Just a head's up, re: the upcoming CDC stuff...

[pdx.mothernurture]

Not looking good...

http://www.publichealthreports.org/a...articleID=2352

[bandgeek]

I just skimmed it, but ugh! I rarely get in debates with people about RIC anymore since it's not a hot topic now that my DS isn't a baby, but when and if it comes up, I'm going to have this thrown in my face. I know how to argue it of course, but who's going to believe a single mom with only a high school diploma over the CDC?

Love how they report that men don't feel a decrease in sensitivity...don't ask them immediately after the surgery! Ask them in 2 years! See if it's still all fine and dandy.

Whatever. Nothing they could say will change my mind. Circumcising babies for risky sexual activity they may or may not have 15 years from now? Now that's common sense.

[Greg B]

Thanks for the link. Interesting read. I am not sure I would characterize it that way. I think I would instead say that it simply continues to try and promote circumcision to prevent HIV, not unexpected if that is your prime directive, but does a passing job in including a number of issues that raise questions and uncertainty. A few things stuck out for me:

"The potential impact of MC (male circumcision) on...HIV...currently limited" (due to way it is most commonly transmitted in the US)

This is a pretty interesting finding, confirming that this will have a minor benefit most likely, in the US

"No researchers have conducted clinical trials of MC in the U.S..."

Again, indicating that there is not much solid support for circumcsion in the US.

"Studies of sexual sensation and function in relation to MC are few...Taken as a whole, the studies suggest that some decrease in sensitivity of the glans can occur following circumcision and that there may be a consequent increase in ejaculatory latency."

This is where they really fall down. They have an overall finding that there are negative affects, but try to mimimize it with the rest of the wording used in this section, and in the studies cited. Still, they actually find the negative effect. What we need is bettter studies comparing intact vs circ'd men, including restored me....


"The role of informed and voluntary consent for MC involves a thin line between persuasion, peer pressure, and the potential for undue influence. And for children, there are competing rights: (1) the right of parents to make decisions for their children, (2) the right of children to be protected from serious harms, and (3) the right of children to choose different values
from their parents."

I was really happy to see this. I do not htink I have seen a statement before that clearly indicated that parents may be unduely influenced in their decision making. And statements about children's rights are great. The weakness is the way they phrase and set it up as competeing with parent's "rights". This is not an accurate characterization in my mind. However, they have raised the issue fairly well.

"The most important principle...clarify what is known, what is not known, and where there is uncertainty."

I think this is a good guideline, and if they follow this properly, the decision and decision making will be good. Of course, people should be doing this now...and don't.

"Developing information resources to guide adult/adolescent men, parents, medical practitioners, public health programs, and communities about the potential benefits and risks of MC..."

Again, good statement. The proof will be in the pudding. But this is not saying to recomend circ, it is saying to give people the unbiased information with which to make informed decisions.

"Because the recent trials of MC provided no evidence that MC protects against HIV acquisition during anal or oral intercourse, there was not general support for providing MC as an HIV-prevention strategy among..." (men who have sex with men)

Clear statment to those who read it carefully that the benefit is not certain if a variety of activities engaged in.

"Many in this working group felt that the efficacy found in the African trials could be extrapolated to heterosexual sex in the U.S..."

Interesting. Many, but not all feel that the African Research can be used to support recomendations in the US, but only for people engaged in certain activities and theh they should avoid making it sound like foreskins are dirty, and trials are needed. Certainly not a slam dunk statement that circ is good across the board.

"Consultants in this group stressed the importance of providing evidence-based risk and benefit information to physicians and parents, allowing for a fully informed decision about neonatal circumcision...."

Well, in my mind, if you first ensure that there is evidence based risk and benefit inforation to parents, then removing financial barriers is not a big deal. Yes, having financial barriers makes it easier to reduce circ, but over the long haul, better decisoon making is a better strategy. Beyond that, all they are saying is to review your statements.

Now of course, there are many subtle ways to bias information provided to parents, ways to have "undue influence" etc. But they are essentially staying the course, HIV prevention is their prime directive and anything that can help reduce it is worthwhile.

