you're a researcher who proposed one of the complications in the long-winded section name. What does that structure say to you? By contrast with "possible complication", it implies that your complication is unlikely. It's like telling two of your three children that you love them, while maintaining a stern silence towards the third. Jakew (talk) 21:25, 26 September 2008 (UTC)

On the whole there is more evidence to suggest that the complications happen, than there is to suggest benefits of circumcision in each of the conditions. Also, there is no debate to be had on the complications therfore the use of the word "analysis" isn't need. The so-called benefits of cirucmcision there is a debate to be had. That is the difference. Now that you have changed the parent heading to possible benefits, it is massively over-favour the pro-cirucmcison point of view and massively overhyping the benefits. None of these things have been conclusively proven. I also thought you said that "possible benefits" wasn't a good heading. It just shows you how biased you are. Tremello22 (talk) 19:22, 28 September 2008 (UTC)

Tremello, as has been explained to you several times, the benefits and the complications have about equal "evidence to suggest" that they happen. The complications are debated as much as the benefits, but the current article structure violates NPOV, by taking a position - your position - that the complications are all real, while the benefits are "debated". Ignoring this, or continually pretending it doesn't exist, is unacceptable. The article will be refactored so that it complies with WP:NPOV. Jayjg ^(talk) 23:45, 28 September 2008 (UTC)

O.K then, to Jakew i will ask this, which specifically of the complications is there debate over whether they happen or not? Here are the complications listed: blood loss,infection ,urinary fistulas,chordee,lymphedema,ulceration of the glans,necrosis,hypospadias,epispadias,removal of too much/too little tissue, sometimes causing secondary phimosis,urinary tract infection,skin bridges,Venous stasis,Urinary retention,Painful erections. Also I thought Jakew you agreed that the parent heading wasn't adequate because the diseases themselves aren't the benefits, for instance "prostate cancer" isn't a benefit of circumcision. I disagree with you saying the complications are debated as often - that is a totally false thing to say. The way it looks like at the moment is that there are 16 headings for benefits and 3 headings for complications. So I guess that means that the benefits to downsides ratio is 16-3 in favor of circumcision. And that is your definition of neutral? Tremello22 (talk) 19:20, 29 September 2008 (UTC)

The best structure for the article

Clearly the current structure is inadequate and non-neutral. Here are some ideas that would be neutral:

1. Divide the article into "possible complications" and "possible benefits" (or "potential...", or "possible increases in risk" and "possible decreases in risk"). Create sub-headings for each condition (or, if closely related, group of conditions).
2. Avoid dividing the article by complications/benefits, and have a flat structure with a heading for each condition for which an association with circumcision has been proposed.

My personal preference is (1), many because 2 would be difficult to navigate. What do others think? Jakew (talk) 18:28, 25 September 2008 (UTC)

(1) will be better for the reader, and more neutral. Jayjg ^(talk) 23:48, 25 September 2008 (UTC)

I prefer (1) as well. -- Avi (talk) 14:44, 28 September 2008 (UTC)

Undecided. I think I prefer (1), but it reminds me of articles with "criticism" sections, which are supposed to be a lower life form; I haven't figured out yet what the difference is here. ☺ Coppertwig (talk) 00:54, 29 September 2008 (UTC)

My thoughts exactly coppertwig. Jakew et al. seem to want this page to turn into a debate - pro vs. con. The parent heading "possible benefits" is also very biased in favour of the pro-circumcision point of view because it starts off assuming a benefit rather than letting the reader decide. I notice jakew hasn't answered my question above. When there is a section over which there is debate then we should be neutral and call it "Effect of circumcision on certain conditions" or something similar. What is wrong with that? The proposed structure by Jakew just shows you how biased he is.

I think we all agree the complications I listed above only occur a small amount of the time. Given that fact, according to you there are 16 conditions over which circumcision has a protective effect, so why isn't everyone circumcising? Why is the USA the only 1st world country that does it routinely? Why do all the medical associations in the world not recommend it? Clearly it is because there isn't enough evidence to suggest that circumcision has a protective effect against those conditions. Therefore Jakew et al. it is wrong to take a debate format and it is wrong to propose these conditions as "possible benefits" because there are no proven benefits to circumcision. Tremello22 (talk) 18:28, 30 September 2008 (UTC)

Come now Tremello. Jake has turned over a new leaf and I agree with him. Very non-neutral. Heavily slanted towards pro circumcision. I dislike pros and con pages also. Personally I would scrap the whole article and start from scratch with the references but don't have the time or energy that particular edit war would entail. It's good to see Jake, Jayjg, and Avi on the truly neutral side and wanting to trim down the pro circ propaganda. Garycompugeek (talk) 22:55, 30 September 2008 (UTC)

I don't think the article needs to be scrapped Gary. I have no problem with studies showing slight benefits to circumcision but we must also list criticisms of those studies and add studies which show no protective effect. Also the references need to be properly formatted. As for the structure, like I said - with most, if not all of the complications, it is proven that they do occur as a result of circumcision (not all the time - hence "possible")- also proven is that the conditions exist. But fear of these complications isn't the biggest reason most people in the world have chosen not to circumcise is it? This is what is implied when Jakew takes a debate format. No, the reason most people don't circ is because the evidence for it's protective effects is wanting. So having a title like "possible benefits" is totally misleading to the reader and it doesn't reflect the real-life view of the subject. Tremello22 (talk) 11:46, 2 October 2008 (UTC)

It was not my intention to impart a new article that did not cover both sides of the story. That would be a complete violation of NPOV and not truly informative. Practically speaking, a facsimile of #2 would be most neutral. Sectional situations that explain the medical effects of circumcision. Garycompugeek (talk) 12:17, 2 October 2008 (UTC)

Tremello22, it is utterly pointless to speculate about why most people do not circumcise. It is impossible to know whether that is even a conscious choice. If I understand your argument correctly, we should start with the fact that most people don't circumcise, infer from that that the evidence of benefits is lacking, and consequently structure the article to represent complications as "possible", and benefits, by implication, as "impossible". The obvious problem is that one cannot start with "most people don't do X" and conclude that "X has no benefits". For example, "less than half of the global population have enough to eat" does not imply that the harms of starvation are overstated.

