Talk:Circumcision and HIV/Archive 1

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Archive 1

Archive 2

HIV/AIDS topics

First of all, beautefully done, Jakew. To me, what you just did is magic! I added a See Also section. I hope this time there are no issues with it? Anyway, there is a HIV/AIDS topics template(I think?) with many links to HIV/AIDS related articles. I think this article belongs with them but am not sure, and have no clue how to make it happen in any case. --Nakerlund (talk) 17:38, 23 March 2009 (UTC)

Thank you, Nakerlund. The template is {{AIDS}}. It would be straightforward to include it, but I'm not sure whether this article should be included in the template. I've requested input from other editors at Talk:HIV#Input requested. Jakew (talk) 18:48, 23 March 2009 (UTC)

FGC/Stallings

This edit, which introduces a conference presentation by Stallings, is problematic, for several reasons.

First, every source in this article discusses the relationship between penile circumcision (that is, the removal of the penile foreskin) and HIV. Stallings' paper, in contrast, is about female genital cutting. Thus, there is no logical reason for including this material here.

Second, the edit appears to be very poorly thought out. For example, the material was placed in the section entitled "Langerhans cells and HIV transmission", in spite of the material having no obvious connection with that subject.

Third, the edit is misleading. For example, it begins "Stallings (2005) cited 3 prior studies which showed a correlation between female circumcision and a lower risk of HIV...". The words "showed a correlation" imply that a statistically significant correlation was observed. Slide 11 of Stallings' presentation, however, shows the opposite to be true: the 95% confidence intervals for the odds ratios for all three studies include 1.0, so in fact it would be more accurate to say "...showing no correlation...". (To be precise, one shows a non-significant association between FGC and lower risk of HIV, the other two show a non-significant association between FGC and higher risk.) Further, the conclusions are quoted somewhat selectively. For example, the following conclusion (from slide 38) seems rather important: "As no biological mechanism seems plausible, we conclude that it is due to irreducible confounding."

For these reasons, I'm reverting the change. Jakew (talk) 15:57, 17 June 2009 (UTC)

The title is "Circumcision and HIV", rather than "Male Circumcision and HIV", and the Stallings paper mentions both "circumcision" and "HIV" in the title. You might regard male and female circumcision as being fundamentally different, but many people don't, including most of the people who actually practise female circumcision. I know this isn't something we're going to agree on any time soon, but I placed the Stallings study there because the preceding paragraph discusses FC/FGC/FGM: <<Dowsett (2007) questioned why it was just males that were being encouraged to circumcise: "Langerhans cells occur in the clitoris, the labia and in other parts of both male and female genitals, and no one is talking of removing these in the name of HIV prevention.">>

You're right about the 3 prior studies not showing a significant correlation. My mistake. The Stallings paper itself does though, and whilst it doesn't mention Langerhans cells, I think it belongs there. Either that, or maybe there should be a separate section or even a new page for "Female Circumcision and HIV" (or "FGC and HIV" or "FGM and HIV").

I don't think it makes much difference whether the correlation is explained away as a "conundrum" or due to "irreducible confounding".

I have made another change, and I would like this to be moderated by a third party rather than just reverted. I know we have very differing views on circumcision, but I hope we can find something for the Wiki page we can both agree on.

regards, Mark --Ml66uk2 (talk) 16:50, 17 June 2009 (UTC)

Stallings may well mention both "circumcision" and "HIV", but that's a very poor basis for randomly inserting material about a different procedure into the article. This is suppossed to be an encyclopaedia article, not a collection of sources that mention at least two words. The fact that circumcision and FGC are different is really beyond dispute. Some people believe that there are similarities between the two, but I think that nobody would deny that they are performed with different methods, on different anatomy, and with different consequences. Thus, female genital cutting is a far more appropriate place for this material.

Dowsett made a comparison between circumcision and FGC within the context of Langerhans cells. Such a comparison cannot be used as an excuse to include otherwise unrelated material; see WP:SYN.

Thank you for acknowledging your mistake about the 3 studies cited by Stallings, but your apparent solution (deleting all mention of the other studies) is — if anything — worse. Including Stallings findings, we know of a total of four studies of FGC and HIV, and all but one of these found no statistically significant difference. Knowing this, why on earth would we want to cite an anomaly? This is actively misleading to the reader, because it creates the impression that such an association exists, when the majority of the literature that we know of is to the contrary. If FGC and HIV is to be discussed anywhere, then we should cite all known studies to avoid giving undue weight to anomalous results.

Similarly, selective quotation still remains. It paints a misleading picture to quote "A lowered risk of HIV infection among circumcised women was not attributable to confounding with another risk factor in these data." but not "As no biological mechanism seems plausible, we conclude that it is due to irreducible confounding." Jakew (talk) 17:14, 17 June 2009 (UTC)

"The fact that circumcision and FGC are different is really beyond dispute."

You know that's not true. Whether you like it or not, "FGC" is also referred to as "female circumcision", and there is much debate as to how different they really are. I personally feel that there are many similarities, especially with the lesser forms of female circumcision. One form of FC/FGC is removing the female prepuce, so directly analogous to the usual form of male circumcision. Just because you don't see any similarity between FC/FGC and male circumcision, doesn't mean you can pretend it's not an issue. Most of the English-speaking people that cut females also refer to it as "circumcision" and regard it as similar to male circumcision. The terms "FGM" and "FGC" are relatively recent as you know.

The Stallings study is later than and appears to have been a lot more rigorous than the other studies, and in my view carries a lot more weight.

I chose that quote because it is actually in the abstract which was cited. Anyway, why would a biological mechanism be plausible for cutting parts of male genitals off, but not for cutting parts of female genitals off?

I'm disappointed that you and Avraham seem to be excluding discussion of female circumcision (aka FGC/FGM) and HIV from a page on circumcision and HIV, and regard it as a sign of bias. --Ml66uk2 (talk) 19:14, 17 June 2009 (UTC)

Seriously? You come back after ostensibly a 6 month hiatus and jump into a discussion that has been going on for years? Perhaps you can take a look at the 40+ pages of Circumcision archives? -- Avi (talk) 19:44, 17 June 2009 (UTC)

I know this has been going on for years, and it will go on for years. I've also read some, though by no means all of the Wiki talk pages on circumcision. That's why I was surprised to read that "The fact that circumcision and FGC are different is really beyond dispute." I regard them as very similar, but I'd never claim that to be "beyond dispute". I find it very sad that a paper titled "Female circumcision and HIV infection in Tanzania: for better or for worse?" is excluded from a page on circumcision and HIV. What do you think the English-speaking people who practise FGC call it? Do you think they see much of a difference between male circumcision and "FGC"? The people who blog about circumcising their daughters get furious if you call it "mutilation" btw.

What exactly do you mean by "ostensibly"? I haven't been posting on circumcision-related issues from another account if that's what you're suggesting. --Ml66uk2 (talk) 20:47, 17 June 2009 (UTC)

I'm sorry that my comment surprises you. To clarify, nobody seriously argues that the two are one and the same (if that were the case then every true statement about one would be a true statement about the other); what is generally disputed is not whether they are different, but how great are the differences. Some (like yourself) believe the differences to be small. Others believe the differences to be substantial. The terminology used is of little help in this respect, as identical terms are sometimes used to describe wholly different concepts (consider, for example, the use of the term "heavy metal" to describe both a class of chemical element and a type of rock music). Jakew (talk) 09:15, 18 June 2009 (UTC)

I don't understand how it can be reasonably claimed that a study on female circumcision and HIV is beyond the scope of an article on circumcision and HIV. The contribution by Ml66uk2 appears relevant and reasonable. Trying to assert that a thing is "beyond dispute" merely contradicts the assertion.

Over on the main HIV page we are treated to a WHO panel recommendation that some people should have pieces of their bodies cut off to benefit some other people, but there is no link to the genital mutilation page, from which it emerges that the WHO condemns similar practices in the case of female circumcision. These two types of mutilation provide context for each other, and for the issue of HIV transmission. Without this context, you don't have NPOV.68.178.59.178 (talk) 17:31, 9 July 2009 (UTC)

Maybe the terminology that some use to describe female genital cutting ("female circumcision") is confusing. For the purpose of this discussion, let's temporarily rename female genital cutting as apples and penile circumcision as bananas. Now, this article is about bananas and HIV. Stallings' presentation was about apples and HIV, so why is it relevant? Jakew (talk) 17:50, 9 July 2009 (UTC)

This article was created as a subarticle of Medical analysis of circumcision, (because that page was getting too long,) which is about male circumcision and which is itself a subarticle of Circumcision, which is also about male circumcision. I've edited the lead to make it clear that this article is about male cirucmcision. ☺Coppertwig (talk) 00:44, 10 July 2009 (UTC)

Uncertainty about efficacy

Given the overwhelming scientific evidence that male circumcision effectively reduced HIV infection, I have to wonder what editors here believe is scientifically proven in medical science? Is antibiotics effective? I am just curious about what standards relate to scientific inquiry here. For example, three RCTs that independently indicate significant efficacy should not be made dubious just because some people bicker about them- Leifern (talk) 19:09, 4 February 2012 (UTC)

1st it's not overwhelming, look at the study in uganda they stopped for "ethical reasons" because it showed circumsized people getting HIV more often than those uncircumsized.

More people get AIDS in Africa just because they're mostly poor there, uneducated, don't get sex education, plenty of prostitutionm around, their govts are too corrupt to pay for proper medical care for the people, etc. Why would skin being on the penis effect that. You have to be an idiot to believe this. 170.3.8.253 (talk)

Need to update

Several important papers have been published recently that are not mentioned. There is a need to update this article. Southdoc (talk) 19:25, 26 March 2012 (UTC)

I agree. This Nature article, dated 30 November 2011, says "For the past three years 13 countries in southern and eastern Africa at the heart of the HIV/AIDS epidemic have been on a mission to circumcise 80 percent of their men by 2015 in an effort to cut in half the rate of sexual transmission of the disease from 2011 levels. And a new series of nine papers, published online Tuesday in PLoS Medicine, assesses whether the ambitious goals could work—and whether they are worth it." It would be good to track down and cite those papers (if they are as relevant as seems likely).

This WHO page (viewed 16 July 2012 claims great certainty about the value of circumcision: "There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%." Unfortunately it doesn't tell you what the evidence is.

They could be referring to a newer Cochrane review Published Online: 7 OCT 2009, which reviews three large scale studies: "Results from three large randomised controlled trials conducted in Africa have shown strong evidence that male circumcision prevents men in the general population from acquiring HIV from heterosexual sex. At a local level, further research will be needed to assess whether implementing the intervention is feasible, appropriate, and cost-effective in different settings."

I have to confess to being uncertain as to how convinced I should be. I haven't studied this in detail; but I am aware that new treatments (including preventive treatments) often fail to live up to their initial expectations. Issues such as the Hawthorne effect and various forms of bias often make the treatments more valuable than one might hope; and things like Risk compensation effects can reduce the interventions' efficacy. But I also have a prejudice against what I consider mutilation - unnecessary cutting; so I cannot trust my instincts on this one. --peter_english (talk) 14:09, 16 July 2012 (UTC)

The WHO also tells us that cellphones cause cancer, although the statistical facts tell the opposite. If you take the time to read the original studies on circumcision and HIV-infection (especially the RTCs) and you have a proper understanding of scientific methods, you'll find that they're at best inconclusive. Further, the actual infection rates among circumcised men are higher in many African countries than for uncircumcised men. If reality doesn't fit your hypothesis, the latter is wrong --84.130.161.37 (talk) 14:02, 18 July 2012 (UTC)

Keratin Thickness

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0041271 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951978/

These seem to contradict the findings of McCoombe, Cameron, and Short. — Preceding unsigned comment added by Feathergun (talk • contribs) 21:01, 23 July 2012 (UTC)

Things look messy

So I happen to be going through this page, specifically the Observational Studies section, and I'm surprised by how many of the articles are poorly represented. For instance, most of the studies seem to be on high-risk African-based studies, but not all of them specify this in the body. Now I have no history with this topic, but is the "African-based" thing just a given? Should I have been assuming that these studies are mostly done in high risk areas to begin with? I only ask because I was confused while reading through the text and I'm sure others would be as well. I've since followed the citations and looked up many of the articles, so it is a bit more clear. But should this section maybe be subdivided into the different types of studies? Like, an African-based section, one for the General population studies, and one for cross studies? Just my brief look through some of the articles tells me that the results of the studies seem to vary a lot. Cheers! Ibanez Guy (talk) 18:40, 9 June 2013 (UTC)

There is tremendous variation in the southern African studies with some showing that the circumcised got HIIV more than the uncut. Conversely the big study was stopped for exactly the opposite result early on ethical grounds. There seems to be a big push to promote circumcision as a partial solution to HIV epidemics in Africa. Some other studies have shown that risk behaviour increases for the cut as some cut men think they have gained a sort of universal immunity and behave accordingly. There is a danger in extrapolating these results to other populations where HIV rates can be higher amongst circumcised too. It may be that some high risk multiple partner groups also have a cosmetic or aesthetic fondness for the cut and so any protective effect it may achieve may be masked in these cases. I agree with your suggestion of regionalizing results --— ⦿⨦⨀Tumadoireacht ^Talk/_Stalk 19:40, 9 June 2013 (UTC)

Thanks for your input! I've now gone through all of the studies in that section and looked at the findings in a bit more detail (for those still accessible). While it is difficult to have a complete picture for every study, many of the comments in this article are misleading or very incomplete (especially with regards to geographic regions). Some of the parsing of the paragraphs also suggests connections between studies that aren't really there. Maybe we should start with a basic updating of the information for each study and then go from there. I'll try to sort something out and suggest it here before I change anything. Anyone else have any thoughts on how to make things more clear? Cheers! Ibanez Guy (talk) 21:08, 9 June 2013 (UTC)

I'd agree that this article is long overdue for an overhaul. At this point, only secondary sources should be used to support statements of fact about the scientific consensus regarding the effect of circumcision on HIV transmission. This is an extremely well-studied field and primary sources should not be cited at all. They may be interesting for a historical overview but still need to be used within the context of secondary sources, the history of circumcision and HIV is now very well-documented in secondary sources. To start, as with any other medical intervention, you should make use of resources like PubMed, the TRIP database, and up-to-date texts from medical libraries. The Wikipedia guideline governing the sourcing for medical content is WP:MEDRS so all the sourcing updates need to be compliant with that guideline. Zad68 02:15, 10 June 2013 (UTC)

To help get you started: There's lots and lots out there discussing the use of circumcision as part of an HIV management program in Africa. Here's the central repository of information on it from the World Health Organization: link. Here's a recent review article on the use of circumcision within a larger program for HIV management: PMID 23257232, published in The Lancet, one of the most prestigious medical journals around. The full article text is available here. Here's another review article along the same lines, discussing PEPFAR: PMID 22797745, full free text available via PMC; here's a related review PMID 22797743.

Outside of Africa: Here's a review discussing reasons to promote neonatal circumcision in Thailand: PMID 23431830. Here's a review arguing against neonatal circumcision in the particular localities of Australia and New Zealand: PMID 21973253. Here's a rebuttal review countering the arguments of advocates against the practice in developed countries: PMID 22452415.

Hope these are helpful! Zad68 02:52, 10 June 2013 (UTC)

Sourcing review

Here's a review of the current status of the sourcing of this article. There are a lot of problems with the sourcing, hope this is useful for cleaning up the article. Zad68 16:30, 9 January 2014 (UTC)

Sources table

In this table:

Source lists the source as cited in the article
Seems WP:RS? means, "Does this source appear to meet WP:RS for reliable sourcing?"
Use OK? means, is the source used appropriately in the article? For the review, a few selected sources will be spot-checked to ensure they aren't plagiarized and support the article content. ? indicates the source was not spot-checked.
Notes will summarize problems found and what needs to be done to fix them

Discussion

Alexbrn, you asked where to start. I have removed the obviously outdated letters, editorials and comments. I would say next is to add the type=Review or type= Meta-analysis parameter to the cite journal template on those known, and then the rest can be more easily examined. If a review is more than about seven years old, I would also add {{old fact}} or {{MEDRS}} depending on the info. SandyGeorgia (Talk) 17:47, 9 January 2014 (UTC)

Alexbrn, I did a bit, but don't have time to finish. There is still a whole lot of text that might be merged to History, then History needs to be rationalized, then article still needs to incorporate newer sources. That's all I have time for today-- nowhere near finished. Also, some of what is here seems culturally important and may be moved to Society and culture. SandyGeorgia (Talk) 12:51, 10 January 2014 (UTC)

It's great you guys are getting started! Just wanted to point out that some months ago I identified some up-to-date secondary sources and a source repository from the WHO that might be useful. Links are in my comments at the end of the section above this one, hope they are useful. Zad68 13:39, 10 January 2014 (UTC)

And society and culture needs updating to:

Uthman OA, Popoola TA, Uthman MM, Aremu O (2010). Van Baal, Pieter H. M (ed.). "Economic evaluations of adult male circumcision for prevention of heterosexual acquisition of HIV in men in sub-Saharan Africa: a systematic review". PLoS ONE (Review). 5 (3): e9628. doi:10.1371/journal.pone.0009628. PMC 2835757. PMID 20224784.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)

SandyGeorgia (Talk) 14:07, 10 January 2014 (UTC)

Super, I'm going to concentrate on the History section for now ... Alexbrn ^{talk|contribs|COI} 16:25, 10 January 2014 (UTC)

(Update) I've worked some way through this sections and am taking a break from it now; lots more to do - should be back tomorrow ... Alexbrn ^{talk|contribs|COI} 20:54, 10 January 2014 (UTC)

I added the recent reviews to "Further reading", where one can grab the citations for incorporating them into the article-- which is woefully, woefully outdated. SandyGeorgia (Talk) 17:03, 11 January 2014 (UTC)

I for one appreciate the effort here to provide clarity either way on this topic. It seems like dangerous information to suggest circumcision as a prevention method when more high quality research is needed. I had always thought the head was more vulnerable to infection that other parts of the skin? — Preceding unsigned comment added by 195.11.194.228 (talk) 09:28, 26 June 2014 (UTC)

Edit using de Witte and Ogawa

An editor recently added this:

A research group of Youichi Ogawa et alii ^[1] confirmed the findings of de Witte et alii, that langerin protects Langerhans cells from being infected by HIV and other STD. ^[2] "This study also showed that langerin was involved in capture of HIV and subsequent internalization within Birbeck granules, where it was degraded." However, Oguwa et alii found, "when LCs were exposed to high viral concentrations of HIV, there was significant infection of LCs by R5 virus, followed by viral transmission to T cells." Oguwa et alii also observed, that anaerobic bacteria do not "enhance HIV susceptibility in LCs". However they conclude, that Gram-positive bacteria components "directly augmented HIV infections in LCs by activating TLR2".

References

^ Ogawa, Youichi/Kawamura, Tatsuyoshi/ Kimura, Tetsuya/Ito, Masahiko/ Blauveit, Andrew/ Shimada, Shinji 2009: Gram-positive bacteria enhance HIV-1 susceptibility in Langerhans cells, but not in dendritic cells, via Toll-like receptor activation. In: Blood, 21.5.2009, Vol. 113, Nr. 21, 5157-5166.
^ Lot de Witte et alii: "Langerin is a natural barrier to HIV-1 transmission by Langerhans cells" http://www.nature.com/nm/journal/v13/n3/abs/nm1541.html

I do not think it is an improvement to the article for many reasons: the sourcing is insufficient per WP:MEDRS, the sources do not appear to actually cover the topic of this article: circumcision and HIV, the proposed article content actually appears to contradict what one of the sources says and so fails WP:V, and the proposed content quoting selected very technical passages is much too hard for our typical lay reader to understand, or see the connection to the article topic.

The first source is de Witte here, which does not mention "circumcision" at all and mentions "foreskin" only in one of the captions accompanying a multi-part illustration, so it does not appear to be directly on the topic of this article. This is a letter to the editor and so is at the bottom of our evidence quality scale per WP:MEDASSESS. The Ogawa source is PMID 19279330 (full text here), it is an in vitro primary study from 2009, and it does not mention "circumcision," "foreskin" or "prepuce" anywhere in it all. Also the proposed article content interprets this primary study by saying that it "confirmed the findings of de Witte alii" but actually in the two places where Ogawa source cites de Witte they discuss contrary findings. Interested in the thoughts of others. Overall the use of these two lower-quality/off-topic sources should not be used to cast doubt on the clearly-stated summaries of the higher-quality sources currently in use in our article.