<note edited to remove much of the quoted text in order to stay within the forum rules that prohibit having too much copyrighted text>

Regards

[Fellow Traveler]

I agree largely with Greg on this issue. I am not in a position to fully reply but this seemed to jive with what I expected. It won't be recommended, doctors should explain the risks and benefits but I do forsee them reinstating Medicaid and other insurance. That is unfortunate but we'll have to live with it for now.

I was not surprised by the lack of ethical discussion.

[Night_Nurse]

For whatever reason, I can't get the link to open (I couldn't earlier either). Can someone sum it up for me? Is it a done deal and they are now recommending it for all babies based on the Africa study?

[tennisdude23]

Originally Posted by Night_Nurse

For whatever reason, I can't get the link to open (I couldn't earlier either). Can someone sum it up for me? Is it a done deal and they are now recommending it for all babies based on the Africa study?

No, absolutely not. I have not read this particular link, but I'm fairly certain that in terms of large scale policy the AAP recommendations won't change, except for perhaps a suggestion towards Medicaid funding of circumcision, which to be honest won't happen in states that already dropped coverage. I think that the final set of recommendations will be pretty neutral.

[Laur318]

I hope medicaid doesn't pay for it in any state....the AAP no longer can routinely recommend the practice so why can the CDC?

[Fellow Traveler]

Originally Posted by Laur318

I hope medicaid doesn't pay for it in any state....the AAP no longer can routinely recommend the practice so why can the CDC?

It's not that they no longer can, they never have but that's besides the point. There are some boobs in both of those groups who seem to think that because of some positive results in third world countries with drastically different HIV epidemics that it might be useful to American boys. They are the only ones, all other first world organizations have essentially brushed this aside.

[glongley]

To me, the most concerning part of this paper is the "program guidance" item that outright states the "medical benefits outweigh risks for infant MC, and there are many practical advantages of doing it in the newborn period. Bebenfits and risks should be explained to parents to facilitate shared decision-making in the newborn period."

If this isn't a green light to recommend neonatal circumcision, I don't know what is. The problem is there is no clear evidence that "benefits outweigh risks." They can only make this claim by minimizing complication rates, denying ethical or sexual harms, and conveniently avoiding admitting that we do not actaully know the true complication rates of circumcision, including the more serious outcomes like, rehospitalization, blood transfusions, MRSA infections, repeat corrective surgeries, loss of all or part of the glans or penis, and death. If they would just put a fraction of the money that has been poured into the AFrican HIV/STD studies that they are now waving about as "compelling" proof of the medical benefits of circumcision, into setting up an adverse event reporting system for circumcision, or into research on the sexual functionality of the foreskin, their claim would quickly be seen as the fraud that it is.

They REALLY need to be called out on this!

Gillian

[Fellow Traveler]

Originally Posted by glongley

To me, the most concerning part of this paper is the "program guidance" item that outright states the "medical benefits outweigh risks for infant MC, and there are many practical advantages of doing it in the newborn period. Bebenfits and risks should be explained to parents to facilitate shared decision-making in the newborn period."

They REALLY need to be called out on this!

Gillian

I do agree Gillian, I don't see how they reached such a conclusion. In their own paper they state that only 5% of new HIV infections are of the male heterosexual variety (and it's not clear what portion of those were high-risk). If there were about 56,000 new infections and 75% of those were in men that means that in a given year 56,000 * .75 * .05 ~= 2100. In a population of 150,000,000 your odds of infection in a lifetime of 80 years is less than 1/1000. That assumes that you're at equal risk those whole 80 years, everyone was at equal risk, and other things we know are not true. I like how they try to marginalize the risks too. The logical course would be to offer it to at risk men, if they choose it. Only they will know their individual risk.

[Bea]

Personally, I'm delighted to see they have a Doctor of Veterinary Medicine advising on the board of consulting physicians.

It's always a toss up for me and my family whether to go to the MD with our health concerns or the VET!

[Greg B]

Originally Posted by glongley

To me, the most concerning part of this paper is the "program guidance" item that outright states the "medical benefits outweigh risks for infant MC, and there are many practical advantages of doing it in the newborn period. Bebenfits and risks should be explained to parents to facilitate shared decision-making in the newborn period."