Nor, as you argue above, can we start with an absence of recommendation from a medical organisation and conclude that benefits are non-existent. If, for example, the AAP concluded that the benefits were non-existent, they would doubtless have said so. But instead, they stated: "Scientific studies show some medical benefits of circumcision. However, these benefits are not sufficient for the American Academy of Pediatrics (AAP) to recommend that all infant boys be circumcised. Parents may want their sons circumcised for religious, social and cultural reasons. Since circumcision is not essential to a child’s health, parents should choose what is best for their child by looking at the benefits and risks." (AAP, Circumcision Information for Parents, 2001) and "There is no disagreement between the Task Force and the authors over the fact that there are potential medical benefits to circumcision. There is disagreement over the magnitude of these beneficial effects. The Task Force found the evidence of low incidence, high-morbidity problems not sufficiently compelling to recommend circumcision as a routine procedure for all newborn males." (Pediatrics 2000 Mar; 105(3 Pt 1): 641-2)

It is not neutral to treat assertions differently, on the sole basis of whether a benefit or harm is asserted. Whatever structure we have must treat assertions equally. Jakew (talk) 12:39, 2 October 2008 (UTC)

By naming it medical analysis rather than possible benefits I am not implying that circumcision does not have any benefits though, am I ? I am just leaving the question open more, rather than starting from the point of view that it does have benefits and then having to try to disprove those benefits.

On the question of assertion, the definition of assertion is "to demonstrate the existence of". Now if we are demonstrating the existence of complications vs. demonstrating the existence of benefits, then there is wide gulf in the degree of assertion between those 2 things.

Even if there were "small benefits" as has been claimed, the way the article is setup leads the reader to believe that the benefits are not small but vast, in fact some might get the impression that it prevents against all these diseases. This is all due to the misleading heading "possible benefits" which as I have said before is not a very good description, and doesn't correlate very well with what is underneath.Tremello22 (talk) 15:14, 2 October 2008 (UTC)

Tremello, the problem is that "medical analysis" is so vague that it also describes complications. More to the point, it again introduces the problem of unequal treatment of sources. If a source proposes a benefit then it should be treated just the same as a source proposing a complication. Much as I admire your desire to find neutral headings, it is essential that the headings are neutral for all sections. If we create a situation in which we seem to distance ourselves from claims of benefit while endorsing claims of complications, it comes across as one-sided. Jakew (talk) 20:00, 2 October 2008 (UTC)

(unindent)I noticed you changed it to "potential benefits", it is slightly less misleading than "possible benefits" but still not satisfactory imo. I'm glad you recognise my efforts to get the structure right - if the foundation is faulty, it is hard to build a good article. How about "analysis of proposed benefits"? Tremello22 (talk) 22:21, 2 October 2008 (UTC)

It's a little clunky, but I can tolerate it if the other section is titled "Analysis of proposed complications".

In general, I'd prefer to avoid using "analysis" in headings (or indeed, in the title - I proposed renaming the article to "medical aspects of circumcision" here, and intend to revive that proposal at some point...). I fear that using "analysis" tends to invite the analysis of Wikipedia editors (ie., original research). Also, it would logically include only analysis, and would thus exclude facts, opinions, etc. Jakew (talk) 23:19, 2 October 2008 (UTC)

hmm the problem with with the complications being titled "Analysis of proposed complications" is that most of the complications do happen. For example it would be odd to put blood loss or infection under that title because it would imply that we aren't sure if they have ever happened or not. Just so I am sure, which of the complications do you think don't necessarily happen and which do you think we can definably say they do happen?

On your other point, I think analysis is better than aspects. The definition of analysis is :"The separation of an intellectual or material whole into its constituent parts for individual study" - so that can comprise facts and opinions as well, as they are part of the debate too. Tremello22 (talk) 13:18, 3 October 2008 (UTC)

There's no doubt that bleeding and infections occur, but similarly there's no doubt about whether HIV infection occurs. The question is whether these conditions occur more or less frequently as a consequence of circumcision or non-circumcision.

One point of view is that all proposed complications, from bleeding to breastfeeding difficulties, definitely occur as a result of circumcision, and at a high frequency, and that all proposed benefits are dubious or mythical. Another point of view is that some proposed complications occur, at a low frequency, but that others are dubious or mythical, and that all proposed benefits definitely occur. (There is obviously a middle-ground as well.)

