Saturday, December 20, 2014

Centers for Dick Control

In these modern times, it is easy to be under the impression that society has left behind strange, unnecessary, medieval medical procedures and is enveloped in the warm glow of evidence based healthcare.

This assumption is manifest when we come to learn that vaccines are thought by some to be a plot by western governments to control the population.

What utter absurdity! Those that have a respectable science-based outlook on the world know that vaccines are not mind control serums! Enlightened folks know better - smart people understand that what vaccines really do is cause autism. Right?

While not a uniquely an American problem, it is perhaps not an accident that the wealthy nation that seems to have the largest appetite for fantasy (or appetite generally) has made some of the furthest departures from reality when it comes to health and wellness.

The United States does happen to be the nation that did grant Dr Oz a career, for goodness sake.

Another way the United States is exceptional in a bad way is the practice of routine male infant circumcision. Most of the well fed world does not see the purpose in male circumcision. Circumcision is an oddity that is only widespread in the United States and various muslim countries.

On occasion, American health agencies have a moment of clarity to wonder what Americans could possibly be gaining by maintaining their phobia of infant foreskins.

The latest organization to look at the issue is the Centers for Disease Control, which published a document titled "Recommendations for Providers Counseling Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV Infection, STIs, and other Health Outcomes" (accompanied by a backgrounder document)

The American psychosis that is the need to have some medical reason - any medical reason - to cut foreskin is baked right into the paper's title.

Let's circumcise the absurdities in this document.

HIV hysteria 

The document speaks about how studies in Africa showed that cutting off the foreskin of an adult male lowered his chances of contracting HIV by some measurable amount. Of course, this is making the rounds as people that have cut their boys need something to feel happy about.

"Circumcise your infant son now so he will be one of the ones still standing after the HIV pandemic strikes several decades from now!" or so the propaganda goes.

It is stupid, and the CDC document underlines just how silly things really are. In addition to a lengthy discussion of the multitude of HIV prevention techniques that actually work, the CDC instructs:

Although it is biologically plausible that male circumcision could benefit MSM during insertive sex, no definitive data exist. Currently, there are no study results from RCTs including large enough numbers of MSM and results from observational studies are not conclusive among MSM overall or among MSM who practice exclusively insertive anal sex. For example, some epidemiologic data suggest that male circumcision provides partial protection for the insertive partner during penile-anal sex while other studies do not. In contrast, male circumcision provides no biologically plausible HIV risk-reduction benefit for the anal-receptive partner and receptive anal intercourse carries a substantially higher risk for acquisition of HIV than insertive anal sex.

In short - if your son is gay, all bets are off. He'll be in a high risk population and potentially be doing some high risk things. If a parent chooses to circumcise their son for the marginal reduction in HIV transmission risk, they make the choice with the assumption that their son's sex life does not extend beyond repeated insertions of a condomless penis into a vagina.

It cannot be argued that it is ethical to remove a choice from an infant and needlessly perform a surgery early based on silly assumptions about choices later in life.


Reduction of nonexistent risks

Among other things, the document refers to reduction of risk in infant risk of UTIs and penile cancer.

What is an infant male's risk of UTI? 0.07%.

What is a male's risk of penile cancer? 1 in 1,400.

Stop the presses.


Your cut penis might look funny

Hidden within the "risks of circumcision" section for people willing to scroll to the very bottom of the damn document:
For adult male circumcision performed by clinicians, the rate of adverse events is between 2% and 4%, with pain, bleeding, infection and unsatisfactory post-surgical appearance most commonly reported. 
This is saying somewhere between 1 in 40 or 1 in 30 adults that undergo the procedure have some sort of issue with it. Apparently a common problem is that their penis looks unsatisfactory.

Unsatisfactory looking penis. This is where the numbers must come together, as one can imagine that it is difficult to acquire a sexually transmitted infection with an unsatisfactory looking penis.

It is said that infant circumcision has less reported ill effects (0.04%). Maybe the procedure is safer at a younger age. Then again, perhaps infants have less to report about phallus appearance, for some reason...


Money, Money, Money

Under the "positives" of infant circumcision the following is given:

Neonatal male circumcision is, safer, and heals more rapidly than circumcision performed on older boys, adolescent males, and men, and is less expensive

Buy now before the prices go up! It's natural to give the CDC the benefit of the doubt as they are not in the business of selling used cars.

However maybe someone should take up a career in car sales, for the background analysis of expense they used is quite absurd:

In a cost-effectiveness study of male circumcision at different ages in Rwanda, an African country with an adult HIV prevalence of 3%, infant male circumcision was found to be less expensive than adolescent and adult male circumcision (US$15 instead of US$59 per procedure) and cost-saving despite a delay in realization of savings from infant circumcision. 

Let's be clear - the United States is not Rwanda.

While this is obvious, in bizarre way we do not even need to look at recent history or any unrelated comparison to make this argument. We already know what circumcision cost is in the United States - NPR, another source of concern and worry, has already lost its mind about circumcision cost.

The NPR article spoke about infant male circumcision costing about a thousand dollars in the state of Alaska. As shown by its geography, Alaska is an outlier - in Alaska, presumably every procedure is cheaper when deferred to adolescence as older people would find it cheaper to seek care in other states.

However let's assume infant boy exists in an "average" state and assume the procedure costs around $500. To conclude that the procedure will be more expensive later, one needs to make the following assumptions:

  • The return on investment on the $500 will not result in an amount higher than the circumcision price 10-14 years from now (early adolescence)
  • Technology will not force the cost of the procedure to go down
  • No other factors will impact total cost (e.g. more than a decade later, the young male will still not be able to arrange his own transportation to the medical practitioner)
  • No other deflationary pressures exist (e.g. absolutely no positive health care reforms)
For many reasons, it's natural for medical practitioners to want to do stuff sooner rather than later, but there is not an economic argument to be made when a patient will not need substantially more work done later. It turns out adolescent males do not have considerably more foreskin to deal with.

The economics of infant circumcision is a clear win only for the person performing the surgery. Left entirely unaddressed in the CDC literature is the open secret that no right-minded sober adolescent male is going to sign up to be circumcised. Circumcision as it exists today is a money maker, and it relies on undermining consent in the most reprehensible ways.

To round out a tale of marginal improvements to embellished risks with a half-assed analysis of what routine infant male circumcision actually costs the nation is incredibly negligent. 

Like many other discussions of circumcision, the most troubling pieces of this "evidenced" counsel is what is not actually on the pages. Each new review of male circumcision is lengthy, but uninspired. Proofread, but not serious. Evidenced, but not logical. Clinical, but not honest.

Luckily, you have an opportunity to tell "the man" your thoughts by submitting a formal comment about the CDC notice.

January 15, 2015 is the cut off date.

Get typing - for if we know anything it is that these people love to cut things off early.

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