Editor Alexbrn recently did a significant clean-up of the sourcing for this article so I am notifying him of this discussion. Zad68 14:47, 30 July 2014 (UTC)

I concur with Zad68 - we would need much stronger WP:MEDRS sourcing to support this kind of material here. Alexbrn ^{talk|contribs|COI} 11:18, 4 August 2014 (UTC)

Circ and HIV

The problem with this text

"The effect of circumcision in the developed world is unclear, although among a sample of developed countries, UNAIDS found that The United States(70% circ rate) HIV infection rate per 100,000 was 61, compared to England's 11(20% circ rate), therefore making Americas HIV rate 700% higher then England's, who had only 1/3rd the circumcised population America did.^[1]^[2]"

This ref is not suitable [1]
This ref's content is being misrepresented.[2]

What it says about circ is "The interplay of multiple factors obscures causal linkages and prevents categorical conclusions. A study in four African cities (Cotonou, Kisumu, Ndola and Yaoundé) revealed that the most common behavioural and biological factors in those cities with the highest HIV prevalence were: young age at women’s first sexual intercourse; young age at first marriage; age difference between spouses; the presence of HSV-2 infection and trichomoniasis (a sexually transmitted infection); and lack of male circumcision."

References

^ page 197-http://data.unaids.org/pub/Report/2002/brglobal_aids_report_en_pdf_red_en.pdf
^ bottom of page, table 2 http://www.historyofcircumcision.net/index.php?option=content&task=view&id=61

Doc James (talk · contribs · email) 02:52, 20 October 2015 (UTC)

Concur: we shouldn't have this content for the reasons Doc gives. Alexbrn (talk) 04:50, 20 October 2015 (UTC)

This Article is Biased

Evidence of the University of Oxford and other prestigious institutions critize the studies to be biased and even claim that circumcision might be a reason for AIDS.^[1]^[2]

I know. The studies are mostly made by interest groups. And even though I don't know it for sure: I bet the Wikipedians are circumcised or part of circumcised cultures. If we take a closer look, we definitely see, that countries with the highest circumcision rate have the most AIDS patients. If circumcision would protect from AIDS, how can this than happen? Oh, because it doesn't. This is just another ridiculous claim to not ban male genital mutilation.Élisée P. Bruneau (talk) 03:24, 31 January 2017 (UTC)

Compliments for article contributors

I'd just like to say, you guys have done a great job with this article. I was watching a program that mentioned the controversy over condom efficacy on the HIV issue in Uganda, and I came across mention of the additional preventative step of circumcision. I was looking for a specific article, regarding the studies done on the efficacy of circumcision on HIV prevention, and this page did an excellent job of presenting all the elements, in a framework that's easy to understand. Obviously it's incredibly important to note, that the different circumstances of a patient's life, would affect the efficacy of the procedure - particularly if they more regularly engage in anal sex versus vaginal, and whether being circumcised will lead one to riskier behavior, like lack of condom use. This article makes the distinctions, without ever trying to interpret whether any one fact is or is not an argument for male circumcision - it's one of the least POV articles I've come across, despite covering a potentially volatile topic.

And I was pleasantly surprised to see the Talk page wasn't littered with people advocating for sentiment over facts, or a lot of personal agendas, just a commitment to presenting all the applicable information, in a factual way, with the appropriate sources.

As a person who really depends up Wikipedia for giving as much information as I can acquire on a topic - hence why I check the Talk page as well as the main page - I just want to say thanks for your efforts. I did check the Help system, to confirm it was acceptable to simply interject a thanks into the Talk page, and the Cup of Tea page suggested it was. So if it is not appropriate, my apologies - but this page deserves props :) CleverTitania (talk) 05:51, 17 April 2014 (UTC)

"it's one of the least POV articles I've come across".. were we reading the same article? JQ (talk) 06:52, 6 October 2014 (UTC)

Well it was in April of 2014 that I posted this. And a lot of edits were made in July, So technically no, we probably weren't "reading the same article." However I have read it now, and my opinion stands. If you have an example of lack of POV, or a suggestion to improve the NPOV, perhaps you should share it with everyone. CleverTitania (talk) 10:48, 10 July 2015 (UTC)

This article is not neutral. It is heavily biased. An interest group created an article with findings that suit there point of view. It was criticized by real scientists. But scientists from the elite university of Oxford aren't counted as reliable. --Rævhuld (talk) 00:50, 27 June 2017 (UTC)

Guy is deleting my contributions also every single source I used were published in peer-reviewed journals

If the guy is deleting again, please contact an administrator. Here my contribution:--Élisée P. Bruneau (talk) 15:40, 11 July 2016 (UTC)

Criticism of Circumcision as HIV prevention

The scientific methods and arguments for circumcision as HIV prevention has been criticized by many scientists. Some scientists argue that circumcision even may increase HIV.^[2]

Circumcision may increase HIV transmission in Africa

Brian D. Earp, a Research Associate to the University of Oxford, called the recommendation of circumcision as HIV prevention as "a fatal irony". The "AIDS epidemic in Africa may increase transmission of HIV" because of the "circumcision solution".^[2]^[1]Distributing free condoms is 95% more cost effective and gives much better safety. Condoms reduce both female and male HIV with at least 80%.^[3]^[4] The circumcision reduces the HIV risk with maximum 1.31% according to three dubious surveys. The "behavioral dis-inhibition" is another argument against circumcision as additionally treatment.^[2] The risk of HIV infections is increased by circumcision due to the fact that it's promoted as "natural condom" and that the attention is divirted away from effective solutions (like condoms).^[5]^[6]^[2]

Internal Validity

Experimental doubts

The argument for circumcision as HIV prevention is based on three studies from 2005-2007. An extensive analysis showed, that the circumcised group weren't allowed to have coitus in 6 weeks of the experiment and had additional schooling in HIV prevention (like how to use condoms), which the uncircumcised placebo-group didn't got.^[7]^[2]^[1]

While the “gold standard” for medical trials is the randomised, double-blind, placebo-controlled trial, the African trials suffered [a number of serious problems] including problematic randomisation and selection bias, inadequate blinding, lack of placebo-control (male circumcision could not be concealed), inadequate equipoise, experimenter bias, attrition (673 drop-outs in female-to-male trials), not investigating male circumcision as a vector for HIV transmission, not investigating non-sexual HIV transmission, as well as lead-time bias, supportive bias (circumcised men received additional counselling sessions), participant expectation bias, and time-out discrepancy (restraint from sexual activity only by circumcised men).
— Gregory Boyle and George Hill ^[7]

Misleading results

The absolute decrease of HIV in the three studies give a reduction of 1.31%. The relative reduction was 60% due to the fact that two very small percentages were compared.^[7]^[8]^[9]^[2]^[1]

What does the frequently cited “60% relative reduction” in HIV infections actually mean? Across all three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV-positive, so the absolute decrease in HIV infection was only 1.31%.
— Gregory Boyle and George Hill ^[7]

Questionable public health recommendations

The implementation of circumcision to prevent HIV is inefficient and the results can't be reproduced. The test subjects had "continuous counseling", "frequent monitoring" and the surgeries were performed by highly skilled, Western sanitary.^[4]^[2]

Effectiveness in real-world settings rarely achieves the efficacy levels found in controlled trials, making predictions of subsequent cost-effectiveness and population-health benefits less reliable.
— Lawrence W. Green, DrPH, John W. Travis, MD, MPH, Ryan G. McAllister, PhD, Kent W. Peterson, MD, FACPM, Astrik N. Vardanyan, MA, Amber Craig, MA^[4]

Distributing free condoms is 95% more cost effective and gives much better safety. Condoms reduce both female and male HIV with at least 80%.^[3]^[4] The circumcision reduces the HIV risk with maximum 1.31% according to three dubious surveys. The "behavioral dis-inhibition" is another argument against circumcision as additionally treatment.^[2]

The risk of HIV infections is increased by circumcision due to the fact that it's promoted as "natural condom" and that the attention is divirted away from effective solutions (like condoms).^[5]^[6]^[2]

How rational is it to tell men that they must be circumcised to prevent HIV, but after circumcision they still need to use a condom to be protected from sexually transmitted HIV? Condoms provide near complete protection, so why would additional protection be needed? It is not hard to see that circumcision is either inadequate (otherwise there would be no need for the continued use of condoms) or redundant (as condoms provide nearly complete protection).
The argument that men don’t want to use condoms needs to be addressed with more attractive condom options and further education: [they need to be told] that sex without a condom and without a foreskin is potentially fatal, while sex with a condom and a foreskin is safe. No nuance is needed. Offering less effective alternatives can only lead to higher rates of infection.
[...] Rather than wasting resources on circumcision, which is less effective, more expensive, and more invasive, focusing on iatrogenic sources and secondary prevention should be the priority, since it provides the most impact for the resources expended.
— Robert S. Van Howe, Michelle R. Storms^[6]

References

^ ^a ^b ^c ^d Rizvi, Ali A. (2009-09-03). "Male Circumcision and the HIV/AIDS Myth". The Huffington Post. Retrieved 2016-07-11.
^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j Earp, Brian D. (2009-09-03). "A fatal irony: Why the "circumcision solution" to the AIDS epidemic in Africa may increase transmission of HIV". University of Oxford: Practical Ethics. Retrieved 2016-07-11.
^ ^a ^b Weller SC and Davis-Beaty K, “Condom Effectiveness in Reducing Heterosexual HIV Transmission” (2002) 1 Cochrane Database of Systematic Reviews Art No CD003255.
^ ^a ^b ^c ^d [Male circumcision and HIV prevention: Insufficient evidence and neglected external validity.]. Green et al. (2010). American Journal of Preventive Medicine.
^ ^a ^b Cite error: The named reference Goyle was invoked but never defined (see the help page).
^ ^a ^b ^c [http://www.zimeye.org/wp-content/live_images/2012/01/44-419-1-PB.pdf How the circumcision solution in Africa will increase HIV infections]. Robert S. Van Howe, Michelle R. Storms. Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Marquette, MI, USA. Cite error: The named reference "PagePress" was defined multiple times with different content (see the help page).
^ ^a ^b ^c ^d Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. Boyle, G. J. and Hill, G. (2011). Journal of Law and Medicine.
^ Welch, H. Gilbert (2012-06-21). "The Problem Is Relative". The Huffington Post. Retrieved 2016-07-11.
^ Garenne, Michel; Giami, A.; Perrey, C. (2012-04-11). "Male cicumcision and HIV control in Africa : questioning scientific evidence and decision making process". Horizon (in French). pp. 185–210. Retrieved 2016-07-11.

blogs, the Huffington Post and fringe journal articles are not WP:MEDRS (or even WP:RS) for the serious aspects of this topic. Please familiarise yourself with Wikipedia's principles. You also appear to be publishing links to illicit copies of copyrighted material, which is a problem. Alexbrn (talk) 15:46, 11 July 2016 (UTC)

Oh, yes, clearly. Despite the fact that 4 of my 6 sources are peer-reviewed and published in journals with great reputation:

[Cochrane Database of Systematic Reviews Art No CD003255]
[American Journal of Preventive Medicine]
[Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Marquette, MI, USA]
[Journal of Law and Medicine]
[Horizon (in French). pp. 185–210 (a French research database)]
[Global Public Health: An International Journal for Research, Policy and Practice: Volume 10, Issue 5-6, 2015]

And I have not used "blogs", I have only used one blog. And it was not a "blog", but an article written by a Researcher at the University of Oxford and the article was published at the blog of Oxford University. And I only used one Huffington Post article. You try to censor this article, that is clear. Not to mention that the 2 sources are all covered by peer-reviewed articles. And do you know what? Read the article and you see, that most sources are published in mass media - like Huffington Post. My material is research and peer-reviewed. Still you deleted my submission, despite the fact that I am the guy with the best sources. Nice done.--Élisée P. Bruneau (talk) 16:18, 11 July 2016 (UTC)

Please read WP:MEDRS and maybe WP:WHYMEDRS for background. Peer-review alone means little. Cochrane reviews can make great sources, but you appear to be using them for the purposes of WP:Original research to discuss condoms. Alexbrn (talk) 16:29, 11 July 2016 (UTC)

We have newer sources that say something different. Doc James (talk · contribs · email) 11:29, 31 January 2017 (UTC)

@Alexbrn: Please read WP:MEDRS and maybe WP:WHYMEDRS for background. Peer-reviewed sources in top academic magazines shouldn't be good enough? I am sure that you can explain how Oxford Medical Journal isn't a good enough source for Wikipedia. Oh, wait. You can't.--Rævhuld (talk) 01:32, 19 July 2017 (UTC)

Bias

It seems like some users here try to bias the article. While some scientists claim that circumcision reduces AIDS risk, other scientists are highly critical. According to WP:POV both point of views should be included. There are high quality peer-reviewed articles on it.^[1] If scientists who published in Oxford University owned journals aren't count as reliable, I think that no one is. --00:46, 27 June 2017 (UTC)

References

^ Mehta, Supriya D.; Moses, Stephen; Agot, Kawango; Parker, Corette; Ndinya‐Achola, Jeckoniah O.; Maclean, Ian; Bailey, Robert C. (2009-08-01). "Adult Male Circumcision Does Not Reduce the Risk of IncidentNeisseria gonorrhoeae, Chlamydia trachomatis,orTrichomonas vaginalisInfection: Results from a Randomized, Controlled Trial in Kenya". The Journal of Infectious Diseases. 200 (3): 370–378. doi:10.1086/600074. ISSN 0022-1899. PMC 3081655. PMID 19545209.{{cite journal}}: CS1 maint: PMC format (link)

— Preceding unsigned comment added by Rævhuld (talk • contribs) 00:50, 27 June 2017 (UTC)

We don't WP:GEVAL give both sides but weight in favour of the best sources. The source you cite is not a WP:MEDRS. Alexbrn (talk) 03:04, 27 June 2017 (UTC)

Removed the tag per Alexbrn. Doc James (talk · contribs · email) 03:08, 27 June 2017 (UTC)

@Alexbrn: Oxford Medical Journal (peer-review) is not a reliable source? Bullshit! Maybe you can explain why it isn't a reliable source? According to the article you link to, it IS a reliable source.--Rævhuld (talk) 01:30, 19 July 2017 (UTC)

Because it's an RCT i.e. primary research. Alexbrn (talk) 07:36, 19 July 2017 (UTC)

Exactly the same as the research made by the WHO.--Rævhuld (talk) 00:24, 20 July 2017 (UTC)

There is a difference between primary sources and secondary sources. Doc James (talk · contribs · email) 08:48, 20 July 2017 (UTC)

And I used both.--Rævhuld (talk) 04:37, 24 July 2017 (UTC)

Misleading result related to HIV

The study cited stating that circumcision reduces the risk of HIV had trials limited to Sub-Saharan men. This does not mean that the same observations are applicable to men around the world.

Secondly, the trials did show a correlation between circumcision and HIV risk. However, it doesn't explain why this is true. I mean, correlation is not same as causation.

These were RCTs not observational trials so the second part is incorrect. Doc James (talk · contribs · email) 01:21, 10 March 2019 (UTC)

Editor conflict of interest: Petersmillard

User:Petersmillard has a vested interest in promoting circumcision (his day job consists in making studies about circumcision techniques https://scholar.google.fr/scholar?hl=fr&as_sdt=0%2C5&q=peter+s+millard+circumcision&btnG=) and should not be allowed to edit this article, or at least not be allowed to make the calls re. WP:NPOV as he did two days ago. —PrimNonNoc 2A01:E35:8B10:A450:6084:4564:9383:E3D2 (talk) 00:41, 10 March 2019 (UTC)

What part has neutrality issues? This article reflects the mainstream scientific position.

There has been a mass of sockpupptry around this topic which raises concern. Doc James (talk · contribs · email) 01:21, 10 March 2019 (UTC)

I'll be signing my comments as "PrimNonNoc", but I'd rather stay pseudonymous and would rather not create an account. I'm a long time, occasional editor here, I know some of the ropes, but it the first time I try to move the needle on a politically sensitive topic... I've never edited this article beside adding the WP:NPOV tag. —PrimNonNoc 2A01:E35:8B10:A450:4194:947B:6793:9118 (talk) 19:43, 10 March 2019 (UTC)

Better still, I have an account now (since you can still register without an email address). For the non-initiated, the username is an abreviation of the Latin phrase "Primum non nocere" which means, "First, don't harm". It is a core tenet of medical education and practice and reflects the position I come from on this topic. —PrimNonNoc (talk) 20:19, 10 March 2019 (UTC)

My day job is as a family physician. Petersmillard (talk) 12:29, 10 March 2019 (UTC)

Still Peter, you do active research on the topic, and while it means that you probably know the subject inside out, it also makes you more likely than not to have bias. The article is guarded by editors who have systematically refused to address the criticism in the Boyle and Hill paper. All I see is vague weaseling out and claims that the contraption built on top of the 3 bogus 2007 papers is solid science. —PrimNonNoc 2A01:E35:8B10:A450:4194:947B:6793:9118 (talk) 19:43, 10 March 2019 (UTC)

You get the CDC and WHO to change their positions and we will follow. Some 13 year old position meh whatever. Doc James (talk · contribs · email) 06:04, 11 March 2019 (UTC)

I understand they have the ultimate decision makers in terms of policy. I also understand that the campaign is successful in curtailing HIV. However I don't think that they are the arbiters of scientific truth. I have one question that would probably clear things out: Does the circumcision campaign also includes condom advocacy and education? If it does there's still no evidence that circumcision reduces HIV transmission rates, even if the campaign is successful. Offering ice cream to lure people in to condom school could be as effective and less harmful. If it doesn't I'll rest my case. —PrimNonNoc (talk) 09:17, 11 March 2019 (UTC)

Wikipedia follows what reliable sources say, following specifically WP:MEDRS in this instance. The path from scientific truth to what Wikipedia says has to go through MEDRS-compliant sources, i.e. the likes of systematic reviews and guidelines. That can be frustrating, but it makes for a better Wikipedia all in all. Bondegezou (talk) 23:51, 11 March 2019 (UTC)

Thanks Bondegezou I agree that MEDRS makes WP better in general, but definitely not in this case, where a gigantic "public health" campaign was started based on shoddy science... Does the circumcision campaign also deliver condom education to the target populations? —PrimNonNoc (talk) 04:04, 12 March 2019 (UTC)

Yes, they are recommended as an essential part of the campaign. Condoms have never been shown to be effective on a population level, and the HIV epidemic exploded in spite of condom education. Petersmillard (talk) 14:55, 13 March 2019 (UTC)

Having professional expertise from working in a field is not a conflict of interest. Wikipedia wants subject matter experts to edit. Peter seems to be applying mainstream content to this article. @Petersmillard:, please, can you apply a citation to everything you add here? Using citations everywhere is a Wikipedia best practice but in case of dispute it is essential. Thanks. Blue Rasberry (talk) 20:58, 25 April 2019 (UTC)

This article lacks a neutral point of view.

This article lacks a neutral point of view and balance of various viewpoints. It should be substantially redrafted. There are other similar comments above.

One of the problems is the blind acceptance of the WHO statement as something like the Word of God —not to be questioned. This statement was written for political reasons, not medical reasons. There was a demand that something be done about HIV/AIDS and the WHO seized upon circumcision as something they could do, whether it actually worked or not..

Ten years later, their viewpoint still has not been universally accepted. That needs to be reported in this article.

Sugarcube73 (talk) 22:23, 21 October 2017 (UTC)

I'll add a WP:NPOV banner. This article treats a topic that is scientifically controversial and only presents one side of the argument (see the above sections). This is literally advocating for male genital mutilation on a large scale. --2A01:E35:8B10:A450:1D5:ED3E:F57B:F689 (talk) 13:05, 27 February 2019 (UTC)

Specifically, the 2011 Article by Boyle and Hill is a meta-analysis whose conclusion is that the papers cited by this WP article are methodologically garbage. The meta-stats derived from them are thus as worthless (garbage in, garbage out: https://europepmc.org/abstract/med/22320006 / http://artemide.bioeng.washington.edu/2011-12_JLM-Boyle-Hill.pdf (the full-text version is also available from multiple places through Google Scholar)). --PrimNonNoc 2A01:E35:8B10:A450:1D5:ED3E:F57B:F689 (talk) 13:48, 27 February 2019 (UTC)

That article is 8 years old. WHO is a better source.