When selecting headings, we need to ensure that each heading is neutral from either point of view. If "Analysis of proposed complications" implies that we aren't sure a complication has ever happened or not, then perhaps it should be avoided because it would contradict the first point of view. Similarly, if "Analysis of proposed benefits" implies that we aren't sure a benefit has ever happened or not, then perhaps it should be avoided because it would contradict the second point of view. What is desired is a heading that is neutral without conveying doubt. I've suggested "possible", "proposed", and "potential" - what would you suggest? Jakew (talk) 13:59, 3 October 2008 (UTC)

There is ambiguity in the term "possible". "Possible benefits" could be taken to mean things that may or may not be established by scientists as being benefits. Or, it could be taken to mean things that have been shown to actually occur in a percentage of cases, so that for a given person having circumcision, that benefit is a definite possibility.

I see Tremello's point: if "possible benefits" is interpreted in the second way, and if it's followed by subheadings mentioning various diseases, then the headings could give the impression that it's been established that circumcision reduces the rates of those diseases.

Some alternatives for headings:

• "Complications or suspected complications" and "Benefits or suspected benefits";
• "Short-term effects" and "Long-term effects";
• "Physical effects", "Effects on infectious diseases", and "Sexual effects";
• Just "Effects", with subtopics such as "Effects on rate of HIV infection".

An advantage of the last two suggestions: under HIV, we can discuss both the risk of contracting HIV at the time of circumcision if instruments are not clean, and also the reduction in later contraction of HIV infection; I think it would be best to include both of these in the same place, which couldn't so easily be done if it's divided into complications/benefits or short/long term.

Re use of the word "analysis": I would prefer not to use it in the title of this article or in subheadings simply because it takes up space while providing little or no information. ☺ Coppertwig (talk) 14:55, 3 October 2008 (UTC)

I am glad you see my point coppertwig.

Responding to Jakew:

There's no doubt that bleeding and infections occur, but similarly there's no doubt about whether HIV infection occurs. The question is whether these conditions occur more or less frequently as a consequence of circumcision or non-circumcision.

It is quite hard to get my head around your way of thinking Jakew. So you are arguing then that circumcision doesn't increase the rate of complications? How can there be complications if there is no operation? If there were no circumcision these conditions (bleeding and infection) would not occur.

One point of view is that all proposed complications, from bleeding to breastfeeding difficulties, definitely occur as a result of circumcision, and at a high frequency, and that all proposed benefits are dubious or mythical. Another point of view is that some proposed complications occur, at a low frequency, but that others are dubious or mythical, and that all proposed benefits definitely occur. (There is obviously a middle-ground as well.) When selecting headings, we need to ensure that each heading is neutral from either point of view. If "Analysis of proposed complications" implies that we aren't sure a complication has ever happened or not, then perhaps it should be avoided because it would contradict the first point of view. Similarly, if "Analysis of proposed benefits" implies that we aren't sure a benefit has ever happened or not, then perhaps it should be avoided because it would contradict the second point of view. What is desired is a heading that is neutral without conveying doubt.

I think we can leave frequency aside - The point of view then I would adhere to is : Some proposed complications definitely occur (i.e bleeding and infection, skin bridges, too much/too little skin removed, Loss of glans) others there is debate over whether they occur or not ; all proposed benefits may occur but none have been categorically proven, either way there is a big debate over whether there are protective benefits.

( side note: You have yet to name the complications there is debate over, I wish you wouldn't mention breast-feeding complications because that should be in a separate section anyway)

I've suggested "possible", "proposed", and "potential" - what would you suggest?

Like I said before there is doubt over the proposed protective benefits against certain conditions. Can we agree on that bit? If I have got this straight you have doubts over whether some of those in the complications section occur more frequently as a result of circumcision. The easy solution then is to take the complications that we are unsure about out of that section. So which complications is there debate over and which occur more frequently for definite, circumcision vs. birth without being circumcised. Tremello22 (talk) 18:58, 4 October 2008 (UTC)

There is disagreement over certain proposed benefits, true, but that does not imply that those benefits are doubtful. Disagreement does not always imply doubt: as an extreme example, the Flat Earth Society would disagree with the statement that the earth is (roughly) spherical, but that does not mean that such a statement is doubtful. It's important to understand this in terms of points of view. From one point of view (that of those who disagree), the proposed benefits are doubtful. From a different point of view, they are not doubtful.

I understand that you believe, as you put it, that "none [of the proposed benefits] have been categorically proven". However, please understand that others may disagree with such an assessment. We need to avoid reinforcing either point of view in the article structure. We shouldn't imply that proposed benefits are "doubtful", since that would implicitly endorse the first point of view. Similarly, we shouldn't imply that proposed benefits are "proven", since that would implicitly endorse the second point of view. That means that we need to be neutral without implying doubt. I think Coppertwig's suggestions of "Complications or suspected complications" and "Benefits or suspected benefits" are good. What do you think? Jakew (talk) 21:28, 4 October 2008 (UTC)

I think I see Tremello's point: If someone is cut and they bleed, I don't think anyone disputes that it was the cut that caused the bleeding. Similarly if too much of the penis is accidentally cut off during circumcision, that's obviously caused by the circumcision, I don't think anyone disputes that. But there may not be any benefits with that degree of consensus that they are benefits. If we put symmetric headings, that could be taken to imply that there are somewhat similar situations with the two. Instead, how about "Complications, risks or suspected risks" and "Benefits or suspected benefits"? ☺ Coppertwig (talk) 23:56, 4 October 2008 (UTC)

Why aren't the situations similar? There are possible complications from anything: for example, cleaning your ears with a cotton swab can kill you. Strangely, though, the cotton swab article doesn't have a "Complications and risks" section. Go figure! Jayjg ^(talk) 02:01, 5 October 2008 (UTC)

There are possible complications and possible benefits from anything. That's not enough to establish the symmetry. The difference, as I point out above, is in whether there are any which are considered to the same degree of consensus to be proven.