If this isn't a green light to recommend neonatal circumcision, I don't know what is....

Oops, I missed that, thanks for pointing it out. I see it now, in the table of Working Group Proposals. Yep, pretty green, and pretty black box, since it does not lay out how they arrived at the recomendation.

Regards

[Fellow Traveler]

Originally Posted by Greg B

Oops, I missed that, thanks for pointing it out. I see it now, in the table of Working Group Proposals. Yep, pretty green, and pretty black box, since it does not lay out how they arrived at the recomendation.

Regards

There in lies the problem. They don't give specific information as to how they arrive at their conclusions. They parrot that the complication rate is supposedly low and give some absolute values for that. But they don't provide absolute information about the risk reduction for HIV, among others. They just say, oh about 50%. In the general population though the absolute risk of HIV and the reduction is almost certainly lower than the complication rate.

I would not anticipate this being explained in any reasonable way.

[Papai]

Wow. That report seems to lay out the CDC's goals very easily. Their whole goal is to undo the past 10 years that the AAP released a "neutral" statement on circ and states dropped medicaid funding for the procedure.

This part stuck out to me:

To address these questions, the Centers for Disease
Control and Prevention (CDC) convened a Consultation
on Public Health Issues Regarding Male Circumcision
in the United States for the Prevention of HIV
Infection and Other Health Consequences on April
26–27, 2007, in Atlanta. Invited participants included
epidemiologists; researchers; health economists;
ethicists; physicians; and representatives of practitioner
associations, community-based organizations,
and groups objecting to elective circumcision.

Which anti-circ groups were invited??

[Fellow Traveler]

Originally Posted by Papai

Wow. That report seems to lay out the CDC's goals very easily. Their whole goal is to undo the past 10 years that the AAP released a "neutral" statement on circ and states dropped medicaid funding for the procedure.

This part stuck out to me:

Which anti-circ groups were invited??

None that I am aware of. And there are no groups that object to elective circumcision for an adult. That is a misrepresentation even if such a group was present.

[Papai]

Originally Posted by Fellow Traveler

None that I am aware of. And there are no groups that object to elective circumcision for an adult. That is a misrepresentation even if such a group was present.

Yeah, I looked through the organizations listed on the document and saw NO anti-circ groups, so exactly WHO did they consult with??

And yes, they might be confusing people's personal aversion to circ as saying they are against elective circ for everybody. Just because I might think piercing your genitals is an awful idea, doesn't mean I want to make it illegal for another adult to choose to do that to themselves.

[Papai]

More nuggets from the paper:

the desire to frame the messages about MC in the context of penile hygiene and prevention of STDs as well as HIV without suggesting
that uncircumcised penises are unhygienic

Uh....nice thought, I guess, but I can't see how you can cast MC in the context of male hygiene and NOT thereby imply that intact penises are unhygienic. I imagine this part of the "effort" will receive little, if any, careful consideration.

[Papai]

The disparity with respect to evidence between MSW and MSM is jaw-droppingly and woefully contradictory.

From the recommendations for the MSW population:

R1 There is no need for, or equipoise to conduct, a U.S. trial for MC for HIV prevention among men who have sex with women.

From the recommendations for the MSM population:

R1 There may be equipoise to conduct an efficacy trial of MC for the prevention of HIV transmission among MSM. If conducted, the trial should include both U.S. and international sites.

So in order to recommend circ to the MSM population, we need an efficacy trial in both the US and internationally (btw, forget that trials have already been conducted that show male circ does little if nothing to prevent HIV in MSM), but in order to recommend circ for the MSW population, the trials in Africa are more than sufficient?

[Papai]

This recommendation makes me positively cringe with discomfort:

R2 CDC, working with state and local health departments, professional provider groups, and community stakeholders, should
establish demonstration projects to introduce adult/adolescent MC in high-incidence U.S. populations of men who engage
in penile-vaginal sex. Data should be collected in the projects on implementation issues including messaging, acceptability,

So male circ is gonna go on a road show? I can't wait to see how those "demonstrations" are carried out....

[Papai]

OP, enlighten me. What is a practice paper and what does it mean in the realm of public health?