Additionally you are calling it a "meta-analysis". However it is not. Doc James (talk · contribs · email) 01:42, 10 March 2019 (UTC)

What recent WHO source assesses the safety and efficiency of the treatment? All I could find in the WHO sources more recent than 2011 is reports on the number of circumcisions and epidemic projections. The article is a meta-non-analysis. It reviews the article as you'd do when preparing a meta-analysis, in order to determine if they are worthy of inclusion for further analysis. It then goes at length to explain why they are rubbish and should not be used as evidence of what they claim to prove, and strongly implies that the authors may have committed scientific misconduct (a single multi-center/multinational study turned into three papers in order to pad their resume). —PrimNonNoc 2A01:E35:8B10:A450:8B6:F56E:76C:B266 (talk) 03:55, 10 March 2019 (UTC)

See http://www.samj.org.za/index.php/samj/article/view/12543/0 Petersmillard (talk) 12:35, 10 March 2019 (UTC)

Thanks Peter. So there hasn't been any other clinical trial to properly assess the effect of circumcision vs condom education (which was only given to the circumcision group, but not to the control group in those studies). Provided that condom usage is the gold standard for HIV prevention (beside abstinence which is not a realistic approach), this is as if you told me that circumcision is an effective treatment for hypertension (provided the patient also takes beta-blockers). There's nothing in those papers that could let one determine that circumcision is a better bait for condom education than, say, a voodoo ritual. Provided that circumcision is a destructive, irreversible procedure that can have nasty side effects, it would have been nice to look for safer ways to get the attention of the local population. Did the WHO ever address the substance of the 2011 article by Boyle and Hill? Or was it swept under the rug as it happens here? That article is scathing, and the points it makes are solid. Beside the lack of a proper control group, there are other issues that would, by themselves, disqualify those papers for serious policy consideration (e.g. the dropout rate that is several times larger than the effect size, or the authors' bias and shifty publication practices). —PrimNonNoc 2A01:E35:8B10:A450:4194:947B:6793:9118 (talk) 19:30, 10 March 2019 (UTC)

My day job is as a family physician but I also have a PhD in epidemiology. It would be polite for you to introduce yourself. You are an amateur scientist, it seems. The most dangerous kind in this case. Petersmillard (talk) 20:16, 10 March 2019 (UTC)

I'd rather stay pseudonymous. I have a medical degree and did clinical research professionally at some point. I hope I'm dangerous, thank you! Could you now address the arguments instead of attacking my credentials? —PrimNonNoc (talk) 21:18, 10 March 2019 (UTC)

Also, Petersmillard, your bio states that you worked for several years in Africa. Did you take part in the circumcision campaign during that time? —PrimNonNoc (talk) 14:34, 12 March 2019 (UTC)

I agree. the relationship between HIV and circumcision is uncertain, and the supporting studies are criticized for flawed methodology. this article presents an uncertain position as if it's solidly proven, which it isn't. here's an article of interest: [3]. Xcalibur (talk) 04:53, 7 June 2020 (UTC)

Eswatini

Should we change Swaziland to Eswatini? While the article talks about the country in the past tense before the name change, it just seems kind of outdated to continue referring to the country with its former name. Prcc27 (talk) 11:49, 15 July 2020 (UTC)

Text

Have trimmed "The methodology of the original studies which were the subject of a meta-analysis and guided the policy of the World Health Organization (WHO) was severely criticized ^[1]: "Our results clearly show that these African CRFs were methodologically flawed from start to finish... From the start, there was almost nothing correct with these studies. It was quite clear that these studies were unethical. They would never have been approved by a single ethics committee in the United States.", George Hill."

This is undue weight. And old. Doc James (talk · contribs · email) 22:02, 26 February 2020 (UTC)

a brief passage is not UNDUE, especially when it helps balance the article with a dissenting view. and the fact that it's from 2011 should not disqualify it, unless the critique has been proven wrong since then. Xcalibur (talk) 03:30, 5 August 2020 (UTC)

References

^ "Sub-Saharan African randomized clinical trials into male circumcision and HIV transmission: methodological, ethical and legal concerns.", Gregory J. Boyle, George Hill, Journal of law and Medicine, 30 Nov 2011, 19 (2): 316-334, PMID: 22320006

Fallacious criticism

A quick question about a recent revision. The revision author stated (unfounded, by the way) criticism of the meta-analysis of RCTs of circumcision and HIV incidence. The addition is the paragraph below:

The methodology of the original studies which were the subject of a meta-analysis was severely criticized:[28] "Our results clearly show that these African CRFs were methodologically flawed from start to finish... From the start, there was almost nothing correct with these studies. It was quite clear that these studies were unethical. They would never have been approved by a single ethics committee in the United States.", as stated by George Hill.

The reasoning is fallacious, but it is criticism nonetheless and I am therefore hesitant to remove it. Should it be deleted? Petersmillard (talk) 00:18, 30 July 2020 (UTC)

I see nothing fallacious about this. it briefly sums up what an RS has to say on this topic, and brings much-needed balance to the article. Xcalibur (talk) 03:29, 5 August 2020 (UTC)

Actual balance, or more like giving equal validity to viewpoints that aren't equal?

The usual problem that we have in this area is this: Science says X is good for Y. Some editors don't like X. Therefore, we decide that the scientists are wrong, and X actually isn't good for Y. For example: Science says that we can stop human-cased CO2-based climate change by getting rid of humans. We don't want humans to be extinct. Therefore, we try to say that getting rid of humans won't stop climate changed, instead of just saying "No, thanks, I'm sure you're right that it would work, but we don't think killing off all the humans is a reasonable and proportionate response to climate change".

It sounds stupid when I put it that way, right? But that's what we usually do around circumcision: Science says there may be certain health benefits. Some editors don't like circumcision. So those editors say the scientists are wrong, instead of saying "No, thanks, I'm sure you're right that it would work, but we don't think circumcision is a reasonable and proportionate response to the HIV pandemic".

That's what we ought to be doing. We should be saying that while science says circumcision may well be good for preventing HIV transmission, that there's a difference between "technically, it would work" and "let's do this". There are a large number of other considerations in between a technical solution and an appropriate policy, including:

non-scientific considerations such as human values, personal preferences, informed consent, cultural preferences, etc., AND
scientific considerations such as whether the scientifically established benefits (e.g., reduced transmission of HIV) are greater than the risks (e.g., post-circumcision infections).

WhatamIdoing (talk) 18:58, 10 August 2020 (UTC)

First of all, false balance should not be used to keep out valid minority viewpoints (so long as they're valid).

the examples you gave are predicated on 'science says this'. but a few RS I've consulted recently unequivocally state that the science is lacking in validity and integrity, calling the entire idea into question.

that aside, even if there's a correlation between circumcision and decreased risk of HIV transmission, this only concerns F2M transmission, which is already relatively uncommon. many sources agree that M2M, sharing needles, and contaminated blood transfusions are far more significant vectors, as is M2F, which is not affected by circumcision. in any case, condoms, education, and testing blood are far better methods anyway, and my sources mention that circumcision can lead to a 'false confidence', in which circumcised individuals forego condoms and increase risk.

to summarize, it's not certain that there is a correlation, and if there is, it's not very significant. to claim that circumcision helps prevent HIV transmission is misleading, since it doesn't apply to the major vectors. we should clearly state that the science is disputed, and that the purported benefits are limited. Xcalibur (talk) 09:09, 12 August 2020 (UTC)

I don't think this is a "significant minority" in science terms. If it were a "significant minority", you'd be able to find multiple sources from researchers who are not primarily focused on the perceived evils of circumcision. None of us have been able to find those. Instead, the only people who are criticizing these studies are the ones who are paid to criticize anything and everything that might possibly sound like a reason to choose voluntary medical male circumcision.

For background, I think your view of risk factors might be out of date. For example, contaminated blood supply has been an almost non-existent source of HIV transmissions for decades. If memory serves, the F2M risk via vaginal intercourse with an otherwise healthy HIV+ woman is generally estimated to be about a third the risk of insertive anal sex. If the HIV+ woman also has another STI, the F2M risk for vaginal sex is the same as the risk of insertive anal sex (NB: that risk is the same regardless of the receptive partner's sex, so it's a significant route of F2M transmission). If this sounds like an "uncommon" route of transmission, then you might want to remember that there are several million HIV+ female sex workers, and STIs are an almost universal experience among sex workers. I'm sure you wouldn't recommend that men ignore safer sex advice when paying for sex with an HIV+ woman, precisely because F2M transmission is not that uncommon. WhatamIdoing (talk) 02:27, 13 August 2020 (UTC)

you're still greatly exaggerating motive/COI. I've found a few different scholarly sources questioning the narrative, which to me is significant enough.

"contaminated blood supply has been an almost non-existent source of HIV transmissions for decades." this is only true of the first world; it remains an issue in the third world, especially Africa.

"If the HIV+ woman also has another STI, the F2M risk for vaginal sex is the same as the risk of insertive anal sex" I'm well aware. in fact, the HIV epidemic began in Leopoldville because of promiscuous sex among prostitutes/johns with genital sores (an interesting bit of history).

"I'm sure you wouldn't recommend that men ignore safer sex advice when paying for sex with an HIV+ woman, precisely because F2M transmission is not that uncommon." of course not, I'd recommend condom use in that case. that ties into the point I made before, which is that circumcision is no guarantee, and can lead to 'false confidence' as mentioned in the literature. and that's assuming that it does reduce risk; this is not certain, given that the studies may have been faulty, and the langerhans link hasn't been proven.

to summarize, circumcision may reduce (but not eliminate) risk for F2M transmission only, and there are much better preventative methods available. the article should focus on this, and not become an endorsement for circumcision as HIV prevention. there are too many limitations and confounding issues involved, as I've said. Xcalibur (talk) 06:31, 13 August 2020 (UTC)

Criticism of African Studies

I've created a new sub-section for critiques of the widely-cited African studies, and I've added a substantial amount of new content from a rock-solid RS. I also restored the old criticism, since it's derived from an academic paper, and now has the additional support of the new content. Any questions/concerns can be filed here. Xcalibur (talk) 08:32, 10 August 2020 (UTC)

First, we don't typically use separate criticism sections; criticism is worked into the flow of the text, which I have done. Second, you were overquoting. Third, all of the content in the entire section is dated, including the 2009 Cochrane review. Please find newer reviews upon which to base the entire mess. SandyGeorgia (Talk) 14:11, 10 August 2020 (UTC)

I wanted to be as informative as possible, but I can see where it was excessive. the current summary works, although I could add a little more to it. newer sources would be helpful, but not strictly necessary. the african studies were conducted in 2005-07, and are heavily cited, so we need to cover them and the relevant criticism. Xcalibur (talk) 17:13, 10 August 2020 (UTC)

To the extent that you're talking about Wikipedia:Biomedical information, rather than speculation about what a different committee in a different country might have done 20 years ago, then WP:MEDRS applies, and you need sources within the last 5 years for heavily researched areas, and within the last 10 otherwise.

'Criticism' sections are inappropriate. WhatamIdoing (talk) 19:00, 10 August 2020 (UTC)

This Wikipedia article seems to overstate the overall scientific view on circumcision preventing HIV. The main article says "the effectiveness of using circumcision to prevent HIV in the developed world is unclear", yet this Wikipedia article seems to insinuate that circumcision does clearly prevent HIV, despite a lack of evidence that this is true outside of Africa. The Royal Dutch Medical Association says there are studies that contradict the African RCTs, but not sure if it and/or the studies they cite are MEDRS. I also don't completely buy the whole "conflict of interest" argument for the study written by someone from Attorneys for the Rights of Children; we use pro-circumcision activist Brian Morris's sources on Wikipedia so.. Regardless, we need to stop pretending like the "circumcision prevents HIV" viewpoint is universally recognized as applying to developed countries, because there is actually a lack of evidence. Even the American Academy of Family Physicians is skeptical that the evidence is generalizable in the United States of America. Prcc27 (talk) 06:05, 13 August 2020 (UTC)

Reliable MEDRS-compliant sources please ... always happy to change my mind if sources support it, but reading another Wikipedia article is not a reliable source, and you have provided none. SandyGeorgia (Talk) 06:17, 13 August 2020 (UTC)

@SandyGeorgia: Are you being serious, or are you just joking..? It literally takes 15 seconds to find the source that was used on the main article. And obviously the *main* Circumcision article complies with MEDRS, which is why it is a "good article" . The source they use is MEDRS compliant [4]. It's time that this article matches the *main* article by clarifying that the HIV claim is unclear in the developed world. Prcc27 (talk) 07:42, 13 August 2020 (UTC)

Quite. “Good article” means less than nothing: it is one person’s opinion at one point in time. Fairly meaningless when conferred and more meaningless as time evolves. (Like, seven years in this case.) Thank you for providing a ten-year-old review; that is not surprising for a “good” article. If you have a serious source, I will seriously consider it. How that works is you propose text you want to change or add here, and provide a source for that text. Not one that is dated. SandyGeorgia (Talk) 08:51, 13 August 2020 (UTC)

Oh, I'm sorry. I didn't realize my source was "outdated", considering many of the sources currently up on this page are as old or even older! Can you please come up with a real reason why the source doesn't work.. Also, we are allowed to use major medical organizations as sources per WP:MEDORG. Prcc27 (talk) 17:01, 13 August 2020 (UTC)

Yes - I can. Source 107 is a legal journal, not a medical journal at all, and it asks a ton of questions while providing zero answers to begin with. The analysis is shoddy at best, and again, it's not a medical source. Source 108 actually isn't criticism of the studies at all - but it merely says "take it with a grain of salt and realize that circumcision alone isn't going to be effective to curb the pandemic" - it doesn't say "it's not effective at all" like you claim. Source 109 is a public policy debate, not a scientific validity debate. Furthermore, it uses the fact that circumcision wasn't "double blinded"... please explain to me how you possibly blind someone to the fact they are circumcised or not? It's possible that this (109) is an okay source to claim that there's "some debate" - but one source does not mean it's not WP:FRINGE. Source 110 isn't really about whether it reduces the risk of HIV transmission, but about whether that reduction is worth overruling cultural norms in other countries where circumcision isn't commonplace.

If this is such a mainstream view that the studies are wrong or deserve question, you should be able to find much stronger sources than these few. There is a consensus on this very talk page that the idea that the studies were wrong is a WP:FRINGE view that does not merit mentioning in the article - the onus is now on you to provide sources that show it's not a fringe view. In fact, by bringing up things that are not MEDRS at all, and trying to pass off legal journals, cultural questions, and the like as saying it's "bad data", you're just showing even more so that this is a fringe view. -bɜ:ʳkənhɪmez (User/say hi!) 17:22, 13 August 2020 (UTC)

@Berchanhimez: No idea why you are even talking about the Van Howe source.. All I said was that the conflict of interest argument isn't very convincing to me considering we ignore Brian Morris's conflict of interest whenever we cite him. I never said the Van Howe source was MEDRS, for the record. However, the sources *I* provided/mentioned are not fringe. This is not a fringe source. The Royal Dutch Medical Association and the American Academy of Family Physicians are not fringe medical organizations. Ergo, the view that circumcision may not be effective at preventing HIV *in the developed world* is not "fringe". Where on this talk page did I say that "the studies are wrong"? Some medical organizations question whether or not the HIV studies are *applicable* to the developed world; that doesn't mean those organizations think those studies are "wrong" or flawed.. Prcc27 (talk) 19:20, 13 August 2020 (UTC)

You have yet to show a medical organization which says it's not applicable - just that it's not the sole thing that's needed. You've shown quite a few non-medical people arguing against it - and this is exactly why WP:MEDRS exists. Public policy and culture does not change the underlying science. If you want to add a section about "culture" to this, explaining that some countries have not implemented policy based on this because of cultural/public policy reasons, that's fine. But it is not appropriate for Wikipedia to give, in WP voice, credibility to claims that the science is not credible/settled. And that's what this section is about - the "criticism". The science is there - circumcision decreases the risk of infection. Whether that makes it in public policy or not does not change the science - and any information in the article would need to make clear that the science is being ignored by some people based on "cultural" or other reasons - and not claim that there is valid criticism of the data itself. -bɜ:ʳkənhɪmez (User/say hi!) 20:44, 13 August 2020 (UTC)
- @Berchanhimez:I think you are confusing me for another user on this talk page..? I have NOT cited *any* non-medical people on this talk page. That was someone else that brought up the Van Howe source. Also, I wasn't trying to say that the medical organizations said that the African studies aren't applicable; I was trying to say that they believe that the studies *might* not apply to developed countries due to a lack of evidence. For example, the AAFP says "There is also evidence that circumcision can prevent some other STDs, including the acquisition of HIV, but the evidence for this comes from studies of adult circumcision in Africa and may not be generalizable to neonatal circumcision in the U.S." By the way, I made no arguments about "culture", so that's a strawman argument. The argument that *African* studies might not be generalizable in *America* or other developed countries has nothing to do with culture, it is not fringe, and it complies with MEDRS since MEDRS allows us to cite major medical organizations as sources. [5] Prcc27 (talk) 00:19, 14 August 2020 (UTC)

Yes, many of the sources on the page are dated, which is why I have now tagged them. WP:OTHERSTUFFEXISTS is not a reason to continue same. Advice: fix the blooming article, which is quite a wreck, by updating all the sources. Elsewise, this talk page is a timesink and waste of time, because the article overall is crap, and the way to resolve underlying content disputes is to first deal with the crap, rather than introduce more crap on top of existing crap. SandyGeorgia (Talk) 17:42, 13 August 2020 (UTC)

By the way, circumcision is no better, but I Don't Do GA, because it's a fairly useless process, so I won't go initiate a GAR. SandyGeorgia (Talk) 17:43, 13 August 2020 (UTC)

You still haven't explained why we can't use the Royal Dutch Medical Association and the American Academy of Family Physicians as sources. Per WP:MEDORG, we should be able to use those two sources to point out that it is unclear if the African studies are generalizeable to developed countries. Prcc27 (talk) 19:20, 13 August 2020 (UTC)

Please pardon my brevity for iPad typing, but I am fairly certain I have never said you cannot. In fact, that is my entire point. We have people on this talk page beating dead horses over faulty sources, rather than updating the article in its entirety to newer sources. You have alleged the positions of those organizations, but you have provided no source. I guess you expect others to go look them up? SandyGeorgia (Talk) 20:38, 13 August 2020 (UTC)

It looks like the AAFP website is currently unavailable..? But here is a web archive of what was on the website up until recently. And it will probably be back up there once the website completes its maintenance. The AAFP says "There is also evidence that circumcision can prevent some other STDs, including the acquisition of HIV, but the evidence for this comes from studies of adult circumcision in Africa and may not be generalizable to neonatal circumcision in the U.S." Here is The Royal Dutch Medical Association source (click on "Non-therapeutic circumcision of male minors - KNMG Viewpoint"). The KNMG says "In recent decades, evidence has been published which apparently shows that circumcision reduces the risk of HIV/AIDS, but this evidence is contradicted by other studies. Moreover, the studies into HIV prevention were carried out in sub-Saharan Africa, where transmission mainly takes place through heterosexual contact. In the western world, HIV transmission is much more frequently the result of homosexual contact and the use of contaminated needles. That the relationship between circumcision and transmission of HIV is at the very least unclear is illustrated by the fact that the US combines a high prevalence of STDs and HIV infections with a high percentage of routine circumcisions. The Dutch situation is precisely the reverse: a low prevalence of HIV/AIDS combined with a relatively low number of circumcisions. As such, behavioural factors appear to play a far more important role than whether or not one has a foreskin." Prcc27 (talk) 00:19, 14 August 2020 (UTC)

Good material. I don't have time to rewrite this article to incorporate that with balance and due weight, because the article needs a top-to-bottom rewrite. While medical organizations are allowable, what would be even better would be to find the underlying literature those positions are based on. I am not sure, considering how badly organized the article is now, where you would put this kind of content to keep everything in balance. Solving content disputes on articles that were always poorly written and have been neglected for years is always difficult because the overall condition of the article makes it hard accord due weight. My recommendation would be to get agreement on sources to use, clean up the mess that is there now, get an organization of sections that will work for everything (it's rather off now), and THEN work in new material-- that will lend to better consensus and talk discussion with less of people talking past each other and confusing who said what. Sorry I have been so busy and typing brief responses filled with typos from my iPad. I am concerned that the lead here is very bad, and that the issue that circumcision is only one piece of the puzzle in dealing with HIV epidemics is not mentioned. I also feel it important to balance those views with the WHO's positions, which aren't always sound. SandyGeorgia (Talk) 02:11, 14 August 2020 (UTC)

Yes, it would be great to find the underlying literature that those circumcision policies are derived from. I definitely agree that this article is bad (especially the lead), and can use some work. It also needs to flow better, honestly. Good point about circumcision only being one piece of the puzzle. That seems to be in line with the Royal Dutch Medical Association pointing out that behavioral factors play a bigger role in the fight against HIV than foreskin status. Maybe we should post on the circumcision talk page and ask users if anyone is interested/willing to help improve and rewrite this article. I am not much of a medical researcher (the ethics of circumcision, especially on minors, is actually what drew me to edit circumcision pages) and I'm still not very familiar with MEDRS. Consequently, I don't see myself rewriting this page. I'm more effective at tweaking articles to improve them. But regardless, the applicability of the African RCTs to developed countries, and your suggestion to reference other factors in HIV prevention, should be added to this article as soon as it is possible to do so. Prcc27 (talk) 05:35, 14 August 2020 (UTC)