Actually, my preference is not to use my last suggestion above, but to divide it into "Physical effects", "Effects on infectious diseases", and "Sexual effects", for the reason I give above re HIV. ☺ Coppertwig (talk) 02:17, 5 October 2008 (UTC)

As has been pointed out before, the "hemorrhage" section under Possible Complications is supported by one case of death. There's a "symmetry" with the risks from cleaning your ears cotton swabs for you. Jayjg ^(talk) 19:32, 5 October 2008 (UTC)

(unindent)Copper I like your suggestion. I think it would satisfy both points of view. Am i right in thinking that "complications" would change to "Physical effects" and the other section would be "Effects on infectious diseases". One question, you mention sexual effects but there is already a page on that: Sexual effects of circumcision Tremello22 (talk) 21:37, 5 October 2008 (UTC)

Lead Policy Sum

I have recently added to the lead the AMA's policy sum that we have been using in Circumcision. This gives the same benefit that it does in Circumcision so I fail to see Jayjg's objection that it is 10 years old and relies on one organization's statement. Garycompugeek (talk) 13:07, 3 October 2008 (UTC)

I.e. this edit, which I oppose for the following reason. Note that in the lead of Circumcision, there is a balance: it states "There is scientific evidence supporting both sides of the circumcision controversy," and it also provides the more recent WHO recommendations re HIV in addition to this older medical statement. Providing the medical statement without those balancing thingies violates WP:UNDUE in my opinion.

The lead to this article is very short because it is very difficult to write a lead that will satisfy all editors as being NPOV. Lengthening the lead is a good goal but will probably require a lot of discussion. I suggest proposing changes on the talk page for discussion before making significant changes to the lead. ☺ Coppertwig (talk) 14:45, 3 October 2008 (UTC)

The AMA policy sum is the best source of policies that we have at the moment. The lead is supposed to be a summary of main points in the article. The AMA is not some anti circ organization. They are merely quantifying a fact. This lead is abysmal and needs to be fleshed out. Garycompugeek (talk) 19:19, 3 October 2008 (UTC)

Fine: if you have time, it would be useful as a first step if you would propose text here on the talk page that addresses the concern I raised above. Perhaps we could use all the material relevant to medical analysis from the lead of the Circumcision article. ☺ Coppertwig (talk) 16:32, 4 October 2008 (UTC)

Draft lead

Numerous medical studies have examined the effects of male circumcision with mixed opinions regarding the benefits and risks of the procedure. Opponents of circumcision claim that it is medically unnecessary, is painful if performed without anesthetic, adversely affects sexual pleasure and performance, and is a practice defended by myths. Advocates for circumcision claim that it provides important health advantages which outweigh the risks, that it has no substantial effects on sexual function, has a complication rate of less than 0.5% when carried out by an experienced physician, and is best performed during the neonatal period.

The American Medical Association stated in 1999: "Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice."

The World Health Organization (WHO; 2007), the Joint United Nations Programme on HIV/AIDS (UNAIDS; 2007), and the Centers for Disease Control and Prevention (CDC; 2008) state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides partial protection and should not replace other interventions to prevent transmission of HIV.

Comments

Feel free to edit the above draft. It's formed from the current (one-sentence) lead followed by the last 3 paragraphs of the lead from Circumcision, except that I've replaced "violates the individual's bodily rights" with "is painful if performed without anesthetic" (slightly later in the sentence) as more relevant to this article, and I've deleted "There is scientific evidence supporting both sides of the circumcision controversy" as saying almost the same thing as the sentence which is the current lead, and I've joined that current lead into the following paragraph. ☺ Coppertwig (talk) 16:50, 4 October 2008 (UTC)

This looks good to me. Jakew (talk) 21:31, 4 October 2008 (UTC)

Organisation of penile cancer section

I'm a little concerned about recent changes to the penile cancer section. The organisation is poor, and some of the added material questionable.

