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Critique of Canadian Journal Reviews Studies on Circumcision

So we now know that the anticircs outnumber the procircs in this canadian committee. To say that they support Wiswell's claims is only superficially true. It would be better to say that for this particular political compromise they choose not to dispute them.

Sigh. You would make fewer embarrassing errors if you would actually read the articles you're commenting on, rather than just the abstracts. Here, e.g., is the "conclusions" section of the review in question:

Please allow me some comments to illustrate my point that this is a political compromise forged in a large committee, and not hard science.

 

Conclusions - We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following.

There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1 percent to 2 percent.

This is a very, very guarded way of bringing it. They avoid saying if the evidence is weak or strong. It means that the committee members disagreed on this matter, and could not achieve consensus.

The social dynamics are fairly obvious. The anticircs won and the recommendation is against circumcision. In return the procircs get to dictate most terms of their own defeat. So they open the conclusions with mentioning their strongest research. Its claims are highly controversial in the group, so the compromise is to mention it 'as is', neither really buying in to it nor mentioning its weaknesses.

This is what I mean by 'choose not to dispute'. I trust you'll agree 'support' is too strong a phrase, it would mean that the committee agrees that solid research will very likely show that circumcision reduces UTIs 12-fold. Do you think the committees text means that?

 

-The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2 percent to 2 percent. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision.

Evaluation of alternative methods of preventing UTI in infancy is required.

Social dynamics: the anticircs agreed not to attack the Wiswell studies directly. In return they are allowed to point out it answers an fairly irrelevant question.

 

More information on the effect of simple hygienic interventions is needed.

Information is required on the incidence of circumcision that is truly needed in later childhood.

This is one of the 'plausible claims of benefit - with questionable evidence' I was talking about in my previous post. The claim is 'he might need one later so let's get over with it' argument.

My gripe is not about whether this claim is true or false, but these claims come and go, and there is no point in refuting them as they will simply be replaced by new claims.

 

There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases.

When circumcision is performed, appropriate attention needs to be paid to pain relief.

The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed.

Group dynamics: nobody gets accused of any wrongdoing. This means all can go home with out any bad feelings toward each other. This is the purpose of consensus building; a decision is made without anybody getting hurt.

 

When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors.

Note this, specifically: -There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. This, while you said that my characterization (that they agreed with Wiswell's basic conclusion) was "only superficially true."

The problem is that you are reading this as if it were published in a peer reviewed journal, which it isn't, and never could be, as it is much squirmy and evasive to make it through peer review.

I read it like what it is; a committee consensus opinion. That means you have to read between the lines, as half the meaning is in what's not being said and how they're not saying it.

"does circ prevent UTIs" rather than "how do we prevent UTIs"
"does circ prevent penile cancer" rather than "how do we prevent penile cancer"
"does circ prevent AIDS" rather than "how do we stop AIDS"
"does circ prevent circ" rather than, err, you figure it out.

The reason is they're trying to justify circumcision and the method is the drive-by claim: claim a plausible benefit and keep it alive with weak evidence and when you can't keep it up just switch to a different claim. I pointed out that you can do exactly the same in the opposite direction and hence in whole you have an experiment of which the outcome is completely determined by operator bias. This is bad science and it remains bad science no matter how many p-values and mumbo jumbo you pour into it.

Another claimed they didn't support Wiswell because they don't support circumcision, you claimed they support him because they acknowledge his evidence, and I claim they don't support him because they acknowledge him in such a non-committing and politically safe way you can't really call it supporting. So we're all in agreement, we're all right, we're just getting progressively more anal.

As to (2), I never mentioned penile cancer. I know nothing about penile cancer. I'd like it to remain that way.

When you stated that we should go by the current preponderance of evidence I brought up (3), that in this case that's stupid because there is a strong drive to prove existing habits right. Simply by continuously inventing new benefits they can keep proving themselves right. It leads to people seriously researching the most insane things.

Take for example, the latest claim that circumcision reduces the risk of getting HIV infected through sexual contact. Sounds interesting until you stop looking at crappy studies and engage your brain for about 15 seconds. When the AIDS epidemic broke out most of the US sexually active males were circumcised, most european males were not. But the US didn't get spared, so as a public health measure it isn't very good. Besides, if you cut newborns it takes about 15 years before they start to get sexually active, and that's mostly with their peers who haven't yet had a chance to become infected, so it's about 20 years before you can possibly see any effect, if there is any. Yes, this really is going to be the final blow against AIDS!

So the only scientifically valid response is shut up and pass the condoms. But no, people like you get fooled and start looking at how valid are these studies and were they done right. Suddenly they look promising even if they have some weaknesses, so we need bigger and better studies and in the mean time we need to go by the tentative evidence. And thus we stumble through the darkness.

I just wanted to point out that if something follows the rituals of science doesn't necessarily mean it is science.