To solve the "as soon as it is possible to do so" issue, while neither of us has time to rebuild this article, I went over to circumcision and said, wow, we can just move over the first three sentences of the third paragraph of the lead there, to fix the lead here for now. Which are all also dated, and don't use the most recent sources. I wouldn't hold out much hope of getting someone from circumcision to fix this article (with its piddling daily pageviews), when they can't be bothered to fix that article, with thousands of daily pageviews. There are scores of updated sources, and that article is still referencing WHO 2007, among others. Unlike you, I hate tweaking articles; I hate working on poor articles. I want to fix the whole thing, or alternately, stick a tag on top to warn our readers that it's another piece of Wikipedia baloney. Without time to repair this article thoroughly, and seeing that circumcision has similar problems, I will probably just unwatch here, because I so hate working on articles this bad. And since there are very few medical editors concerned about the state of Wikipedia's medical GAs, I don't hold out much hope. Best regards, SandyGeorgia (Talk) 06:59, 14 August 2020 (UTC)

SandyGeorge says: "Yes, it would be great to find the underlying literature that those circumcision policies are derived from." Unfortunately, it was she who deleted all the information from the 3 landmark RCTs and meta-analysis because "they are too old." That would mean that Einstein's papers on relativity, the discovery of penicillin can't be included in Wikipedia either because they are "too old." Petersmillard (talk) 00:26, 16 August 2020 (UTC)

@Petersmillard: That was said by User:Prcc27, not by SandyGeorgia. SandyGeorgia removed the information because before she removed it the entire section was sourced almost entirely to the three studies themselves, and the remainder was a 2009 Cochrane review and criticism. As per WP:MEDRS, we prefer newer sources if available, and avoid reporting "pure data" (ex: a primary trial) unless it's absolutely necessary for the understanding. Given that there are review articles and other non-primary sources (such as textbooks), we have no need to report on the individual trials themselves outside the context of reporting on the review thereof. I'm working now on adding back these reviews as they're the newest I can find and I agree that some systematic review information should be included until newer is found. -bɜ:ʳkənhɪmez (User/say hi!) 00:37, 16 August 2020 (UTC)

Petersmillard, primary studies are not considered underlying authoritative sources by MEDRS ... I am referring to finding the newer MEDRS-compliant secondary sources, which I expected was obvious to anyone participating here, but perhaps I should have spelled it out. The primary sources I removed are not a source at all for the text Prcc27 and I were discussing. SandyGeorgia (Talk) 00:47, 16 August 2020 (UTC)

Proposal

Here is my proposed wording, based on the sources that I provided: "Circumcision might not be effective at preventing circumcision in developed countries. Aside from circumcision, there are other ways to prevent HIV; other factors, such as behavioral factors, seem to have more of an effect on HIV prevention than whether or not one has a foreskin." I think it would fit best in the lead. If there are no objections, I would like to add this to the article. Prcc27 (talk) 04:12, 17 August 2020 (UTC)

It is a nice opinion you have, not backed up by MEDRS and doesn't belong here. Why not "Circumcision Controversies?" Petersmillard (talk) 10:59, 17 August 2020 (UTC)

Peter, not helpful, for multiple reasons. First, Prcc has provided sources, and they are MEDRS. We can argue that they aren't the best sources (underlying authoritative literature would be secondary reviews), we can try to argue that they are UNDUE, we can argue whether the text accurately reflects the sources, and we can argue that this text may not belong in the lead, but we can't (mis)apply MEDRS to keep out viewpoints from the sources given earlier by Prcc. Second, the placement of the proposed text here is appropriate; a position held by the MEDORGs stated by Prcc are not "controversies", and the summary style used at Circumcision#Effects indicates this article is where the specifics of circumcision as it relates to HIV belong.

Prcc, you can now see, I hope, that when you propose a text addition, it is helpful to add your references to the proposed text, as some won't read the page; it also benefits new readers to the page (including those coming along years from now). You might also put it in a separate section so it isn't lost at the bottom of a discussion. Next, the WP:LEAD is a summary of content already in the article; I STRONGLY suggest you read that page to see how leads are constructed. Proposing to add text to the lead, when you haven't even gained consensus to add it to the body of the article, is a non-starter. Third, if you FIRST focus on fixing the article globally, you will then have a better chance at correctly summarizing the article to the lead. SandyGeorgia (Talk) 13:07, 17 August 2020 (UTC)

Petersmillard removed some of the comments on this talk page for no reason, without explanation. I am re adding them below. Prcc27 (talk) 15:39, 17 August 2020 (UTC)

Oh, my, I missed that entirely. Which renders my response ridiculous. I am unwatching; this page is a chore. Please post to my talk if you come to some sort of consensus and want my feedback. (Pinging me is not optimal, as I lose track of pings.) SandyGeorgia (Talk) 15:46, 17 August 2020 (UTC)

Many objections. 1) You’ve provided no sources specifically for this wording - all sources say “may” not be effective “on its own” as “sole” prevention - or similar. They do not say it’s useless in developed countries like you’re trying to claim. 2) The lede does not, period, ever, include information not discussed further down in the article. Given that your viewpoint has been determined by consensus to be fringe here, it cannot be discussed in the article itself or in the lede. Seriously, at this point please just drop it - it’s clear you have some form of ulterior motive for trying to discredit the information, be it religious, moral, personal beliefs, or some obscure financial benefit. You’re twisting what is actually reservation about not taking the data too far and twisting that into “its ineffective” - which is at its best synthesis and at its worst deliberate misrepresentation of sources. Happy to have someone disagree with me but I doubt anyone will take the time to respond given that you’ve beaten this horse to death and are still beating it. -bɜ:ʳkənhɪmez (User/say hi!) 05:35, 17 August 2020 (UTC)

What would be acceptable to me is including a statement in the body itself of the article along the lines of “some developed countries (list examples maybe) have questioned the applicability of the African studies to their public health recommendations” - this makes it clear that the data itself is clear yet some national organizations still question it, and allows us to cite and attribute specific instances. -bɜ:ʳkənhɪmez (User/say hi!) 05:38, 17 August 2020 (UTC)

1) That is absolutely not what the AAFP source says.. "There is also evidence that circumcision can prevent some other STDs, including the acquisition of HIV, but the evidence for this comes from studies of adult circumcision in Africa and may not be generalizable to neonatal circumcision in the U.S." Nowhere in that source is there an insinuation that they are trying to say that it "may not be effective on its own as sole prevention". Making an assumption that the source meant to say that, even though it did not actually say that is a violation of WP:OR. 2) Nope. Show me where there is consensus that "my viewpoint" is fringe. And if it is "fringe" like you say, why is that similar wording is used on the Circumcision article..? I can assure you that many of the people on that article are not against circumcision, and if the wording was as fringe as you are suggesting it is, it would have been removed from that article promptly. Are you serious? Here at Wikipedia we assume good faith; that is a Wikipedia policy. Please refrain from personal attacks, it is very disruptive and counterproductive. My wording was a rough draft, based on the wording we already have on the main article. Also, we can in fact include this information in other parts of the article, so that it can also be in the lede. But the lede needs an overhaul in general, so I can yield on that for now. Prcc27 (talk) 08:28, 17 August 2020 (UTC)
I can get behind that wording, although I'd rather say "some medical organizations", since medical organizations do not get to speak on behalf of a country as a whole. How about "some medical organizations, like the American Academy of Family Physicians and the Royal Dutch Medical Association, have questioned the applicability of the African studies to their countries' public health recommendations." See, you could have proposed that wording as an alternative to mine without making personal attacks, and it would have made life a whole lot easier. But instead, you incorrectly assumed that I was POV pushing. Prcc27 (talk) 08:28, 17 August 2020 (UTC)
Actually, how about we say "the evidence that circumcision prevents HIV mainly comes from studies conducted in Africa. Some medical organizations in developed countries, like the American Academy of Family Physicians and the Royal Dutch Medical Association, have questioned the applicability of those studies to their countries' public health recommendations"? Prcc27 (talk) 15:47, 17 August 2020 (UTC)

I am 100% okay with that, with the potential (but not required) tweak of recommendations to “policy”. I think the biggest thing is to make sure we aren’t questioning the science itself in Wikipedia voice, but are only reporting that it isn’t being applied by some medical organizations because of concerns about applicability (which, in some cases stem from cultural concerns as well). A potential second sentence could cover countries where cultural concerns can be shown to be the primary reason for this, such as I believe some European countries (but I’m not at home right now so don’t have access to my resources to verify what exactly I saw). I have no problem if you want to add your proposed sentence for now though. As an aside, apologies for the tone of the previous message, I was on very little sleep and had once again confused you with some other comments from earlier in the discussion. -bɜ:ʳkənhɪmez (User/say hi!) 17:22, 17 August 2020 (UTC)
- We can change "recommendations" to "policy". I don't think a follow-up sentence about culture is necessary. Especially since the AAFP questioning the generalizability of the African studies to America doesn't seem to be because of cultural concerns, but rather a lack of data stemming from the developed world. Which section should I add the sentence to: Society and culture or Recommendations? Prcc27 (talk) 20:48, 17 August 2020 (UTC)

I agree it's not necessary for understanding, but I think personally it'd be necessary for completeness - especially in society and culture. I think the sentence could go in the Recommendations section as is now, but I still think information about the cultural barriers to implementing circumcision as a part (not whole) of HIV prevention is still prevalent. Put another way, while the AAFP isn't culturally biased, most of the European organizations/articles I've seen seem to me at least to have heavy cultural reasons for taking pause on including it - but that doesn't limit the ability to add the recommendations from specific regions in that section at all.
I'd like to apologize again for the way I acted towards you User:Prcc27 during this conversation - when it began, it was trying to fight against completely fringe views that the studies were invalid in their whole and had absolutely no applicability to the developed world, and due to real life stress I let that blind me to your desire to add sourced, valid information to the article, and didn't work to keep your views and desired additions separate from the other users. It was a failure on my part, and I definitely will work on forming my thoughts better in the future and making sure I'm replying to specific people separate from others. Thanks for continuing to work on this even after the way I treated you. -bɜ:ʳkənhɪmez (User/say hi!) 21:48, 17 August 2020 (UTC)

I think it's pretty clear you can't say any of that, because it appears to be WP:SYNTH. Also, which "medical organizations in developed countries" aside from the AAFP and RDMA question this? Jayjg ^(talk) 21:49, 17 August 2020 (UTC)

User:Jayjg It's not synth at all to say "X organization does not recommend inclusion because of X" as long as they say that. From my cursory reading, many medical organizations across Europe shy away from recommending circumcision due to a historical cultural bias against it and/or a progressive view that circumcision is "mutilation". Regardless of reasoning, we certainly can and should report that while the WHO does recommend it, national/regional medical organizations don't always recommend it. Even if it's only a few, it is recommendations from notable organizations that should be covered for completeness in this article (without making any claim as to whether those organizations are correct or not). For clarity, the recommended addition (with a minor copyedit by me which Prcc27 is welcome to use or not) is Because the evidence that circumcision prevents HIV mainly comes from studies conducted in Africa, some medical organizations in developed countries, including the American Academy of Family Physicians and the Royal Dutch Medical Association, have questioned the applicability of those studies to their countries' public health recommendations and not included circumcision in their HIV prevention recommendations. That is not synth at all based on the recommendations themselves, which are a valid primary source per MEDRS for this instance. -bɜ:ʳkənhɪmez (User/say hi!) 21:54, 17 August 2020 (UTC)

Honestly, I think we need to get rid of the sentence "Aside from circumcision, there are other ways to prevent HIV." Given the previous paragraph, it seems redundant. Prcc27 (talk) 16:47, 18 August 2020 (UTC)

Yes, of course "we need to get rid of the sentence". Berchanhimez, if the claim is not WP:SYNTH, then please find the source that explicitly states some medical organizations in developed countries, including the American Academy of Family Physicians and the Royal Dutch Medical Association etc.. Also, please review WP:DUE and WP:REDFLAG. Jayjg ^(talk) 17:32, 18 August 2020 (UTC)

Med school textbooks as the arbiter

In controversial subjects, such as this one, the normal method for Wikipedia to identify the accepted, conventional medical POV is to see what the recent medical school textbooks are saying. Harrison's Principles of Internal Medicine is particularly favored for this purpose, because it is so widely used.

Here's what the 20th edition of Harrison's (2018) says on this subject:

"A number of studies including large, randomized, controlled trials clearly have indicated that male circumcision is associated with a lower risk of acquisition of HIV infection for heterosexual men. Studies are conflicting as to whether circumcision protects against HIV acquisition among men who have sex with men, but data suggests that circumcision is protective in those men who have sex with men who are insertive only." (p 1400)

This article should, overall, reflect exactly this medical POV. In other words, yes, it reduces risk for most men. No, it doesn't eliminate risk for anyone. And nobody knows whether it works for MSM. This is the overall POV that the article should present as "the facts", even though there are some critics of the science and many more critics of circumcision in general.

It is still reasonable for this article to disagree about whether circumcision is desirable overall, but we should not be casting any serious doubt on whether the accepted medical–scientific view is, in fact, the accepted medical–scientific POV. For example, circumcision should not be presented as 'allegedly' reducing the risk of HIV transmission from HIV+ women to to HIV– men; it actually reduces (but does not eliminate) the risk.

And, again, just because the scientific facts are currently believed to line up this way does not mean that any particular social policy needs to follow. Wikipedia can acknowledge these facts without promoting that any individual get circumcised. There are, after all, other ways to reduce transmission risk, and some of these are more effective. WhatamIdoing (talk) 19:56, 10 August 2020 (UTC)

That's a good recent source-- thanks for doing the leg work. Good sourcing is the BEST way to resolve most content disputes. So, do you want to go ahead and make the edits? I don't :) Since I don't have access to the source ... SandyGeorgia (Talk) 20:03, 10 August 2020 (UTC)

textbooks are one RS among many. here's the problem, as I see it: the african trials are the linchpin of the claim that circumcision reduces HIV transmission; yet those same african trials are heavily criticized by some RS for being flat out unscientific. this casts doubt on the entire subject. not only that, but some RS directly question risk reduction, or even postulate that circumcision increases risk. therefore, I think this should be regarded as a contested, ambiguous topic, unless there are new studies & RS which clear up the matter. Xcalibur (talk) 22:14, 10 August 2020 (UTC)

That might all be true, and as soon as the high-quality secondary sources, such as medical school textbooks, adopt that POV, then Wikipedia can reflect it. But right now, we can't, because they don't. Wikipedia's job isn't to analyze which trials are the linchpin of what claims and whether those trials are, in the opinion of editors, good enough to support the claims being made. Wikipedia's job is to say that the mainstream, convention viewpoint, for better or worse, is currently that this has some positive effect in reducing transmission in serodiscordant het couples.

If you are interpreting this as me saying that Wikipedia should be exactly as wrong-headed as the conventional-medical sources are (right now), then you've probably understood me. WhatamIdoing (talk) 01:17, 11 August 2020 (UTC)

I have access to a few textbooks as well, and stumbled across this argument so figured I'd see what Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases 9th edition says:

"Data from three randomized controlled trials undertaken in South Africa, Kenya, and Uganda show that male circumcision reduces the risk for heterosexually acquired HIV infection in men by approximately 60%. 737475 This evidence strongly supports the findings of numerous observational studies. At this stage, what, if any, protective effect male circumcision may have on a woman's risk for acquiring HIV during sexual intercourse is unclear. A study in Uganda and Zimbabwe found that it neither increased nor decreased a woman's risk for infection. 77 A more recent mathematical modeling analysis conducted in Zimbabwe and Kenya suggested a 46% reduction in the rate of male-to-female HIV transmission, suggesting that women also benefit greatly from male circumcision."

There is absolutely no mention in Mandell's of any concern this is untrue, nor is there any coverage of "these studies are contested". To be quite frank here, it looks to me (from spending some time looking into this) like MEDRS are in virtually unanimous consensus that circumcision provides some protection against transmission of HIV from a woman to her heterosexual male partner during vaginal intercourse, and less unanimous but still consensus that it provides (or could provide) some protection in other situations as well. This to me means that we cannot say alleged protection, as the MEDRS consensus is that it is protection, and we should not provide weight to criticism from non-MEDRS sources, or MEDRS sources in a significant minority in saying that it's "bad science". If the scientific consensus is that it's good science, then that by definition makes it good science. Please feel free to also reference the following source I found quite quickly in a cursory search on PubMed:

Farley, Timothy MM; Samuelson, Julia; Grabowski, M Kate; Ameyan, Wole; Gray, Ronald H; Baggaley, Rachel (June 2020). "Impact of male circumcision on risk of HIV infection in men in a changing epidemic context – systematic review and meta‐analysis". Journal of the International AIDS Society. 23 (6). doi:10.1002/jia2.25490.

"The evidence that circumcision reduces the risk of HIV infection in heterosexual men is strong and consistent from a wide diversity of study designs and settings."
"While some studies had serious limitations and biases, restricting the analysis to the observational studies without serious risk of bias had little impact on the pooled estimates and overall conclusions."

TLDR: Disagree with alleged, disagree with any "dispute" tag or information, and strongly disagree with any inclusion of non-MEDRS or "fringe" MEDRS criticism of the dead horse that's been bludgeoned to death by those who disagree with it for ulterior motives. Hopefully these comments help a little bit. bɜ:ʳkənhɪmez (User/say hi!) 22:33, 10 August 2020 (UTC)

Based on now several recent high quality sources, I support removal of the word “alleged”, but as long as the UNDUE text is unresolved, we need a disputed tag. The article should reflect these new sources before the tag is removed ... a 2009 Cochrane review was not sufficient for 2011 criticism— now we have more recent sources, and we have little reason for any of the dated secondary and primary sources now in the article. Rewriting to high quality sources usually resolves content matters... this article was a dated mess, where only the lead was maintained. SandyGeorgia (Talk)

I am puzzled why you added a primary source, since these should not be used in medical articles

Svoboda and Van Howe (2013) compared the African studies to the "lowest common denominator", claiming methodological flaws.[27]? Petersmillard (talk) 00:15, 11 August 2020 (UTC)

@Petersmillard: I've indented your comment - I hope you don't mind. Furthermore, I've removed that comment and source based on the following:

Not a strong MEDRS - it is not a RCT or review article at all.
One of the authors of that paper has a COI, as an employee of "Attorneys for the Rights of the Child" - which has a financial interest in publicizing the "rights of the child". This would be akin to using a drug company's "letter to the editor" about why their drug works instead of waiting for actual data.