• We start with "Penile cancer is a rare form of cancer, mostly occurring in men over the age of 60.[89].". The link doesn't work.
• Next, we have "Annually, there is one case in 100,000 men in the United States. Penile cancer is very rare in North America and Europe; it accounts for about 0.2% of cancers in men and 0.1% of cancer deaths in men in the United States. However, penile cancer is much more common in some parts of Africa and South America, where it accounts for up to 10% of cancers in men.[90]". The link has nothing whatsoever to do with circumcision, and, in fact, doesn't even mention circumcision.
• Next, "Frisch et al evaluated penile cancer rates in Denmark and found that Danish men (who are predominantly not circumcised) had an incidence of 0.9-1.0 per 100,000 in 1975.[91]" The incidence of penile cancer in Denmark seems to be excess detail for an article about the medical aspects of circumcision, but I suppose at least this source actually mentions circumcision.
• Then we jump from annual incidence to lifetime prevalence: "Kochen and McCurdy performed a life table analysis on penile cancer rates, and estimated that penile cancer affected uncircumcised males at a rate of 1 in 600.[92] However, Poland has criticised the assumptions used in their analysis.[93]"
• Next, in a new paragraph, we have: "Burkitt (1973) states that the geographical distribution of penile cancer is strongly influenced by circumcision status. However, he notes wide differences in penile cancer rates between African tribes who do not practice circumcision, and suggests that additional etiological factors may be responsible.[94]" Well, the first sentence is about circumcision, but the second sentence isn't.
• Next, "The Canadian Medical Association (1982) assert that there could be genetic or environmental factors that influence the incidence of carcinoma and that the association with circumcision could be coincidental.[95]" Several problems here. Firstly, the source is incorrectly described. The authors were actually writing on behalf of the Canadian Pediatric Society. Second, the viewpoint of the authors is misrepresented somewhat through selective quoting. The authors begin their paragraph by stating: "While the literature suggests that circumcision may protect against carcinoma of the penis, the case is not entirely proven", which provides contextual information needed to understand their later statement. Third, surely this quote belongs in the "Positions of medical organisations" subsection (if it belongs anywhere - I'm sure that the CPS have issued more recent statements). Finally, it is far from obvious why this has anything to do with the geographical distribution of penile cancer in Africa.
• Next, we have "Cadman et al.'s (1984) study, published in the Canadian Medical Association Journal, said that using routine infant circumcision to prevent penile cancer would not be cost-effective; the costs of circumcising everyone would be over a hundred times the savings achieved.[96]" Again, there are several problems here. Firstly, two minor points: the link should be this and listing the journal is wasteful of space and inconsistent with the rest of the article. Somewhat more important, what does this have to do with the geographical distribution in Africa or the causative mechanisms? Nothing whatsoever, as far as I can tell. So why is it in the same paragraph?
• Next, in a new paragraph: "Fleiss and Hodges, together with Cold, Storms and Van Howe, suggest that the "myth" that neonatal circumcision renders the subject immune to penile cancer can be traced back to an opinion article in 1932 by the American circumcisionist Abraham L. Wolbarst as a scare tactic to increase the rate of neonatal circumcision.[97][98]" Hang on - if we assume that the reader is reading the section from start to end, this doesn't make sense. Why are we discussing the Fleiss et al's assertions so soon?
• Next paragraph: "Fleiss and Hodges state that epidemiological studies have failed to prove Wolbarst's assertion.[98] Stanton, however, notes that Fleiss and Hodges cited only a single such study, 'that of Maden et al, and, curiously, omit its main conclusion--that "absence of neonatal circumcision and potential resulting complications are associated with penile cancer."'[99]" Again, this doesn't make sense in this position.

I could continue.

The logical order for this section is as follows:

• A brief introduction, giving an overview of penile cancer and citing appropriate sources that mention circumcision.
• Discussion of the evidence. We could start with studies of geographical distribution and move on to case series and then case-control studies. My own preference, however, is to start with stronger evidence first.
• Discussion of analysis, debate, and speculation re the evidence. Where appropriate (eg., Holly's comments about Maden), this can be worked into the previous section. Logically, this should also contain the comments by medical organisations.
• Discussion of the consequences of the evidence. (This would include, for example, Cadman's study. It is only meaningful to ask "would it be cost-effective to do X" once the question "would doing X make any difference" has been discussed.)

Jakew (talk) 20:25, 8 October 2008 (UTC)

I think the first paragraph is fine. I think you need a brief introduction (even if it doesn't mention circumcision) just to put things into perspective. Tremello22 (talk) 21:13, 8 October 2008 (UTC)

"just to put things into perspective" = original research. If the source doesn't even mention circumcision, then it has no place in this article. Jayjg ^(talk) 21:37, 8 October 2008 (UTC)

HIV section

The HIV section of this article is somewhat disorganised. I've made some changes, by reorganising the initial section to begin with systematic reviews and meta-analyses of observational studies, but it is still rather unsatisfactory.

I think that part of the problem is that the content of this section has grown over the years in a rather haphazard, unstructured way, with little or no organisation. As such, we have a bunch of quotes from various primary and secondary sources, seemingly collected at random. This presents something of a challenge for article maintainance.

Another part of the problem is that highly reliable secondary sources — by which I mean systematic reviews and meta-analyses of both observational and RCT data are scattered around the section. I've brought some of these together at the start of the 'observational studies' section, but those pertaining to RCTs are still near the end of the section.

It occurs to me that the appropriate thing to do is to combine all of the systematic reviews and meta-analyses into an 'overview' subsection, presented in rough chronological order. Having presented these, we can then proceed to discuss individual observational & RCT studies, along with comments & criticism, and hopefully with some kind of order. Certain parts of the text indicate that other subsections might be created - for example, one regarding studies of acceptability.

Any comments? Jakew (talk) 14:19, 17 October 2008 (UTC)

I agree. I was working at putting it in some chronological order myself. I put the review studies in chronologically the right place , now you have put them at the beginning. Not a criticism I am still unsure where they should go. Are those the only observational studies that have been done, do you know? I didn't group the USAID document - I must have missed that one. Just looking at the ref it appears that this review was done in 2000, not 2002 - "A systematic review and meta-analysis of 28 published studies by the London School of Hygiene and Tropical Medicine, published in the journal AIDS in 2000.". I have just looked and it appears that it is the Weiss, Quigley and Hayes one, which has already been cited. I've also just added a ref to the full text of the Weiss, Quigley and Hayes study rather than just the abstract. Strange though, in the AIDS document they say it is 28 studies but in the Weiss, Quigley and Hayes paper they say they used 27 studies.

Obviously anything relating to the randomised control trials can go in the appropriate section. I was thinking of starting a new acceptability subheading also - I wrote a small introduction anyway, but wasn't sure anyone would agree. We should try to keep chronological order to a degree but on rare occasions if there is a case where there are similar studies then we should probably forgo year of study and just put similar studies together. for instance Newell and Bärnighausen (2007) is put above earlier studies because it is in favour whereas the others were criticisms. Tremello22 (talk) 01:38, 18 October 2008 (UTC)

My thinking behind putting them at the beginning is that there is rather a lot of material, and I think it helps to provide an overview of the subject before going into more detail. I think strict chronological order would probably work if there was less material, or if it was more similar in nature, but given what we have to work with, I think some kind of overview is needed. Although not perfect, I can't think of a better, fairer way of presenting an overview than using the systematic reviews and meta-analyses.

In the discussion of RCT meta-analyses (last paragraph of the RCTs section), there's discussion of observational studies as well. (This is because the sources have chosen to discuss observational and RCT evidence together.) This makes it a little difficult to decide where this material belongs. Is it about RCTs or observational studies? Both, really. That's why I'm thinking of an "overview" section that isn't specifically about RCTs or observational studies, but which uses meta-analyses and systematic reviews to give a summary of both.

I think that the list of meta-analyses and systematic reviews of observational studies is more or less complete, but I think plenty of primary sources are not included. If there were 40 observational studies in 2000, I wouldn't be surprised if twice that number have been published by now, perhaps more if you include conference abstracts.

I agree that the USAID document refers to Weiss et al., which is cited as the 3rd reference in that document. If that were all it said, I'd suggest that it could be removed. However, the information about the "September 2002 update" appears to be unique. It occurs to me that the full quote should probably be deleted and replaced with a sentence or two at the end of the Weiss paragraph. Jakew (talk) 19:57, 20 October 2008 (UTC)

FYI

Since we've previously discussed what to do with the smegma/cancer material here, those with this page on their watchlists may be interested in a new discussion about that material here. Jakew (talk) 16:25, 18 October 2008 (UTC)

Marshall, CIRP, and misquoting

I just made a series of edits to this article that centered around a link to CIRP quoting a Marshall study. The text in Wikipedia said:

Marshall et al report that the stress of neonatal circumcision may alter feeding behaviour and some male infants may be unable to breastfeed after circumcision.[3]

Here's the problem: The Marshall paper doesn't say anything of the sort. Rather, that is a bracketed "helpful" parenthetical from CIRP drawing the conclusion.

This demonstrates one of the problems linking to CIRP for studies such as this. I propose that when citing studies, we need to cite the original source at a standard publisher, such as PubMed, rather than going through a "clearinghouse" -- especially one that inserts their own commentary into the middle of a paper! Nandesuka (talk) 13:24, 20 October 2008 (UTC)

Note: in my efforts to repair the damage caused by structuring an entire section around this egregiously fabricated citation, I may have cut too much. We can discuss what should be put back in this space. Nandesuka (talk) 13:25, 20 October 2008 (UTC)

Well spotted, Nandesuka! I hate to think how long this error may have been present. I agree: the Marshall paper doesn't even mention breastfeeding. It does report, however, that "circumcision has brief and transitory effects on mother-infant interactions observed during hospital feeding sessions" (the text indicates that this was bottle-feeding: "Although the volume of formula consumed was not monitored, subjective descriptions support the observations that the infants who were circumcised sucked on the bottles harder, faster and more concertedly.").

I also agree with your general comments about linking to studies. We should always cite the published text of a study. In addition, we can additionally include a link for the convenience of the reader, to the original publisher if possible, PubMedCentral if the study is available there, or simply to the PubMed abstract. But there's no obligation to provide a link, and where the link may be less than an authentic reprint (such as if it contains highlighting or editorial comments), it's probably better not to do so. Jakew (talk) 16:28, 20 October 2008 (UTC)

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 Wikipedia, 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. Wikipedia 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 Wikipedia: 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 [keratinization] 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)

Use of an ellipsis instead of "or benefits" in a BMA quote

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 Wikipedia, was "reasonable." The quote is: "The medical harms or benefits have not been unequivocally proven [...]." Put a different way, why, in your opinion, should Wikipedia 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)

The article currently says 'The British Medical Association (2006) stated that the "medical harms or benefits have not been unequivocally proven," and that "[...] it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks.' This looks reasonable to me, and as far as I know no-one opposes that version, so I think no discussion here is needed. I've replied to your question on my talk page, Blackworm. I've changed the section heading to one I consider more neutral. ☺Coppertwig (talk) 02:25, 27 July 2009 (UTC)

overquote in the references?

it seems like the references include very long quotes from references that are available online. is this really necessary? can we just specify page numbers?  —Chris Capoccia ^T⁄_C 04:57, 20 October 2009 (UTC)

Meticillin succeptible or resistent

It must be onbvious that the problem is methicilline resistence not succebility. That is Staphylococcus Aureus infection doesn´t respond to methicillin - MRSA - Methicilline Resistant Staphylococcus Aureus (MRSA) jmak (talk) 13:21, 16 January 2010 (UTC)

Right. It should be MRSA. MRSA is the risk and the topic here. Spelling and formatting. Methicillin-resistant Staphylococcus aureus Methicillin, not methiciline. Staphylococcus aureus should be italicized. Frank Koehler (talk) 13:02, 1 April 2010 (UTC)