I make no comment on whether there is valid criticism out there - but I have not found any and I strongly believe that any criticism of the studies needs to be discussed here before it is added to the article, so that sourcing can be vetted before it's added. I have this on my watchlist and will attempt to remove any additions not sourced well or that are undue weight to minority/fringe views, but I can't right now go through and clean it fully. bɜ:ʳkənhɪmez (User/say hi!) 01:03, 11 August 2020 (UTC)

There might be perfectly valid criticism out there, and there may even be perfectly valid criticism by people who aren't getting paid to promote either pro- or anti-circumcision POVs. It's okay to mention those criticisms, when they appear in decent secondary sources. However, unless and until the med school textbooks change their tune, then someone who knows nothing about the subject and reads this article should still come away with the view that "medicine" and "science" basically think it works. WhatamIdoing (talk) 01:12, 11 August 2020 (UTC)

Oh yes - I was merely trying to say that this criticism I removed was not something that should've been in the article, and I'll be watching to try to ensure that any other criticism that is heavily biased/conflicted doesn't get added. I personally couldn't find any good RS/secondary coverage of criticism in my searches earlier, but I'm not perfect (far far far from it). bɜ:ʳkənhɪmez (User/say hi!) 01:14, 11 August 2020 (UTC)

Petersmillard, you would have to look back in history to see who added Svoboda ... wasn’t anyone in current conversation ... I reformatted and seriously trimmed pre-existing content, and am unsure to whom you are directing the question. SandyGeorgia (Talk) 02:09, 11 August 2020 (UTC)

Here you go: [6]. We hope BigDan201 will not be doing this anymore, and that everyone will consult high quality sources and update articles in lieu of edit warring over poorly sourced content. SandyGeorgia (Talk) 02:16, 11 August 2020 (UTC)

And now I see that BigDan201 is Xcalibur ... why do editors do that? SandyGeorgia (Talk) 02:19, 11 August 2020 (UTC)

First of all, I put 'allegedly' in the lede to communicate that this matter is not settled, and is rejected by a significant minority viewpoint. however, I won't insist on this, and a 'disputed' tag would be acceptable.

there's no need for 'textbook supremacy'. we consult the RS, not just one type of RS. and keep in mind, most textbooks are considered tertiary sources; while these can be used, secondary RS are preferred for WP. Svoboda & Van Howe are in fact a secondary review, as is the paper published by Reuters. they're not primary, a primary source would be the original published results of the african studies. I don't see a significant COI there, and in any case, it was published in a scholarly journal for medical ethics, which should be more than suitable. surely if there were a significant COI, a reputable journal would've addressed this in the first place.

a salient point was made above, which is that there's a difference between analyzing the merits of a study vs providing information on disease/treatments etc. any medical advice naturally must use the best quality recent sources available. critiquing a scientific study (with far-reaching implications) does not have quite the same conditions. the african studies are relevant to this, which is why they had a section in the article, and if there is a section, it should include all relevant critiques and evaluation.

finally, If the scientific consensus is that it's good science, then that by definition makes it good science. NO, it doesn't, this is fundamentally wrong. the definition of good science is following the scientific method, not whether there's a consensus or not. that's not to say we should go to the opposite extreme and dismiss authority entirely, rather, credentials and consensus add WEIGHT to a viewpoint. the stronger the consensus/credentials, the more likely it is to be true, but it's not PROOF. the scientific establishment is usually not wrong, but it can be. this believe in science as dogma, i.e. 'scientists say this, therefore it is true' is a fundamentally anti-scientific perspective. that sort of obedience to hallowed authorities is exactly what the scientific revolution fought against. there is a subtle, but profound difference between giving weight to authorities, vs. taking authority as proof in and of itself. in other words, authoritative beliefs don't shape reality. prestigious institutions could get together and agree that the earth is flat, and balanced on four elephants on top of a giant tortoise, but that doesn't make it so. Xcalibur (talk) 21:03, 11 August 2020 (UTC)

Allegedly does not apply when it is a WP:FRINGE viewpoint. It is settled, it is rejected by an insignificant minority based on personal belief, not based on science. The science is clear. A disputed tag is also unacceptable. There is no valid dispute that has been presented, thus there is no need for a disputed tag. Svoboda and Van Howe are biased and have a conflict of interest, and is an opinion - not a peer reviewed review article. Merely being published does not make something a WP:MEDRS, nor even a WP:RS. Reuters is never a WP:MEDRS. The journal actually does address this - by marking their affiliations - as is common for letters. Anyone can submit a letter to be published - but it's up to the reader (us) to determine if it's useful.

There has been no reliable sourcing provided by yourself or others to claim that this is "obedience to hallowed authorities" and not WP:FRINGE. Until you can provide some reasoning that this should not be covered by WP:FRINGE, it's fringe and should not be given weight in the article. Regardless, it doesn't matter what you consider to be "true" - it matters what's verifiable to reliable sources, and reliable sources virtually unanimously agree with the facts here - that male circumcision prevents F2M transmission of HIV during heterosexual intercourse.

It seems quite clear that you are arguing your fringe viewpoint here against the data, consensus that the data is sound, and consensus that this is a settled topic - not WP consensus, but scientific consensus. We do not report on fringe minority viewpoints as if they are viable - we can certainly consider adding a section regarding these criticisms that are unanimously rejected by actual science, just as the article on Vaccines has a section on autism. Oh wait, it doesn't? That's because it's a fringe viewpoint that while held by a minority is disproven with data that's virtually unanimously agreed to be well more than sound. And that's what your argument is at its core - a plea to include a fringe viewpoint that virtually no actual scientists or doctors hold. -bɜ:ʳkənhɪmez (User/say hi!) 21:15, 11 August 2020 (UTC)

that last passage was more of a general admonition against an unscientific perspective. it was meant to be tangential.

No, it's not FRINGE. the conspiracy theories that claim that vaccines cause autism, or that the moon landing was a hoax, or flat-earth absurdity, etc. are FRINGE because these claims lack support and coherence, and are made against a very well-established body of evidence. that is not the case here. the link between circumcision and HIV is not settled science by any means, it's an ongoing area of study with a majority view and a significant minority view. a view being in the minority does not necessary relegate it to the FRINGE, especially when it has support and the topic is not settled.

Van Howe and Svoboda are published in a reputable journal on medical ethics, what better source are you asking for? that should satisfy RS requirements. dismissing well-sourced information as 'opinion' makes no sense. in fact, you claimed that male circumcision prevents F2M transmission of HIV during heterosexual intercourse. prevents? do you really mean to say that HIV can't possibly be transmitted this way, as long as one is circumcised? at most it would reduce risk, not eliminate it. also, F2M transmission is an uncommon vector for HIV, especially compared to M2M, sharing needles, and contaminated blood transfusions. if it does in fact reduce a minor vector, that is worth documenting, but claiming that it's an overall preventative is misleading.

you're supposed to assume good faith. all I'm trying to do is add relevant criticism to the article, not do a complete overhaul. why is there such vehement opposition to this? I could just as easily accuse you of tendentious POV-pushing, since you're trying to keep out a well-sourced critical view, but I'll give you the benefit of the doubt. Xcalibur (talk) 23:32, 11 August 2020 (UTC)

I am assuming good faith. I'm continuing to ask you to provide more sources - you've provided one low quality non MEDRS that's questionably a RS for their opinions. Put quite bluntly, you have not provided one single MEDRS that has any inkling of support for your claim that this is a disputed fact. It is settled science. All MEDRS I can find agree with the established fact that circumcision decreases F->M transmission of HIV in vaginal intercourse. You are correct I misspoke and used the word "prevent" instead of either "helps prevent" or "decreases the risk of" - that is my fault and I apologize. The article does not claim it is "overall preventative" and in fact makes clear that the science is less sturdy for M>M transmission or non-vaginal intercourse. If you want this included, please feel free to provide some MEDRS to support your claim that this is well sourced. I have nothing against including criticism that's well sourced to MEDRS - but you have not provided a single independent MEDRS to support that there is valid criticism of this that is based in science itself.

On the subject of Van Howe and Svoboda, I can go publish an "opinion" or "letter to the editor" in virtually any medical journal. Being published means just that - that it's published - not that the statements in it are accurate or have been vetted in any way. Even if you attribute it to them, this is still undue weight being given to the topic. The criticism is not valid, it is not widespread (you've still failed to show a single other MEDRS that supports your claims), and it should not be included unless you can prove it's not fringe. At this point, the onus is on you - I've asked you multiple times to provide any other source that supports this - yet you've continued to go back to that one source and haven't produced any other source. Again, if it's well sourced like you claim, you should be able to provide at least one or two more good MEDRS's that provide scientific criticism of the studies that were conducted. If you can do this, I'm more than happy to not only admit I was wrong, but help you add them to the article. Until such time as you can do so, we should not push a fringe viewpoint that flies against multiple dozens of reviews that conclude that the studies were well-conducted and scientifically valid, and the data is valid regardless of any superficial flaws.

I will no longer be responding here if you can't provide more sources. One opinion of biased people does not belong in an article - that's the definition of FRINGE and UNDUE and if you can't provide more sources, it proves that the viewpoint shouldn't be in the article. -bɜ:ʳkənhɪmez (User/say hi!) 23:41, 11 August 2020 (UTC)

F2M transmission is less common per sex act than M2F and much less common that M2M, but millions of people have gotten infected this way. Worldwide, half the HIV+ adults are women.

From my point of view, you aren't trying add relevant criticism to the article. It looks to me like you are trying to convince the reader that the mainstream, conventional medical view is wrong. WhatamIdoing (talk) 23:54, 11 August 2020 (UTC)

Agree ...Xcalibur/Bigdan201, unless you come up with new sources, you do not have consensus for this UNDUE addition, which is opposed by WhatamIdoing, Berchan, Peter and me. With the same text opposed by Doc James in Feb 2020; please stop beating a dead horse. SandyGeorgia (Talk) 00:21, 12 August 2020 (UTC)

I'm pretty sure articles in medical journals go through more vetting/review than you claim. It's a RS, no need to downplay it, and it's consistent with the Reuters article. if we discuss the African studies, then it's not UNDUE to add a few lines of criticism. it's evident that many sources rely on those studies, based on [7] and the first 2 refs used in the article. if those studies were unscientific, that threatens to undermine the entire position. with that said, it's not up to us to connect the dots with OR. and since the African studies are mostly removed from the article, it's no longer as important to include criticism thereof.

I'm willing to accept the possibility that circumcision may reduce F2M transmission to some extent. it makes sense, given that the foreskin has langerhans cells, part of the immune system (although that connection is not proven). still, we should emphasize that this is a relatively minor vector, with M2F being more virulent and unaffected by circumcision (as stated on p. 149 of [8]). there are also many confounding factors: regional, cultural, ethical, and behavioral, as stated by the aforementioned source, and by [9][10][11] and [12] (although your criticisms of using letters applies to the last one, not my first source]. while the article does say that circumcision does not replace safe practices, this could be developed further. a concluding quote from one of my cites: until we know why and how circumcision is protective, exactly what the relationship is between circumcision and other STIs, and whether the effect seen in high-risk populations is generalisable to other groups, the wisest course is to recommend risk reduction strategies of proven efficacy, such as condom use. Xcalibur (talk) 02:12, 12 August 2020 (UTC)

More dated citations

The article is citing 2007 WHO sources as 2011, while the WHO has scores of newer pages. The article is citing a 2013 archive.org CDC page that no longer exists. I am typing on an ipad and have no inclination to fix all of this via hunt and peck with fat-fingered typos, but a good way to resolve content disputes is to not write crap articles. The citations need updating, and text needs to reflect what the sources say in a balanced way ... not just put forward a POV. Everysource I have looked at that is currently in the articles makes disclaimers that are not included. Many of the sources are dated ... why is a 2008 review cited, for example? SandyGeorgia (Talk) 09:57, 13 August 2020 (UTC)

PS, Berchanhimez, per WP:CITEVAR, when you are adding new sources, if you could use the existing style it would save me the time of having to re-do them all. It is so easy to plug a PMID in to the standard medical citation filling tool, and get a consistent vancouver author citation template without all that awful last first last first last first globbing up the article. You will find this is the style most consistently used on most medical,articles, and Boghog’s tool makes it so easy! Thanks, best, SandyGeorgia (Talk) 00:56, 16 August 2020 (UTC)

Is there a way to do this with the "cite" bar in the edit window? I will bookmark that but my primary method of citation has been the cite bar and it'd be nice if I can do it from the citation bar in the edit window. Sorry for the work, I had no clue that it was important to keep them the same. -bɜ:ʳkənhɪmez (User/say hi!) 02:11, 16 August 2020 (UTC)

Not to worry; lots of editors ignore CITEVAR and plug in inconsistent citations, and an inconsistent citation is still better than no citation. I pay attention to CITEVAR for several reasons. First, when there are entrenched disputes, getting an article into clean shape provides a much better basis for discussing the areas of disagreement. When the entire article is a mess of very kind, the tasks just seem more daunting. Cleaning up an article is often a big step towards resolving content issues— as the article begins to look more and more like something worth devoting effort to (as in, right now, this one doesn’t—there are problems everywhere you look). It is like the graffiti effect in a neighborhood. Second, I view every article as a Featured article in the works, and believe doing it right from the get-go is easier than massive cleanup down the road. And finally, I hate working on messy articles, so I tend to clean up the Manual of Style stuff while I work, and reformatting citations takes valuable time.

I do not know what the cite bar is (and I have been editing for 15 years, that says something about me or something about cite bar, take your pick), but poking around in the edit window looking for it, I discovered some miserable features of the software which explain some of the dreadful citations found in student editing. Perhaps it is something I turned off long ago somewhere?

When working in most medical articles ... since most of them use the Diberri citation filling tool, I just keep the tool open in a separate window. (Diberri was a Stanford MD, one of the early WPMED participants, who wrote the tool which most of us adopted, and now Boghog maintains. Boghog could probably answer your question.) Best, SandyGeorgia (Talk) 02:36, 16 August 2020 (UTC)

Thanks for the clarification. Since Sandy George said the meta-analysis was "too old," I thought she had removed it. I agree with you about the RCTs and didn't put them in myself. However, they are historical landmark trials which will never be repeated, and Doc James also agreed with having them included. Petersmillard (talk) 10:31, 16 August 2020 (UTC)

I am indifferent to including the primary studies if that is done correctly. I encountered a section where the studies were mentioned in a primary source context, so they could be criticized by poor sources. It is OK to add a citation to worthy and seminal primary sources as they are mentioned in secondary sources, along with the secondary source mention of their importance. That is, if correctly sourced and due weight text criticizing or discussing them is added, it's OK to cite the primary source along with the secondary source that mentions them, if they are of significant importance (in this case, it can probably be demonstrated that they are). In other words, if the overall article is corrected, I am not objecting to adding back the primary sources in context. Regards, SandyGeorgia (Talk) 18:02, 16 August 2020 (UTC)

Speaking of sources that are old and fail WP:MEDRS, people appear to be trying to insert a 2013 position paper from a tiny Dutch medical organization. Jayjg ^(talk) 21:57, 17 August 2020 (UTC)

User:Jayig - position papers are only ever updated when the position changes or significant new supporting evidence is there. There is no reason to expect a newer position paper than 2013. Further, KMNG isn't "tiny", it is considered the national medical association of the Netherlands. Unless you can find some "better" netherlands source, that is perfectly acceptable to cover in "recommendations" - that they have recommended since 2013 that circumcision is not considered as a preventative measure for HIV. -bɜ:ʳkənhɪmez (User/say hi!) 22:00, 17 August 2020 (UTC)

The position might not have changed, but medical science marches on relentlessly, regardless. That's why 2013 fails WP:MEDDATE. Also, how many medical organizations do you suppose there are in the world? 10,000? 50,000? Why such prominence to this organizations with a few hundred members? I'll give you a hint: it appears to be because it is one of a very tiny number of medical organizations that take this position. See WP:REDFLAG, WP:MEDDATE. Jayjg ^(talk) 22:04, 17 August 2020 (UTC)

2013 position paper of small Dutch medical organization - WP:MEDDATE and WP:REDFLAG

I'm not seeing any consensus to insert the 2013 views of a small Dutch medical organization, as proposed here. Can someone please explain how that insertion complies with WP:MEDDATE and WP:REDFLAG. Jayjg ^(talk) 22:01, 17 August 2020 (UTC)

As I said above, the national organization for medical practitioners (doctors, but also nurse practitioners and others) is not "small", and is certainly relevant. Furthermore, unless they have a newer position paper, the older source is valid per WP:MEDRS given there is no newer information about their position. There is no "exceptional claim" here for REDFLAG to be applicable - the claim is that they made that statement, and the source does support that. Nobody is recommending adding "circumcision is ineffective", but the recommendations section should cover more than just the World Health Organization - and should especially cover contrary opinions, per WP:DUE - it's certainly due weight to inform readers that some national/highly respected medical organizations do not include this in their recommendations - without saying "they're right to do so". -bɜ:ʳkənhɪmez (User/say hi!) 22:05, 17 August 2020 (UTC)

By the way, per the Royal Dutch Medical Association website (and subpages thereof), they have over 40,000 doctor members, not including other practitioners from fields such as nurse practitioner, students, etc. -bɜ:ʳkənhɪmez (User/say hi!) 22:08, 17 August 2020 (UTC)

WP:MEDDATE is not about whether the RDMA has kept up to date, it's about whether the medical information being presented in Wikipedia articles is up-to-date. The RDMA position might not have changed, but medical science marches on relentlessly, regardless. That's why 2013 fails WP:MEDDATE. As for 40,000, it may seem like a lot to you, but other organizations are much larger; the Indian Medical Association has over 300,000 member doctors. Also, how many medical organizations do you suppose there are in the world? 10,000? 50,000? Why such prominence to this organization? I'll give you a hint: it appears to be because it is one of a very tiny number of medical organizations that take this position. If there are others that take this same position, please cite them here. See WP:REDFLAG. Jayjg ^(talk) 22:15, 17 August 2020 (UTC)

The position of a medical organization is not "medical information" so long as it is attributed as the position of the organization and not facts. It is a factual information that they may or may not include it in their recommendation. Furthermore, you are comparing apples to oranges - obviously the Dutch medical association will be smaller than the Indian one because the population of the Netherlands is, just based on my knowledge, no more than a tenth or so that of India. Is it a notable organization? Yes - it is the primary organization in the Netherlands. If you're saying we ignore an entire country just because they're in the minority, then that's absurd. Nobody is saying we use their position to say "it's ineffective', but their recommendation is notable and should be covered in the recommendations section of this article. This is not WP:REDFLAG because no "extraordinary claim" is being made. The claim being made is "this organization does not include the recommendation" - which is well cited and notable for the article. Lastly, 2013 only fails MEDDATE if there is newer. I ask you again - can you provide a newer position statement from the RDMA? If not, then it does not fail MEDDATE. -bɜ:ʳkənhɪmez (User/say hi!) 22:21, 17 August 2020 (UTC)

The problems here are threefold are WP:MEDDATE, WP:REDFLAG and WP:DUE. WP:MEDDATE because you're making specific medical claims about HIV prevention sourced to a paper from 2013; WP:REDFLAG, because the advice appears to contradict the advice of the WHO; and WP:DUE, because the you're trying to include views of one (or two) medical associations out of the tens of thousands that exist in the world. Please address those specific points. Jayjg ^(talk) 16:40, 18 August 2020 (UTC)

I think you are overstating the contradiction between the WHO and the AAFP & KNMG- assuming one even exists. The WHO says "In countries where the HIV epidemic is concentrated in specific population groups such as sex workers, injecting drug users or men who have sex with men, there would be limited public health impact from promoting male circumcision in the general population. However, there may be an individual benefit for men at high risk of heterosexually acquired HIV infection." That seems to be more or less in line with the view that the African studies aren't necessarily generalizable to the developed world. Prcc27 (talk) 17:06, 18 August 2020 (UTC)

If the WHO and the AAFP & KNMG agree, then what need have we for the positions specifically of the AAFP and KNMG? Why those two organizations out of the thousands of national medical organizations around the world? Jayjg ^(talk) 17:34, 18 August 2020 (UTC)

Good point. I actually kind of want to incorporate the WHO source with the others. And maybe we could replace the AAFP & KNMG sources with the WHO source..? But it's also important to note that the WHO source is from 2007, so it is older than the other sources. Prcc27 (talk) 17:41, 18 August 2020 (UTC)

I’ve addressed them already. First of all, MEDDATE only applies if there’s a newer source that has the same information. I’ve asked you three times now - either show us the newer source from the KNMG/RDMA, or stop claiming MEDDATE. REDFLAG does not apply because we don’t just include the one viewpoint, but we include all significant viewpoints, even if they contradict science or each other. Just because the WHO says one thing does not mean we don’t care about national organizations, just as we report that Russia has just “registered” their vaccine even though the WHO has not. Lastly, there are not “tens of thousands of” national general medical organizations, there’s at most a few hundred. The views of a national organization dedicated to family practice are certainly due weight for this article, as opposed to those of an organization of neurologists, which nobody is trying to include.

User:Jayjg, this is now at least the third time I’ve brought up specific rebuttals to your points based in the policies you yourself are linking, and you have yet to actually attempt to discuss my rebuttals yet you keep parroting your same misleading and incorrect concerns. I’ve explained to you why the three policies you keep referencing don’t apply in my view - if you disagree, you may wish to begin an RfC or ask for a third opinion from someone uninvolved, because it’s clear you aren’t going to actually attempt to rebut any of the comments I’ve made. -bɜ:ʳkənhɪmez (User/say hi!) 17:50, 18 August 2020 (UTC)

Berchanhimez, you can't just keep mentioning policies without addressing the fact that your edit violates them. Regarding WP:REDFLAG and WP:DUE, you claim you've included "all significant viewpoints", without addressing the fact that exactly 2 hold to a viewpoint that no others seems to hold. If there are others that agree with the AAFP and KNMG, please list them. While you claim that there are only a few hundred national medical organizations in the world, most medical specialties also have national organizations. In the United States alone there are many national medical organizations, including the American Medical Association, American Academy of Child & Adolescent Psychiatry, American Academy of Dermatology, American Academy of Family Physicians, American Academy of Neurology, American Academy of Ophthalmology, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Association of Colleges of Osteopathic Medicine, American Association of Neurological Surgeons, American Board of Emergency Medicine, American Board of Family Medicine, American Board of Pediatrics, American Board of Preventive Medicine, American Board of Surgery, American College of Physicians, American College of Preventive Medicine, American College of Surgeons, American Osteopathic Association, American Urological Association, Centers for Disease Control, National Institute of Child Health and Human Development, Society of Critical Care Medicine, and dozens more. Other countries have similarly large numbers of national medical organizations. Why have you picked just two out of all of them? Jayjg ^(talk) 18:15, 18 August 2020 (UTC)

You again seem to have ignored what I said. We don't care what the American Academy of Ophthalmology says about circumcision - they aren't in the field of HIV prevention, nor neonatal medicine, nor family medicine. I have not claimed to include all significant viewpoints - but only that we should do so - and this is the first step. Again you haven't read what I said or you wouldn't have listed those organizations that are useless for this discussion. There are two that have a significant, notable, and different viewpoint than the WHO - and per WP:DUE itself we should name the prominent adherents to this significant other viewpoint. -bɜ:ʳkənhɪmez (User/say hi!) 18:33, 18 August 2020 (UTC)

PS - as a comparison, if the American Medical Association has a viewpoint on this, then we should publish that in recommendations too - regardless of what it may be. The AMA is the American equivalent of the KNMG, and the AAFP is the largest American association of family medicine practitioners. Any viewpoint that is notable should be included - but not as scientific fact but as attributed views. -bɜ:ʳkənhɪmez (User/say hi!) 18:37, 18 August 2020 (UTC)

My point about bringing the longer list was to disprove your obviously incorrect claim that there are not “tens of thousands of” national general medical organizations, there’s at most a few hundred. And yes, it's unlikely that the American Academy of Ophthalmology would have anything relevant to say on this topic; but many of the other groups I listed in my earlier comment would indeed be relevant, including the American Medical Association, American Academy of Family Physicians, American Academy of Pediatrics, American Board of Preventive Medicine, American Board of Surgery, American College of Physicians, American College of Preventive Medicine, American College of Surgeons, American Osteopathic Association, American Urological Association, Centers for Disease Control, National Institute of Child Health and Human Development, and more. And those are just the American national organizations; other countries also have many relevant organizations. The point that remains unaddressed is "Why have you picked just two out of all of them?" And I think the obvious answer is that it is apparently only those two, out of all the worlds' national medical organizations, that hold this specific view. And that, of course, is why WP:REDFLAG and WP:DUE are still being violated. It's easy to prove me wrong, though; just bring the positions of other national medical organizations on the topic. Jayjg ^(talk) 19:07, 18 August 2020 (UTC)

The only one of those comparable to the RDMA is the AMA. Feel free to add their position if they have one you can source. The others are not the largest national medical association in their countries. I’ve explained this and you keep grasping at straws, I disagree, another editor seems to as well. -bɜ:ʳkənhɪmez (User/say hi!) 19:36, 18 August 2020 (UTC)

If The only one of those comparable to the RDMA is the AMA, why, then, does the article also include the view of American Academy of Family Physicians? Can I assume you agree they should be removed, then? If not, why not? Jayjg ^(talk) 14:44, 19 August 2020 (UTC)

I’m not aware of an AMA position on it, so the next best is to summarize the notable US positions of the next largest relevant organizations. I don’t believe I ever suggested that including the RDMA and AAFP was complete, nor that they were the best, but it’s a start. If you can find an AMA position for it, then it should be replaced. If you can find an AAP position on it, for example, then it should be added or replaced. Ideally, this article would cover recommendations in line with the WHO, opposite the WHO, and with slight differences - and I guarantee you there’s a lot with slight differences that just need found and added. -bɜ:ʳkənhɪmez (User/say hi!) 15:31, 19 August 2020 (UTC)

Well, if WP:MEDDATE is meaningless here, and the AAFP meets the criteria, then certainly the position paper of the American Academy of Pediatrics (which include the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention), which deals with situation in the United States (not Africa) should be included as well.^[1] Jayjg ^(talk) 16:37, 19 August 2020 (UTC)

MEDDATE isn’t meaningless - it specifically applies when newer is available. If there’s not a newer AAP article, I think that would likely be better to replace the AAFP one with for the “US” recommendation. I think the recommendations section here needs a lot of work but I’ve been very limited in my time to dedicate to Wikipedia so most of my work has simply been commenting here on the work of others. I can potentially work on reorganizing in the next week or so, unless you want to take that on which I have no problem with. -bɜ:ʳkənhɪmez (User/say hi!) 16:48, 19 August 2020 (UTC)

Didn't the AAP policy expire though? AAP policy statements automatically expire 5 years after publication [13]. Was the AAP policy reaffirmed before it expired? The AAFP circumcision policy was approved by their Congress of Delegates in 2013 and reaffirmed in 2018, (so I'm assuming that the AAFP policies also must be revisited every 5 years). Does WP:MEDDATE allow us to use an expired policy as a source? Prcc27 (talk) 17:48, 19 August 2020 (UTC)

That’s a good potential point - my reading of MEDRS doesn’t specify anything about “expiration” of policy statements, and that in and of itself is next to meaningless in real life. In clinical practice, someone’s going to use an expired 2013 policy statement over nothing for sure. I think unless the AAP has published newer, we should use their published policy with attribution such as “In 2013, the AAP published a policy statement recommending XYZ”. -bɜ:ʳkənhɪmez (User/say hi!) 18:01, 19 August 2020 (UTC)

So would the AAFP source be removed altogether, or would we use both sources? If the former, would the AAFP source be replaced by the AAP source simply because the AAP source is a better source? I noticed that before the AAP source was provided, you said that the largest organizations should be represented; it looks like the AAFP has more members than the AAP. Prcc27 (talk) 18:24, 19 August 2020 (UTC)

The AAP statement is endorsed by ACOG (American College of OB/GYN), and the task force that produced it consisted of stakeholders from AAP, AAFP, ACOG, and CDC. Thus, even if AAFP has a different view, the AAP statement is more representative of the US as a whole by including those four organizations in producing it. Remember, our goal isn't to present both sides as if they are equal, but to present both sides with equal weight they merit. If AAFP disagrees with a larger national organization, they've had their chance (during that task force) to present those ideas and to have them accepted - but the task force as a whole does not seem to have taken the same viewpoint. Some things that I note from the AAP statement are that AAP recommends circumcision may be helpful in preventing HIV, but they also point out that much HIV transmission in the US is M2M and thus the data is not as solid for it - but they still recommend all parents of newborns be given the option and explained the benefits. I think that these three things ("helpful", "not as solid given M2M prevalence in US", and "recommend all parents be given the option") are what we should cover in recommendations. I am less convinced we should include their request for further research in the US, as that is less encyclopedic to me. I wonder if both of you User:Jayjg and User:Prcc27 would be okay with the following, with reference as appropriate: In 2012, the American Academy of Pediatrics, along with a task force including ACOG, AAFP, and the CDC, found that circumcision may be helpful for the prevention of HIV in the United States, but that given differences in transmission between the US and countries studied in the past (namely a higher prevalence of male to male transmission in the US) it is not certain. The task force recommended that all parents of newborns be offered the choice of circumcision taking into account the potential reduction in risk of HIV transmission. Hopefully that's a start - it includes their recommendation, as well as their quite clear reservations that I'm reading in their position statement. I'm sorry I haven't been able to look into other countries yet - my Wikipedia time is quite limited for the next week or so. Hopefully this suggestion of specific wording can help flesh out a finalized product to put in the page - I agree however that the AAP/ACOG/AAFP/CDC statement is going to be a better source for a "national" recommendation than the AAFP. Regards, -bɜ:ʳkənhɪmez (User/say hi!) 19:58, 19 August 2020 (UTC)

Berchanhimez, what you propose is better than what's currently there. Jayjg ^(talk) 20:06, 19 August 2020 (UTC)

The AAP is actually called "the American Academy of Pediatrics" (not Physicians). I disagree with the wording as is, because I don't view the AAP policy as a joint AAP/ACOG/AAFP/CDC statement. Neither the AAFP nor the CDC endorsed this statement. Sure, you can mention that there were CDC and AAFP liaisons involved in the making of the statement, I'm not saying that that cooperation isn't important. However, the wording as is insinuates that the ACOG was just as involved with this statement as the AAFP & CDC, even though only the former endorsed it. In fact, maybe we should consider not mentioning the AAFP and CDC cooperation at all to avoid being verbose. For some reason, the "it is not certain" at the end of the sentence bothers me, because I had to keep re-reading the sentence to figure out what "it" was referring to. Would it be possible to re-word that sentence to make it more clear what exactly is uncertain? Or maybe this was just a personal issue in comprehension that I had, that most others wouldn't have..? "The task force recommended that all parents of newborns be offered the choice of circumcision..." now we are getting into the ethics of infant circumcision. If we are going to include the AAP's view on the ethics of infant circumcision, I think we should also include the KNMG's view as well. Here is what the Royal Dutch Medical Association said:

"Thus circumcision as a preventative against urinary tract infections or HIV/AIDS would need to be weighed against other, less intrusive forms of prevention (such as antibiotics, condom use, sex education or behavioural changes) and a scientific cost/benefit analysis made. Only if the results of this cost/benefit analysis were positive should the intervention be offered to all parents of small boys on public health grounds. In addition, it would need to be demonstrated that it was essential that the circumcision be performed during childhood or infancy, rather than waiting until the boy had reached an age at which the risk was relevant (such as in HIV infection) and he could make a decision about the intervention for himself. After all, in many cases, such as in HPV or HIV prevention, it will be possible to put off circumcision until the boy reaches an age at which he can elect to have the intervention himself or instead choose alternatives such as using condoms, HPV vaccination or abstinence."

Furthermore, the KNMG viewpoint was endorsed by several different Dutch medical organizations, and if we are going to mention that the AAP statement was endorsed by the ACOG, then we should also note the endorsements of the KNMG viewpoint. However, since so many Dutch organizations endorsed the viewpoint, we should probably avoid mentioning each of them by name. Prcc27 (talk) 21:16, 19 August 2020 (UTC)

I encourage rewording it - and the statement does not say "they were just as involved", it makes clear that the AAP was primary (yes, it's Pediatrics, I corrected it) and the others were part of the task force. I don't think we included anything on the ethics of it in the AAP statement - simply that they recommend the choice be offered. The statement "we recommend all parents be offered the choice" is not an ethical statement at all - it is simply a recommendation that all parents be given the choice. I think the first statement can be reworded as so: In 2012, the AAP, along with a task force including ACOG, AAFP, and the CDC found that circumcision may be helpful for the prevention of HIV in the United States. They stopped short of being certain it would help as the transmission patterns in the US are different from those studied in the primary studies they examined, namely the US has a higher prevalence of M2M transmission. The task force recommended that all parents of newborns be offered the choice of circumcision taking into account the potential reduction in risk of HIV transmission. Follow that with the same last statement about the recommendation - it's not an ethics statement at all, it's simply stating their recommendation that they made (which is just rewording what they said in a sentence form, but I guess we could quote AAP if we wanted to). Just as we say the Dutch association does not recommend it, we should say whether the AAP statement does or doesn't - and they do recommend offering circumcision to all parents of newborns based in part on the HIV risk reduction they observed. The way it's worded now does not imply "endorsement" by ACOG/AAFP/CDC, but it does state that they were involved in the process of crafting the position statement - which they were, and is important because it shows a multidisciplinary position statement that can be considered the "prime" in the US. -bɜ:ʳkənhɪmez (User/say hi!) 21:28, 19 August 2020 (UTC)

Does the source say that the ACOG, AAFP, and the CDC were part of the task force? From what I read, it says they were "liaisons". I'd prefer "an AAP task force along with liaisons from the ACOG, AAFP, and CDC." The current wording on the article is about whether or not the African studies apply to circumcision in general in the developed world, not just infant circumcision (even though the AAFP specifically questioned whether studies on adult circumcision apply to infant circumcision). If the sentence was saying that "the AAP includes circumcision in its recommendations for HIV prevention", that's one thing. However, you are proposing to say that the AAP recommends "all parents be offered the choice", even though the wording for the Royal Dutch Medical Association's view that is currently up on the article makes no reference to circumcision of children, or whether or not parents should be offered a choice. It is quite clear that they believe that children should not be circumcised for HIV prevention reasons and they also seem to be against it being offered to parents as well. I view your proposed wording as inconsistent with how we currently portray the KNMG's viewpoint. Prcc27 (talk) 23:49, 19 August 2020 (UTC)

It says "The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention" and "The American College of Obstetricians and Gynecologists has endorsed this technical report." Jayjg ^(talk) 19:12, 20 August 2020 (UTC)

Thank you for sharing that quote; I still wouldn't mind the word "liaison" being used, but I won't fight too hard for that word's use. Also, the Ethics of Circumcision page mentions the ACOG endorsement, so we should consider mentioning it as well. I personally think the ACOG endorsement is more noteworthy than the liaisons. Nonetheless, my biggest objection to the proposed wording is that the AAP's viewpoint is portrayed in a different manner than the KNMG's. Prcc27 (talk) 19:41, 20 August 2020 (UTC)

Maybe it's my dialect of english, but to my understanding, if an organization sends a liaison to a task force, they're part of the task force. It seems counterproductive to require the entire hundred/thousands/tens of thousands of member organization to be included to call them a part of the task force. The liaison's entire job is to "liaise" between the task force and the organization's members to ensure their opinions are correctly included. I think your concern about the endorsement is covered well enough by stating the recommendation is that parents are given the choice. Since it seems we're all in agreement at least on the base wording here, I'm going to go ahead and make the edit, and I have no problems with minor editing of format, word choice, order, paragraphing, etc. etc. if anyone else so chooses. I would like to personally thank User:Prcc27 and User:Jayjg for working hard on this talkpage to ensure the best for the article - this is a prime example of Wikipedia at its best, and I think it truly did work here. While the section on recommendations will likely always lack full coverage (due to bias towards european/american editors simply due to this being the english wikipedia), it is better off now than before. -bɜ:ʳkənhɪmez (User/say hi!) 20:40, 21 August 2020 (UTC)

User:Prcc27 - thanks for the copyedits - I've gone ahead and remove the update tag since it seems we have the most up to date information we can - it doesn't mean it's complete though - please feel free to add other countries as we can. -bɜ:ʳkənhɪmez (User/say hi!) 00:22, 22 August 2020 (UTC)

Do you really think we should add more countries? If so, The Royal Australasian College of Physicians and The Canadian Paediatric Society could be good candidates. Even if we only keep what we currently have, I think it was a good call to at the very least compare one of the most pro-circumcision policy statements in the developed world to one of the most anti-circumcision policy statements in the developed world. Prcc27 (talk) 05:18, 22 August 2020 (UTC)

I think a global perspective is important - the Canadian Government does not comment on circumcision as HIV prevention thus I think it would be viable to put in the article that the CPS (the next best source) recommends against routine circumcision of every newborn as HIV prevention, and the same can be said for the RACP given I can't find anything on the Australian Public Health website about it. Of note, however, both fall in line with the AAP task force recommendation that the parents be given the choice of circumcision, but note that the evidence may not extrapolate to their countries. Pinging User:Jayjg for their opinion - and I'd almost like them to craft the wording here to make sure they're okay with it as well. -bɜ:ʳkənhɪmez (User/say hi!) 05:26, 22 August 2020 (UTC)

I don't think the government of New Zealand supports circumcision for HIV prevention either (the RACP covers New Zealand too- not just Australia). Prcc27 (talk) 07:53, 22 August 2020 (UTC)

Side bar: I was trying to find the New Zealand government policy for HIV, and I accidentally ran into something interesting: apparently part of the reason why circumcision for HIV prevention might be viewed as not be applicable in developed countries is because the most prevalent subtype of HIV is different in develop countries than the ones in Africa. The source I found might not be (probably isn't?) MEDRS, but even if it is MEDRS, we probably wouldn't want to include it in the recommendations section of the article because that would be WP:SYNTH. Regardless, I think it's pretty interesting (but sorry for the side bar if this won't be able to help improve the article; I'm pretty rusty on MEDRS).[14][15] Prcc27 (talk) 07:53, 22 August 2020 (UTC)

Recommendations section

Rearrange recommendations section proposal: If we are going to have more medical organizations listed in that section, maybe we should rearrange it so that instead of having one paragraph for each organization- we have a sentence or two about which organizations recommend it for HIV prevention vs. which don't, and then we have another sentence or two about which organizations say circumcision should be offered to parents vs. which don't, etc. Here are some bullet points about the gist of what the organizations say:

African studies on circumcision for HIV prevention might not be directly applicable due to MSM transmission being more prevalent: RDMA, RACP, AAP, CPS
Circumcision not included in HIV prevention recommendations: RDMA, RACP, CPS
Circumcision included in HIV prevention recommendations: AAP
Circumcision for HIV purposes should be/can be deferred until adulthood: RDMA (should be), RACP (can be), CPS (says adult circumcision prevents HIV but does not say whether circumcision of minors does)
Circumcision should be offered to parents for HIV prevention purposes: AAP, (not sure if we can say the RACP or CPS concurs)
Circumcision should be offered to parents in general, not necessarily for HIV prevention purposes: AAP, CPS, RACP Prcc27 (talk) 05:13, 24 August 2020 (UTC)

CDC source

I think what's currently in the article is an improvement over what was there before. I'm not sure we have enough policy positions yet to provide that fine a degree of differentiation of positions (six different positions as you've outlined). Regardless, I think the article should include the CDC's position paper on this, which is current and thorough. Jayjg ^(talk) 18:25, 24 August 2020 (UTC)

Given that the CDC source is more recent, and that the AAP policy is older and might technically be "expired", I definitely think we should consider replacing the AAP one with the CDC one. That would actually seem to be in line with WP:MEDDATE. However, I don't think it would be a good idea to have both sources on the article at this point, especially since we need to add the perspective of more organizations from around the world. Right now, all we have is the American and Dutch positions. This shouldn't just be about the U.S. If you are against the six position outline proposal, how would you incorporate the CPS and RACP policies without repeating what is already in the article given that there is overlap between the policy positions? Prcc27 (talk) 19:58, 24 August 2020 (UTC)

I believe replacing the AAP task force with the CDC is probably best - here's some quotes I pull out that seem to represent their position all uncircumcised adolescent and adult males who engage in heterosexual sex should be informed about the significant, but partial, efficacy of male circumcision in reducing the risk of acquiring HIV ; Men who have sex with men should be informed that: Male circumcision reduces the risk of men acquiring HIV and other STIs duringpenile-vaginal sex, but no definitive statements can be made about whether male circumcision reduces the risk of MSM acquiring HIV and other STIs during penile-anal sex. ; (regarding neonatal information given to newborn parents) Other anticipated health benefits derive in part from future prevention of HIV and someSTIs acquired through heterosexual sex. - TLDR: Is effective in heterosexual sex, no definitive statement can be made regarding MSM, parents should be informed of the "anticipated" health benefit of "future" prevention of HIV. I think the 6-category system Prcc27 came up with definitely helps us here on the talk page, but I don't think we will ever have enough notable organizations to justify sectionining it like that in the article - and besides, WP:Criticism suggests to me we are better leaving it as "recommendations" or if we want to change the name "application of data" or something, versus separating out by viewpoint. I also sectioned this section off more for easier editing/reading - hopefully you don't mind, please feel free to undo/revert if you do. -bɜ:ʳkənhɪmez (User/say hi!) 20:06, 24 August 2020 (UTC)

I think the CDC and AAP task force sources are independent, and I don't think the two make identical recommendations (I'm willing to hear arguments that they do, though), so I think they should both be referenced. If it makes sense to quote the CDC position more extensively, and the AAP less extensively, I'm fine with that. Jayjg ^(talk) 20:44, 24 August 2020 (UTC)

I'm not sure "more extensively", but definitely "more prominently" (i.e. before any other American source) as they are the "official government public health recommendations body" (I made that term up). I am fine with both being referenced still. -bɜ:ʳkənhɪmez (User/say hi!) 21:24, 24 August 2020 (UTC)

The CDC source says "male circumcision can also be conducted in adulthood when the individual can make the decision for himself. However, male circumcision after sexual debut could result in missed opportunities for: HIV and STI prevention during the window period between sexual debut and circumcision." This is in line with other medical organizations around the world cautioning that circumcision for HIV prevention purposes can be postponed until later on in life. As a result, I think we should also mention this when we add the CDC source to the article. Prcc27 (talk) 22:48, 24 August 2020 (UTC)