Miscellaneous comments

• Positions of major health organizations: How about putting the countries in alphabetical order?
• Costs and benefits: "Van Howe is a fierce opponent of circumcision" seems to me to have a non-NPOV tone; how about a different adjective -- maybe "outspoken" or something? This and the following sentence might not be directly relevant: do we put in information just to question the credibility of sources? If the source (which I might not have access to the text of) says something directly relevant to this section, i.e. arguing against Van Howe on the topic of costs and benefits, then perhaps a more relevant statement can be cited from it.
• Potential complications: "one of whom suffered brain damage ... and one suffered brain damage": One, or two? Is this a confused paragraph that mentions the same incident twice in such a way as to make it seem like two separate incidents?
• "It is worth noting that despite the fact that metzitzah is performed exclusively in all circumcisions in chasidic strongholds such as Williamsburg, Monroe, New Square, and Crown Heights, there has never been a case of neonatal herpes reported. ": What does "exclusively" mean here? Does it mean that those places are the only places metzitzah is performed? Or does it mean those places are the only places where all the circumcisions involve metzitzah? Or something else? ☺Coppertwig (talk) 23:24, 14 March 2010 (UTC)

Restraints

I suggest that a paragraph on restraints be added to this article. (There was recently a discussion about restraints at Talk:Circumcision/Archive 61#Circumstraint.) I'm doing some web searches for sources; these might or might not meet Wikipedia's criteria for reliable sources:

• [4]
• [5]
• [6] "A circumcision restraint board safely immobilizes the infant during the procedure."
• [7] "Part of the discomfort a baby feels during the procedure undoubtedly comes from being handled and restrained. Rather than tightly strapping the baby down, using swaddling and a sugar-coated pacifier has been suggested.[41] In addition, a special padded, 'physiological' restraint chair has been devised and shown to reduce distress scores by more than 50 per cent.[42]"
• [8] "The infant is usually restrained in a molded plastic restraint device."
• [9] "If a padded restraint chair is not available, provide atraumatic care by padding the circumcision board and covering the infant as previously mentioned."

☺Coppertwig (talk) 18:02, 21 March 2010 (UTC)

It seems perfectly reasonable to add a paragraph to the 'procedures' section, but could you be more specific about what you have in mind? Jakew (talk) 10:51, 22 March 2010 (UTC)

Er, I dunno. I was hoping the editors who were eager to add a mention of restraints to the Circumcision article would chime join^{(19:34, 5 April 2010 (UTC))} in here. And maybe there isn't enough material for a whole paragraph, anyway. Thanks for replying, though. ☺Coppertwig (talk) 23:25, 28 March 2010 (UTC)

Numerous medical studies?

re: Medical analysis of circumcision/opening sentence "Numerous medical studies have examined the effects of male circumcision with mixed opinions regarding the benefits and risks of the procedure." It might be said of cancer, "numerous medical studies," but to say the same for circumcision is plainly an exaggeration. There have been numerous opinions -- very few "medical" studies. Historys Docs (talk) 17:32, 5 August 2010 (UTC)

PubMed currently lists 4,710 articles when searching for "circumcision". Based on a brief look at the first page of results, 12 of 20 appear to be studies (as opposed to opinion pieces or reviews). Extrapolating from that 60% figure, the total number of studies might be 2,826. Even using a very conservative estimate of 10%, there are still 471 studies. Isn't it reasonable to describe that as "numerous"? Jakew (talk) 19:16, 5 August 2010 (UTC)

Major health benefits are unlikely from an evolutionary point of view.

If there were major health benefits for circumcised individuals those individuals that were born with less foreskin would have had a higher survival rate than those individuals that were born with more foreskin. As humans today are born with foreskin it is very likely that individuals born with the currently normal amount of foreskin had a higher survival rate than individuals born with less foreskin.--158.39.241.139 (talk) 23:33, 17 December 2010 (UTC)

Hmm, your unstated assumption appears to be that the optimal amount of foreskin has not changed over time, in spite of changes to the environment in which humans exist. Anyway, this isn't the place to propose original theories; however, if you're aware of reliable sources making such arguments we might plausibly cite them. Jakew (talk) 10:39, 18 December 2010 (UTC)

This should be kinda obvious to anyone with a good understanding of evolution, but I have no idea if anyone has actually bothered to write an article about it.158.39.241.139 (talk) 18:11, 18 December 2010 (UTC)

Actually you could refer to wikipedia's own page about evolution. This diagram shows how evolution works: http://en.wikipedia.org/wiki/File:Mutation_and_selection_diagram.svg 158.39.241.139 (talk) 18:11, 19 December 2010 (UTC)

I also found this page about it: http://www.historyofcircumcision.net/index.php?option=content&task=view&id=15 158.39.241.139 (talk) 18:21, 19 December 2010 (UTC)

No, we can't. First, Wikipedia cannot be cited as a source. Please see WP:RS#Primary, secondary, and tertiary sources: "Although Wikipedia articles are tertiary sources, Wikipedia contains no systematic mechanism for fact checking or accuracy. Thus Wikipedia articles (or Wikipedia mirrors) are not reliable sources for any purpose." Second, any suitable source would have to explicitly discuss the relationship between evolution and the medical benefits of circumcision; we cannot make an original argument that is not made by a source. Finally, Robert Darby's site (historyofcircumcision.net) is a self-published source, and hence is considered insufficiently reliable for use as a source. Jakew (talk) 18:30, 19 December 2010 (UTC)

This article is linked to some sources about the evolution of foreskin: http://en.wikipedia.org/wiki/Foreskin#Evolution 158.39.241.139 (talk) 18:53, 19 December 2010 (UTC)