I disagree that saying that it "can also be conducted later" means that they're saying it "can be postponed" - there's a difference between saying "if postponed, it can still be done later" and saying "it can be postponed". I think the only thing we can claim about that is going to be something such as "the CDC does not make any recommendation about whether newborn circumcision may be more effective than postponing until later in life" - but I definitely don't read anything that we can extrapolate into "the CDC says circumcision can be postponed until later in life". While they don't explicitly say anything either way (yes or no), we can't editorialize/extrapolate that from their statements, nor can we extrapolate from their lack of a statement that they recommend one way or another. -bɜ:ʳkənhɪmez (User/say hi!) 22:56, 24 August 2020 (UTC)

It can certainly be reworded, (and I wasn't proposing that we use that exact wording). But I think it's too important to ignore what the CDC said about adult circumcision. They mention that most of the health benefits don't arise until sexual debut, and that adult circumcision is an option which gives the individual the ability to make a choice for themselves. This was written in the "Considerations for the timing of male circumcision" section. At the very least, the fact that it was put in that section makes it pretty clear that they want parents to *consider* the fact that circumcision can also be effective when done in adulthood (especially when done before sexual debut), rather than childhood. Prcc27 (talk) 23:22, 24 August 2020 (UTC)

They also said, if my memory serves, that the risk of trying to wait until sexual debut may impart a risk that the teenager/young adult/older adult becomes sexually active before being aware of the risks and potentially contract HIV before they are offered circumcision as an adult. I think it's best in this case, because they didn't say anything clearly one way or another, to only include that they say it may be effective for adults before sexual debut - and not comment on whether "waiting" is a recommendation or not at all. -bɜ:ʳkənhɪmez (User/say hi!) 23:36, 24 August 2020 (UTC)

Agreed. Also, it's worth keeping in mind that all of these position papers are typically about the overall benefits of circumcision, including (but not limited) reducing the transmission of HIV - we should try (where possible) to restrict the material we take from them only to the relevant HIV parts. Jayjg ^(talk) 14:33, 26 August 2020 (UTC)

Right. That I think is the biggest problem - picking out the HIV-relevant information. For example, it's completely viable that an organization recommends deferring circumcision until adolescence or young adulthood, yet still recognizes that it may help prevent HIV and may be less effective if deferred until after sexual debut. In that case, their recommendations on HIV should be mentioned first, but followed with the comment that they do not recommend newborn circumcision itself. I'll go ahead and add the CDC's recommendation, and I'll leave the AAP task force for now per the discussion above. -bɜ:ʳkənhɪmez (User/say hi!) 18:39, 26 August 2020 (UTC)

"copyedit"ed

I've done a general "copyedit" of the section - in quotes because there was some slight change of meaning in that I changed long ways of saying "is recommended" to just say that. User:Jayjg and User:Prcc27, please feel free to review my edits and make further edits as you see fit - pinging so you guys are aware and can take a look. Further, per MOS:QUOTE, a quote of that length should be blockquoted, so I've done so with the {{quote}} template. Regards, -bɜ:ʳkənhɪmez (User/say hi!) 18:55, 26 August 2020 (UTC)

Would we be able to condense the AAP section at all? I think "the task force recommended that all parents of newborns be offered the choice of circumcision after being informed of the benefits and risks, including a potential reduction in risk of HIV transmission" is redundant, and should possibly be removed since it seems to already be covered in the CDC section. Maybe it would be better if we say that the CDC supports offering it to parents and that this view is in line with the task force's view. Prcc27 (talk) 06:11, 27 August 2020 (UTC)

I prefer to wait for User:Jayjg to comment, but I'm fine with condensing the two if they are. -bɜ:ʳkənhɪmez (User/say hi!) 06:13, 27 August 2020 (UTC)

I think the paragraph looks reasonably good now, and am not sure what the exact changes proposed are anyway. I also think it would be valuable to get the views of other large national medical associations. Jayjg ^(talk) 16:08, 28 August 2020 (UTC)

This article says that the task force says that parents should be offered circumcision, and then it bascially repeats the same thing by saying the CDC recommends that parents be offered circumcision. This is redundant, so it should be consolidated into one sentence- something along the lines of: "the CDC recommends that circumcision be offered to parents of newborns, which is in line with the views of the AAP task force". When you say we should include more national medical associations, do you mean more viewpoints from medical associations from around the world, or do you mean include more American association viewpoints? I'm strongly against including more American medical viewpoints when we currently only have 1 non-American viewpoint up there. We need to focus on incorporating the CPS & RACP viewpoints, and then we can consider expanding on the American viewpoints. But first can we please consolidate the wording on parents being offered circumcision? Prcc27 (talk) 19:04, 28 August 2020 (UTC)

Queries

Hi, all; I had earlier unwatched because things were starting to get heated. Prcc27 asked me to look in again, and it is a pleasure to discover a collaborative approach on talk! I am looking at this version of August 30. As I don't have time to delve seriously into every source listed in the Recommendations section, I have general observations and queries, that several of you can probably answer.

One of the effective ways to avoid disputes in contentious topics is to use scrupulous citations. Because the Recommendations section has citations at the end of entire paragraphs, it is not clear on first glance if each sentence meets WP:V, and I am concerned that we assure there is no SYNTH. It would be prudent to put specific citations on these pieces, to make sure we aren't drawing our own conclusions from the sources:

In developed countries, other factors, such as behavioral factors, may have more of an effect on HIV prevention than circumcision. (Presumably here we are talking about more than the Netherlands, since the sentenced is plural, so we should have more than one developed country in the citation; alternately, if the Dutch organization makes the specific statement about developed countries, we should attribute that statement to them and cite it to them.
1. Done -bɜ:ʳkənhɪmez (User/say hi!) 01:46, 11 September 2020 (UTC)
Words like "furthermore" in the Dutch para have the effect of sounding POVish (intended to reinforce a point) and are not necessary. Leave off editorializing, let the cited facts speak for themselves. Ditto for "instead".
1. Done -bɜ:ʳkənhɪmez (User/say hi!) 01:46, 11 September 2020 (UTC)
I would shorten the final sentence (This RDMA policy statement was endorsed by several Dutch medical associations), and just add a clause (endorsed by several Dutch medical associations) to an earlier sentence. Again, because the way the paragraph is built could suggest a POV to someone down the road, so make the entire thing as brief and factual as possible, for the avoidance of future problems.
1. Question: - I can't find a better way to word this and I think as it stands it's purely factual - can we re-evaluate after the other changes if this is perhaps less of a problem now? -bɜ:ʳkənhɪmez (User/say hi!) 01:46, 11 September 2020 (UTC)
Is every sentence in the Dutch paragraph specifically and directly citeable to them? The PDF is 20 pages long and for some reason (impossible to understand) we medical editors have long been under the false impression that we don't have to provide page numbers on lengthy citations. We do, just like any other content area: we can't expect readers to browse 20 pages to verify text. I suggest writing the citations in a way that gives a page number or a section heading for each part of these paragraphs. (See the citations at dementia with Lewy bodies, Buruli ulcer and Complete blood count.)
1. @Prcc27: do you think you could take this one on - i.e. adding the page numbers? -bɜ:ʳkənhɪmez (User/say hi!) 01:46, 11 September 2020 (UTC)
All of the same applies to the US paragraph.
The AAP policy statement was explicitly endorsed by the ACOG. ... the word "explicitly" is not necessary here, and gives the impression of POV. Again, remove that sentence, and just add the clause "endorsed by the ACOG" to another sentence for brevity. The way paragraphs and sentences are built can be used to convey POV, and we should avoid giving that impression here.
1. Done - I removed the sentence at a whole - I'm not sure an explicit endorsement is even notable enough - the task force produced its results. -bɜ:ʳkənhɪmez (User/say hi!) 01:46, 11 September 2020 (UTC)
However, they stopped short of being certain circumcision would help, noting the transmission patterns in the U.S. vary from those studied in the primary studies examined, namely the U.S. has a higher prevalence of MSM transmission. Ditto, unless this wording can be cited to them, the impression of POV is given by the way the sentence is constructed. If this exact concept can be cited to them, give an inline with a specific quote or some direct indication of where to find that. Otherwise, stick to the basic facts, avoid POV words like "noted". --> They stated that the transmission patterns in the U.S. vary from those studied in the primary studies examined, and the U.S. has a higher prevalence of MSM transmission. And specifically cite that. Otherwise, it looks like this para may contain SYNTH to convey a point.
1. Done - edited and added an inline - they did specifically state that the transmission patterns varied from what I am reading, and they did express some uncertainty as to whether the data was directly applicable. I changed the wording around to be less "contradictory" and more "factly". -bɜ:ʳkənhɪmez (User/say hi!) 01:46, 11 September 2020 (UTC)
More of same here: The CDC reiterated this in their 2018 information statement on "male circumcision... and HIV infection". The CDC recommends continued access to circumcision for parents who make the decision to have their newborn son circumcised, after being informed of the benefits and risks, including a potential reduction in risk of HIV transmission. Change to: In line with the AAP task force, the CDC 2018 position on circumcision and HIV stated ... ... there is a lot of excess language that conveys here, whether accurately or not, a sense of POV. Specifically inline cite it.
1. Done - mostly - reworded and removed extra wording. -bɜ:ʳkənhɪmez (User/say hi!) 01:46, 11 September 2020 (UTC)
The CDC also echoed the prior task force by saying that circumcision may be considered for males later in life if it has not been elected by the parents at birth. This appears unrelated to HIV, and again, is written in a way that conveys potential POV. "Also" is unnecessary, and the reader wonders why this sentence is here, other than to convey a pro-circumcision POV.
1. Done - agree - seems unrelated to HIV specifically, so removed. -bɜ:ʳkənhɪmez (User/say hi!) 01:46, 11 September 2020 (UTC)
The CDC paper did not offer any recommendation on whether newborn circumcision would be more effective at preventing HIV than circumcisions performed later in life, but they did suggest that doing it before sexual debut would be more effective. This reeks of SYNTH: we don't say what they don't say: we let it speak for itself. What exactly do they say and why are we drawing our own conclusions here? Unless this can be specifically inline cited, switch to something like: The CDC suggested that circumcision before sexual debut would be more effective. More effective than what at what?

Sorry that I am so busy, but do not have time to watchlist; please do post to my talk if further feedback is wanted once these concerns are dealt with. Best regards, SandyGeorgia (Talk) 14:38, 6 September 2020 (UTC)

@1 Now that you mention it, this wording probably needs to be changed. First of all, I don't think the RDMA directly says that behavioral factors play more of a role in HIV prevention than circumcision does in developed countries only. They do compare HIV & circumcision rates in the U.S. to the Netherlands to illustrate the point that other factors are more important at preventing HIV. But the only reference to the "western world" that they make is that the African studies might not be directly applicable to developed countries. So I'm not so sure if the current wording is accurate.

Proposed wording: "Because the evidence that circumcision prevents HIV mainly comes from studies conducted in Africa, the Royal Dutch Medical Association (RDMA) policy statement, which was endorsed by several Dutch medical associations, has questioned the applicability of those studies to developed countries, and circumcision has not been included in their HIV prevention recommendations or their country's public health policy. The RDMA policy statement says that the relationship between HIV transmission and circumcision is unclear, and that behavioral factors seem to have more of an effect on HIV prevention than circumcision." We might want to consider removing "country's public health policy" too. Does the RDMA even say anything about public health policy..?

@6 I agree that we don't need to say "explicitly". That word was added because Berchanhimez thinks that the AAFP and CDC being involved in the task force means that it is implied that they endorse the policy, even though they don't directly say so. However, we can let the readers decide for themselves what they think the AAFP and CDC involvement does or does not mean.

@7 Here is a relevant quote about the the task force's view on HIV prevention & MSM that we can use to reword that sentence: "The proportions of transmissions prevented are lower than in Africa because a higher proportion of US HIV transmission occurs between MSM". It's also worth noting that the RDMA also references MSM and we could possibly add their take on it as well.

@9 I support removing that, since it has nothing to do with HIV.

@10 Proposed wording: "The CDC suggested that circumcision before sexual debut could be more effective at preventing HIV than getting the procedure done after sexual debut." Prcc27 (talk) 21:02, 7 September 2020 (UTC)

Just checking back in so I can take this off of my To Do list ... I trust that you all will sort this (please ping my talk if further feedback is needed). The goal is to make sure the writing does not appear to be trying to convince or argue for a certain position-- less is more :) Best, SandyGeorgia (Talk) 13:49, 9 September 2020 (UTC)

Daily check-in; I see these suggestions have not been incorporated. The combined effect is that the Recommendations section is POV as it stands. I would rather see the improvements made than to tag the section with {{POV-section}}. It should be possible to add the positions of medical orgs in a way that does not try to argue a point or convince the reader, rather just state the facts, with each piece well sourced. Regards, SandyGeorgia (Talk) 15:09, 10 September 2020 (UTC)

@Prcc27: - I've tried to fix everything SandyGeorgia mentioned, sorry if I stepped on your toes - please review and feel free to change anything I've done if you disagree with it -bɜ:ʳkənhɪmez (User/say hi!) 01:46, 11 September 2020 (UTC)

Sorry I haven't been very active lately, I've been busy with work. I won't have work for a week or two (or possibly even indefinitely if I lose my job), so I will try to be more engaged. I would also like to propose wording for CPS and RACP once we get the RDMA/AAP/CDC wording perfected. I just tweaked the wording in the recommendations section. I am still concerned that the section might lean too heavily on the AAP task force and not enough on the CDC policy. Prcc27 (talk) 04:12, 13 September 2020 (UTC)

Much improved! I won't be checking back unless I am pinged, as you all are doing fine :) Best, SandyGeorgia (Talk) 15:03, 15 September 2020 (UTC)

CPS & RACP

Hello, since there doesn't seem to be any significant objections to how we currently have the RDMA, AAP, and CDC positions displayed, I thought that now would be a good time to introduce a rough draft proposal for adding the CPS and RACP policy statements to the article:

CPS proposal: In Canada, the Canadian Paediatric Society's position statement on newborn circumcision says that the applicability of the African studies on circumcision and HIV prevention is unclear in the developed world due to HIV seroprevalence rates being lower and HIV transmission via injection drug use and MSM being common in these countries. The policy statement notes that the large randomized controlled trials included adults and adolescents, but other studies in sub-Saharan Africa have suggested that the degree of protection from HIV that neonatal circumcision provides is similar. The CPS concludes that adult circumcision can reduce the risk of acquiring HIV.

RACP proposal: The RACP statement says that the protection that circumcision provides against HIV transmission is not significant in developed countries, like Australia and New Zealand, since the HIV prevalence is lower in these countries. The policy statement says that in these countries, circumcision is less effective at preventing HIV than safe sex practices. The RACP statement says that circumcision reduces the risk of HIV/AIDS among adults in developing countries where the prevalence of STIs is high. The RACP policy says that trials in Kenya, South Africa, and Uganda, where HIV prevalence is high, reported that adult circumcision reduced the risk of HIV via heterosexual transmission. A systematic review further confirmed these these results. The RACP says that a population survey that took place in South Africa failed to show that circumcision was beneficial at preventing the acquisition of HIV. The RACP points out that there was "criticism of early cessation of clinical trials because of clear therapeutic benefit because of the tendency for this practice to over-emphasise benefit." They note that it is not clear if the African trials can be extrapolated to Australia and New Zealand or other developed countries. The RACP notes that the health benefits of circumcision like a reduced risk of HIV could largely be obtained by delaying the procedure to a much later age. Prcc27 (talk) 20:31, 18 September 2020 (UTC)

I don't think we want a "shopping list" of every medical organization under the sun, as it's potentially a very long list and without some criteria for selection could be selective. The proposed text here betrays a strong POV too. Alexbrn (talk) 05:48, 19 September 2020 (UTC)

It depends on what we want the recommendations section to look like. Another user on this talk page suggested that we include medical organizations from around the world so that readers will get a better sense of how recommendations from around the world differ. A possible criteria for selection could be to include the most notable recommendation on circumcision from each continent. This would limit the number of recommendations we include, which would avoid a big "shopping list". However, this might mean maybe we'd have to keep the CPS viewpoint out since we already have the American viewpoints in the article. But I really think it's important to include a recommendation from outside of Europe & North America. The RACP viewpoint gives us a good sense of what the prevailing view in Oceania is. Other than that, if you think the proposed text is POV, you are welcome to suggest alternative wording or provide your own proposed text, and we can work from there. Prcc27 (talk) 22:34, 19 September 2020 (UTC)

I'm telling you it's POV. Phrases like "pointed out", words like "noted" and editorial like "further confirmed" are frowned on for a reason. We have been here before. I think it would be much better if we say something like "some national organizations (example, example, example) say it is unclear whether these findings apply in their country". That would avoid the potentially very long list. Alexbrn (talk) 23:07, 19 September 2020 (UTC)

A couple notes - while we don’t want a shopping list of organizations, we should try to have a list of major countries (or regions for those with multinational organizations) - especially when those recommendations differ from the WHO one. A list of countries that includes many is not a bad thing, in fact it makes the article more global and complete. I’m not suggesting including every single country in the world, but Canada and Australia are certainly reasonable to me. It does take finesse to make it “pretty” - meaning continuous, well flowing prose instead of paragraphs or sentences for each country simply listing off their recommendations. My suggestion for this are to decide on a specific organizational method - either organize by view (in which case organizations with similar views are grouped in the same paragraph(s)) or organize by region/area - in which they’re grouped by their location. Both have pros and cons in any article, but I personally think the first is better here, beginning with the WHO recommendations and any that agree with it, followed by each significant viewpoint in some logical order. Another problem here is the “weasel words” pointed out by Alexbrn - @Prcc27: I don’t at all think this is intentional or your fault, but it is a problem. We need to remain as neutral and factual as possible - meaning even words with slightly positive or negative connotations should be avoided if a more neutral alternative is possible. “Noted” implies that it was “of note” (positive), and “further confirmed” implies strength or repetition. I struggled with this a lot too and still kinda do, and if you check my edits/articles I’m sure you’ll find some accidental weasel words that can be improved.

I personally am 100% okay with Alexbrn’s suggestion we limit disagreement with “recommended newborn circumcision” (I.e. encouraging it to parents at birth) to a sentence listing major examples, followed by explanation to include it being offered as a choice (versus recommended/encouraged) to parents, as well as it still being potentially effective in adulthood. I can work on this maaaaybe tonight but more likely won’t be for a day or two as I have a couple other projects on wiki I plan to work on if I have time tonight. Regards, -bɜ:ʳkənhɪmez (User/say hi!) 00:08, 20 September 2020 (UTC)

The "further confirmed" wording very closely matches the wording that the RACP uses. So no, it is not POV nor is it editoralization to use wording that closely matches what a MEDRS source says. Maybe we could quote them if it's still a problem for you..? But removing that sentence while keeping the sentence that criticizes the RCTs in itself could come off as POV. As for the "noted" and "pointed out" words, I agree we need new transitions, which is why I specifically noted that this is a rough draft. I apologize if I didn't spend enough time finessing the wording. That doesn't negate the rest of what's in the proposed text and the need for us to include viewpoints from around the world. Prcc27 (talk) 00:16, 20 September 2020 (UTC)

As far as the "further confirmed" is concerned, we would have to clarify that this is the RACP's view, not ours. So a transition would probably have to be added to that sentence. But once again, I didn't spend that much time on transitions. Prcc27 (talk) 00:24, 20 September 2020 (UTC)

I'm not sure if Berchanhimez (talk · contribs) is still planing on coming up with a proposal of their own.. But I worked on the transitions to improve my proposal just in case anyone might be willing to support my revised proposal and/or would like to use it as a template to make a new proposal.