You might also just link to the sources the wikipedia article about evolution uses instead of linking to the wikipedia article itself.158.39.241.139 (talk) 18:58, 19 December 2010 (UTC)

Well, do any of those sources discuss the medical benefits of circumcision? Jakew (talk) 20:58, 19 December 2010 (UTC)

As I have said earlier. The current configuration of the human body is mostly a result of natural selection according to evolutionary theory. So if we have foreskin it is probably because it is advantageous to our survival and ability to produce offspring. There are some evolutionary leftovers in the human body like the appendix, but I highly doubt that foreskin is such an evolutionary leftover. This is mostly because it probably doesn't take a lot of mutations in the human genome to increase or decrease the size of the foreskin, just like it doesn't take a lot of mutations in the human genome to change the human skin color. We have light skinned people near the poles where there is less sunlight and dark skinned people near the equator where there is more sunlight. This is because it is evolutionary advantageous to have light skin color near the poles in order to synthesize more vitamin D, while it is evolutionary advantageous to have dark skin color near the equator in order to be better protected against skin cancer. So if it was evolutionary advantageous to have less foreskin we would have lost the foreskin now, just like the light skinned people living near the poles have lost their dark skin color. So I highly doubt that there are any major health benefits from male circumcision. Then we wouldn't have any foreskin now. 158.39.241.139 (talk) 23:08, 19 December 2010 (UTC)

As noted previously, Wikipedia isn't the place to advance original theories. The only thing that matters is what reliable sources say about the subject of this article. Jakew (talk) 23:38, 19 December 2010 (UTC)

The theory of evolution is hardly an original idea of mine ( although I wish it was ).158.39.241.139 (talk) 23:40, 19 December 2010 (UTC)

Your specific interpretation in the context of the medical benefits of circumcision, which you outline above, does appear to be an original idea of yours. Jakew (talk) 10:44, 20 December 2010 (UTC)

Well, it is not. Do you have any higher education in biology, or just in software engineering? 84.199.65.2 (talk) 16:08, 20 December 2010 (UTC)

Please discuss content, not the contributor. Jakew (talk) 16:16, 20 December 2010 (UTC)

Well, who do you think should be the judge of whether it is just my interpretation of evolutionary theory or not? Individuals with higher education in biology or individuals without any higher education in biology? 81.167.185.42 (talk) 15:07, 30 December 2010 (UTC)

It doesn't really matter who judges it. Either you cite a source that explicitly links evolution to the medical benefits of circumcision, or it violates Wikipedia's policy against original research. To quote from that policy: "To demonstrate that you are not adding original research, you must be able to cite reliable published sources that are both directly related to the topic of the article, and that directly support the material as presented." Jakew (talk) 15:11, 30 December 2010 (UTC)

It is in the very essence of evolutionary theory that the current configuration of any biological organism has emerged from natural selection. As the loss of biological structures happens much more easily than the emergence of new biological structures it is not very common to see biological structures in species which only serves to decrease their survivability. I am not saying that it is completely impossible that the loss of human foreskin actually increases human survivability, but it is very unlikely because of natural selection according to the normal interpretation of evolutionary theory.81.167.185.42 (talk) 18:09, 30 December 2010 (UTC)

At this point it seems as though I'm wasting my time in trying to explain Wikipedia policy to you. If you want to put this argument in the article, find a reliable source. Jakew (talk) 18:46, 30 December 2010 (UTC)

Use Darwin's on the origin of species as a source. It is the foundation of evolutionary theory.81.167.185.42 (talk) 18:53, 30 December 2010 (UTC)

On what page does it discuss circumcision? Jakew (talk) 19:31, 30 December 2010 (UTC)

Stripping organisms of properties that have emerged from natural selection usually decreases survivability according to the standard interpretation of Darwin's evolutionary theory. Do you need an introduction to deductive reasoning as well? If all bodily modifications that are stripping organisms of properties that have emerged from natural selection decrease survivability it follows deductively that if circumcision is such a modification it also reduces survivability. 81.167.185.42 (talk) 21:22, 30 December 2010 (UTC)

An introduction to deductive reasoning would be fine, as long as it explicitly links evolution to circumcision. That, as I keep trying to explain, is what is required by policy. Jakew (talk) 21:27, 30 December 2010 (UTC)

Huge series of dubious changes

I've just reverted a long series of dubious changes due to multiple problems. These include, but are not limited to:

• Multiple WP:NPOV violations. These range from WP:PEACOCK terms such as "A classic 1993 study on HPV ... A famous study on nongonococcal urethritis ... An exhaustive 1994 study on herpes simplex virus type 2" to assertions of opinion such as "Cutting off a part of your sons penis is not a logical way to prevent a rare and easily treatable UTI" to asserting the results of one study while ignoring contrary results such as "Most notably, circumcision drastically reduces the glans sensitivity to vibration". These are just a few examples, of course.
• Multiple WP:NOR violations. For example, as far as I can tell, none of the sources cited in the sentence beginning "Certain components such as Langerhans cells" actually discuss protective functions of the foreskin.
• Wrong article. If neutral and properly sourced, material about the function of the foreskin belongs in foreskin, not here.
• Failures of basic English (eg., "What is the foreskin? is a question that many Americans would have trouble answering"). (This sentence is inappropriate tone for an encyclopaedia anyway, but I'm including it to illustrate that even the first added sentence is problematical.)

I would request that the person who wishes to make these changes first present each change here on the talk page, so that such issues can be resolved prior to editing the article. Jakew (talk) 09:54, 17 March 2011 (UTC)