RACP revised proposal: The Royal Australasian College of Physicians statement on circumcision of infant males says that the protection that circumcision provides against HIV transmission is not significant in developed countries, like Australia and New Zealand, since the HIV prevalence is lower in these countries. The policy statement says that in these countries, circumcision is less effective at preventing HIV than safe sex practices. The RACP says that circumcision reduces the risk of HIV/AIDS among adults in developing countries where the prevalence of STIs is high. The RACP statment says that trials in Kenya, South Africa, and Uganda, where HIV prevalence is high, reported that adult circumcision reduced the risk of HIV via heterosexual transmission. The RACP says that a systematic review further confirmed these results. The statement says that a population survey that took place in South Africa failed to show that circumcision was beneficial at preventing the acquisition of HIV. The RACP statement says that there was "criticism of early cessation of clinical trials because of clear therapeutic benefit because of the tendency for this practice to over-emphasise benefit." The RACP says that it is not clear if the African trials can be extrapolated to Australia and New Zealand or other developed countries. The RACP statement says that the health benefits of circumcision like a reduced risk of HIV could largely be obtained by delaying the procedure to a much later age. Prcc27 (talk) 17:55, 23 September 2020 (UTC)

That's almost pointedly clunky with its repetitions, and ignores the desire expressed above to reduce these disagreements with the recommendation to a single sentence, giving example organizations. Can you do that? (Add: also exactly what document is being cited for the "RACP" position here?) Alexbrn (talk) 18:53, 23 September 2020 (UTC)

@Alexbrn: I already proposed something somewhat similar at the very end of the #2013 position paper of small Dutch medical organization - WP:MEDDATE and WP:REDFLAG section (for some reason the conversation on that issue picks up in the next section [ #Recommendations ], which doesn't make much sense- maybe we should change this..?), but it was shot down. If you want to start consolidating sentences, please show us how we can do so, despite criticism to a similar proposal made by other editors. The reason why I had to be repetitive is because if we don't attribute each sentence to the RACP, it will come off as POV. So I agree that consolidating these similar statements between the medical organizations into single sentences would take care of this issue of repetitive transitions- but we would have to see a proposal for how this could work, since mine didn't gain much support. Otherwise, we will just have to continue keeping each medical organization viewpoint in its own paragraph, and find a way to make the transitions in my proposal less repetitive. RACP CPS Prcc27 (talk) 20:53, 23 September 2020 (UTC)

Right, so that RACP document from 2010 has a handy executive summary, with a paragraph on HIV/AIDS:

The most important conditions where benefits may result from circumcision are recurrent urinary tract infections in children; and Human Immunodeficiency Virus (HIV) [...] The protection against Sexually Transmitted Infections (STIs) and HIV is less clear-cut in Australia and New Zealand than in high prevalence countries.

It is curious that you have managed to summarize their position in such a different way to they way they summarize it themselves. For summarizing the RACP's document (as far as I can see this is not a current or former "position"), something like "A 2010 document from the RACP said that HIV/AID was an important condition for which circumcision could have a role to play, but that the case for its use in Australasia was not as compelling as in Africa." But I still think we should rather be giving some oganizations as example, in the way I've already outlined above. Alexbrn (talk) 05:11, 24 September 2020 (UTC)

Wait, so are you proposing consolidating a few sentences (whenever there is overlapping views between the organizations) as well as keeping the separate (but condensed) paragraphs for each organization viewpoint? Or are you proposing that we consolidate the viewpoints altogether into a few sentences and get rid of the paragraphs altogether? I think there would be more support for the former than the later. If no users present proposed wording soon, I will try to make a proposal more or less in line with your suggestion. Prcc27 (talk) 20:33, 24 September 2020 (UTC)

New proposal:

RACP condensed proposal: The Royal Australasian College of Physicians statement on circumcision of infant males says that in developed countries, such as Australia and New Zealand, circumcision is less effective at preventing HIV than safe sex practices. The RACP statement says that circumcision reduces the risk of HIV/AIDS among adults in developing countries where the prevalence of STIs is high. The statement says that a systematic review further confirmed the results of the trials in Kenya, South Africa, and Uganda, where HIV prevalence is high, which found that adult circumcision reduced the risk of HIV via heterosexual transmission. The RACP document says that a population survey that took place in South African, failed to show that circumcision was beneficial at preventing the acquisition of HIV. The document says that there was "criticism of early cessation of clinical trials because of clear therapeutic benefit because of the tendency for this practice to over-emphasise benefit." The RACP says that the health benefits of circumcision like a reduced risk of HIV could largely be obtained by delaying the procedure to a much later age.

CPS condensed proposal (we could add this at the end of the AAP/CDC paragraph): In Canada, the Canadian Paediatric Society (CPS) position statement on newborn circumcision says that adult circumcision can reduce the risk of acquiring HIV.

Proposed consolidated concluding paragraph sentence: Some medical organizations, like the RDMA et al., the RACP, the AAP task force, and the CPS say it is unclear whether the findings of the African trials on circumcision and HIV prevention apply to their respective countries and/or to the developed world in general.

I don't want to add too much text to this talk page, so here is what the entire section would look like under my proposal. The RACP transitions probably still need some work, maybe we could say "according to the RACP" for one of the sentences, and "the RACP states" for another sentence, so that the transitions don't keep repeating themselves.

BTW, I moved the "rearrange recommendations section proposal" to the recommendations section of this talk page since it makes more sense.. Prcc27 (talk) 03:52, 26 September 2020 (UTC)

As for Alexbrn's proposed sentence that says: "A 2010 document from the RACP said that HIV/AID was an important condition for which circumcision could have a role to play, but that the case for its use in Australasia was not as compelling as in Africa." Not sure if this would be added to my proposal, would replace a sentence or two currently in my proposal, or if the proposed consolidated concluding paragraph makes their proposal moot. Prcc27 (talk) 03:58, 26 September 2020 (UTC)

I think we need say nothing more about that 2010 RACP document than in my proposed sentence. I oppose your long paragraph since it runs against the grain of the source and surfaces non-MEDRS (an old survey?) in a way which savours of POV-pushing. We are meant to be summarizing sources, and the RACP's own executive summary gives us a good steer on how to do that faithfully. However, I'd not object to a little more detail in a note. Alexbrn (talk) 05:04, 26 September 2020 (UTC)

The RACP proposal aside, if we don't move forward with your consolidated sentence proposal, could we at least add my original CPS proposal to the article? Berchanhimez wants to include the CPS viewpoint in this article, (although they might not support my exact wording), and you haven't really provided a specific reason for why the CPS proposal shouldn't be included. So far, you're the only person that has explicitly expressed the desire to consolidate each medical organization's view on the African trials into one sentence. My concerns with the "some national organizations (example, example, example) say it is unclear whether these findings apply in their country" proposed sentence are that it ignores that some medical organizations go further and say that the trials aren't applicable to the developed world in general (my revised version of this sentence fixes this problem), it doesn't go into depth about why the trials aren't applicable to certain countries like the current and proposed paragraphs do, and you haven't really demonstrated why it is so important to consolidate the African trials sentences, but not other sentences in the recommendations section. Berchanhimez did entertain the idea of consolidating the sentences about adult vs. infant circumcision, but we are still waiting for them to provide a proposal for that, and it is unclear to me if they supported this in addition to your consolidation proposal, or if this is a different consolidation proposal separate from, but inspired by you. Prcc27 (talk) 06:04, 26 September 2020 (UTC)

If other organizations "go further" (whatever that means) then additional positions can be consolidated too. My point is we should group organizations by position, not have a repetitive "shopping list" of organizations which stores up all kinds of problems. I don't believe I have commented on the CPS. If the source for their "position statement" is this then it seems, again, like they are simply saying it's a well-evidenced protective strategy for Africa, but unclear how applicable it is to Canada. I don't think we need to convey more than that. Alexbrn (talk) 06:44, 26 September 2020 (UTC)

"Circumcision in adult men can reduce the risk of acquiring an STI (specifically HIV, HSV and HPV)." That statement does not specifically refer to Africa, Canada, or the developed world. And the summary paragraph as a whole seems to deal with when the optimal timing for circumcision is. So I do think saying that the CPS says that adult circumcision prevents HIV is noteworthy enough for inclusion.

As far as your proposed consolidated sentence goes, it could go something like this: "some medical organizations, like the Canadian Paediatric Society (CPS), the Royal Australasian College of Physician (RACP), and the RDMA et al. question the applicability of African trials regarding circumcision and HIV prevention to developed countries. The CDC and the RACP question the applicability of these African trials to their respective countries." The reason I use the CDC instead of the AAP is because, a) the CDC source is newer than the AAP one, and b) the AAP source mentioning the applicability of the trials to the U.S. seems to be citing a CDC source anyway. I would like to invite SandyGeorgia to this discussion (will probably invite them soon) and maybe wait for others to chime in before moving forward with adding a consolidated sentence to the recommendations section. Prcc27 (talk) 18:12, 26 September 2020 (UTC)

Actually the second sentence should be "The CDC questions the applicability of these African trials to the U.S.", because including the RACP in that sentence is redundant. Prcc27 (talk) 03:45, 27 September 2020 (UTC)

I have to agree here with as much brevity as possible; forcing yourself (one's self) to summarize this down to something more brief will help eliminate the tendency for the text to take on POV, and there aren't that many different positions that we need full paragraphs on each organization. (Noting that the early versions I commented on above had significant POV creep because they appeared to be trying to convince the reader. When we stick to "just the facts", brevity will occur naturally.) SandyGeorgia (Talk) 23:12, 28 September 2020 (UTC)

I just reverted the WP:BOLD edit made by Alexrn. Removing the entire RDMA section was absolutely not what was proposed and talked about here on this talk page. The RDMA section was added with consensus, and should remain until and unless there is consensus to remove it. Please note that the reason we added the RDMA section, as you will see in previous discussions, is a) to be more representative of medical views from around the world and b) it is important to include significant dissenting viewpoints in the article. Prcc27 (talk) 07:16, 3 October 2020 (UTC)

I agree with SandyGeorgia's call for brevity and having this big para on the RDMA and mentioning it again later is not that, and the POV is showing through in your wording. I've reverted back further so you can develop some better proposals for how to continue this section because what you're doing is not improving things. Remember: we want a brief summary of positions, not this tedious shopping list of factoids. Alexbrn (talk) 07:25, 3 October 2020 (UTC)

SandyGeorgia said "there aren't that many different positions that we need full paragraphs on each organization". I think SandyGeorgia meant that the CPS and RACP aren't that different from the other organizations so they don't merit their own individual paragraphs. The RDMA however, does have a significantly different position, so it does merit a full paragraph. We could even consolidate it into one paragraph: "The Royal Dutch Medical Association (RDMA) circumcision policy statement, which was endorsed by several Dutch medical associations, says that the relationship between HIV transmission and circumcision is unclear, and that behavioral factors seem to have more of an effect on HIV prevention than circumcision. Circumcision has not been included in their HIV prevention recommendations. The RDMA also recommends that the choice of circumcision should be put off until an age when a possible HIV risk reduction would be relevant, so that boys can decide for themselves whether to undergo the procedure or choose other prevention alternatives. The Canadian Paediatric Society (CPS), the Royal Australasian College of Physicians (RACP), and the RDMA question whether the benefits of circumcision for HIV prevention apply in developed countries." By the way, this proposed consolidated paragraph is the same amount of words as what is currently in the RDMA paragraph if I'm not mistaken. Brevity is important, but so is representing viewpoints from around the world. But if adding the sentence about the CPS and RACP is too much of an eye sore (even though I will reiterate that this proposed paragraph is roughly the same length as the status quo) then I guess we could have just the RDMA paragraph and the AAP/CDC paragraph. Regardless, removing the RDMA paragraph altogether is not what we should do- it is too important for removal. Prcc27 (talk) 07:55, 3 October 2020 (UTC)

What you have added seems to have some serious POV/WP:V problems. What is your source for "which was endorsed by several Dutch medical associations"? I disagree we need a whole paragraph especially if (as seems is now the case) it is made up. Alexbrn (talk) 08:06, 3 October 2020 (UTC)

What exactly are you saying is POV? Everything in the paragraph is based on the RDMA source. So unless you have a real POV concern, not a perceived one, I feel like we should move forward with the consolidated paragraph I just proposed. "Which was endorsed by several Dutch medical associations" was based on the part of the RDMA document that says "This viewpoint by the KNMG is jointly endorsed by the following scientific associations: The Netherlands Society of General Practitioners, The Netherlands Society of Youth Healthcare Physicians, The Netherlands Association of Paediatric Surgeons, The Netherlands Association of Plastic Surgeons, The Netherlands Association for Paediatric Medicine, The Netherlands Urology Association, The Netherlands Surgeons’ Association." Would you rather that we name each individual association that endorsed the position instead? That doesn't really fit with the expressed need for brevity. Does 7 associations not qualify as "several" to you? We could certainly use a different word if you don't think so. But that is no reason to remove the entire KNMG paragraph just because of one potentially problematic word (I honestly don't see the problem though). By the way, since the source uses the KNMG acronym instead of the RDMA acronym- I feel like we should use the former in the article instead of the latter. Prcc27 (talk) 08:30, 3 October 2020 (UTC)

Right, so when I find the actual source (a PDF, not the web page cited) it says for that "endorsed" viewpoint:

Insofar as there are medical benefits, such as a possibly reduced risk of HIV infection, it is reasonable to put off circumcision until the age at which such a risk is relevant and the boy himself can decide about the intervention, or can opt for any available alternatives.

Which is different from what Wikipedia says was "endorsed". What you have done is cherry-pick some background stuff out of the document and said that those things are "endorsed", which is WP:SYNTHESIS. What are you trying to do? Alexbrn (talk) 08:37, 3 October 2020 (UTC)

Please refer to the proposal SandyGeorgia made in the queries section: "I would shorten the final sentence (This RDMA policy statement was endorsed by several Dutch medical associations), and just add a clause (endorsed by several Dutch medical associations) to an earlier sentence. Again, because the way the paragraph is built could suggest a POV to someone down the road, so make the entire thing as brief and factual as possible, for the avoidance of future problems." So a) I was not the person that originally suggested adding that wording to an earlier sentence and b) SandyGeorgia actually proposed adding it to an earlier sentence to try to avoid coming off as POV, and to shorten the paragraph, but unfortunately this might have actually had the opposite effect. I am not opposed to having a separate sentence that says "This RDMA policy statement was endorsed by several Dutch medical associations" and ditto for the paragraph about the ACOG endorsing the AAP task force viewpoint. That was actually what my original wording was, and the only reason I changed it was because SandyGeorgia suggested for me to do so. Prcc27 (talk) 08:49, 3 October 2020 (UTC)

Prcc27 - you are responsible for the edits you make (which N.B. you have reverted in), at a basic level to make sure Wikipedia is not misrepresenting sources. Your edit in no ways meets the request to make things "as brief and factual as possible"; instead this more evidence of a pattern of editing whereby medical associations' positions are presented in a way which is unrecognisable in reference to the original (I quoted above), and straining every sinew instead to be as "anti" circumcision as possible. In short you are POV-pushing and misrepresenting sources and I am beginning to think this topic area would benefit from your absence, as you are wasting a huge amount of valuable editors' time, as well as your own. Alexbrn (talk) 08:57, 3 October 2020 (UTC)

If we are going to assume bad faith here, I think maybe you are the one pov-pushing. Why is it "POV" in the KNMG paragraph, but when we did the exact same thing in the AAP paragaraph- you are absolutely silent on it! You did not say a single word about the fact that we did the same thing when mentioning the ACOG endorsement of the AAP task force policy. I made my edits exclusively on the request of another user, and I was actually just fine with the way I had the paragraph before. Maybe you should ask SandyGeorgia why they made the proposal in the first place, instead of pissing and moaning about me carrying out their request. Shame on you for assuming bad faith and making basely claims that I am POV pushing. Everyone here is trying to improve the article! Here is my new proposed paragraph, and if it has no POV issues in it, it should definitely be added to the article: "Because the evidence that circumcision prevents HIV mainly comes from studies conducted in Africa, the Royal Dutch Medical Association (KNMG) has questioned the applicability of those studies to developed countries. Circumcision has not been included in their HIV prevention recommendations. The KNMG policy statement says that the relationship between HIV transmission and circumcision is unclear, and that behavioral factors seem to have more of an effect on HIV prevention than circumcision. The KNMG also recommends that the choice of circumcision should be put off until an age when a possible HIV risk reduction would be relevant, so that boys can decide for themselves whether to undergo the procedure or choose other prevention alternatives. This KNMG circumcision policy statement was endorsed by several Dutch medical associations. The Canadian Paediatric Society (CPS), the Royal Australasian College of Physicians (RACP), and the RDMA question whether the benefits of circumcision for HIV prevention apply in developed countries." Prcc27 (talk) 09:13, 3 October 2020 (UTC)

I quoted the actual viewpoint as printed above (in green). It would be nice if Wikipedia, when talking about that viewpoint, actually revealed what it was instead of irrelevant bits of background picked out from the document and cobbled together into a misleading mess. Wikipedia is WP:NOTCOMPULSORY so it is unreasonable to expect me, or any editor, to ferret out every bit of POV-pushing going on. But when it happens right there on my watchlist, it's very noticeable. Alexbrn (talk) 09:21, 3 October 2020 (UTC)

@Alexbrn: Are you sure you're not the one cherrypicking the document..? Nothing I wrote goes against what the KNMG actually says. Guess what, I can quote what the KNMG said too: "Moreover, the studies into HIV prevention were carried out in sub-Saharan Africa, where transmission mainly takes place through heterosexual contact. In the western world, HIV transmission is much more frequently the result of homosexual contact and the use of contaminated needles. That the relationship between circumcision and transmission of HIV is at the very least unclear is illustrated by the fact that the US combines a high prevalence of STDs and HIV infections with a high percentage of routine circumcisions.The Dutch situation is precisely the reverse: a low prevalence of HIV/AIDS combined with a relatively low number of circumcisions. As such, Non-therapeutic circumcision of male minors behavioural factors appear to play a far more important role than whether or not one has a foreskin." If you have a problem with the wording, then why not propose rewording it, instead of bashing me..!? I am definitely open to proposals for alternative wording, especially if there are POV concerns. But at this point, you seem to be the only person vehemently opposed to the current wording as is. So much so, that you unilaterally went ahead and removed it despite no other users being on board for its removal and despite consensus for its inclusion. Prcc27 (talk) 09:31, 3 October 2020 (UTC)

The document falls into two parts, the "viewpoint" (the thing which is endorsed), and "background" - a "memo" on points considered. In presenting the Dutch viewpoint we should focus on the actual, well, viewpoint; the 21 year-old background discussion is probably undue, and in any event should not be promoted so it seem as though it is the policy itself. This is all very simple: like many other developed countrys' organizations the Dutch are unsure whether HIV prevention, which work in Africa, also applies at home - they add the decision on whether to circumcise for this purpose should be delayed until adulthood. All this should be combined in one para grouped by viewpoint. We need to avoid paragraph-by-paragraph slog, especially of cherry-picked bits of background discussion. Alexbrn (talk) 09:40, 3 October 2020 (UTC)
- I was unaware that the background for the viewpoint didn't count as being part of the "actual" viewpoint. In any case, it is interesting that you are only now criticizing the KNMG section, even though it had already been up on the article since August. If you have proposed wording for the KNMG section, then make a proposal so that users can determine whether or not they support your wording. If there is a problem with the KNMG section, we need to fix it ASAP. Prcc27 (talk) 09:58, 3 October 2020 (UTC)

As I've written several times now, we should group by view and not by country. Alexbrn (talk) 10:07, 3 October 2020 (UTC)

Would we still include the KNMG's view on waiting until adulthood for circumcision in your proposal? It looked like you just wanted to consolidate everything into one sentence about the African trials, which would completely ignore the significant view by the KNMG on optimal timing for circumcision for HIV prevention. I am vehemently against consolidating the KNMG paragraph into only a single sentence that only mentions the trials, and AFAIK, nobody here as explicitly said they support replacing the KNMG paragraph with only one single sentence. Prcc27 (talk) 10:28, 3 October 2020 (UTC)

Yes, the suggestion to delay is fine to include. They don't mention "trials" in their viewpoint. Wikipedia does not generally function by expressions of a priori consensus; the relevant guideline is rather WP:BOLD. The Dutch 1999 position is simply stated: circumcision for HIV prevention might well not work here, best to delay any decision on it until adulthood in any case. The latter part is novel to them (in comparison to other countries we mention). Alexbrn (talk) 11:47, 3 October 2020 (UTC)

Asked to comment again

I was asked to comment again. I have not been following the back and forth, but this edit is moving in the right direction, although I think a few more clauses could be added to Alexbrn's text, with a brief explanation of why there is disagreement.

Perhaps some of the confusion here, Prcc27, is my fault. In the "Queries" section above, I laid out an analysis that showed there were POV problems in every single sentence of the proposed text, and that the text was trying to convince/lead the reader. Perhaps if I had more bluntly titled that section "POV" rather than the more polite "Queries", the issue would have been more clear. But I prefer to teach an editor to fish rather than feed them, and prefer explanation over revert. My intended polite message may have been missed.

Summarizing the positions of different organizations is within MEDRS, but we shouldn't be using the position of one (or two) organizations as a vehicle to re-argue the science, unless secondary reviews do that very thing. For example, I once added a summary of the positions held by all major organizations on PSA screening to two prostate articles, based on a high quality secondary review. It took only one sentence, because ALL of the organizations (at that time) were in agreement. (Sample.) That is not the case here, so it may take three or four sentences, but I agree with summarizing by VIEW rather than country. My one-sentence quite correct summary was reverted and substituted for the position of only one MEDORG, which was UNDUE (without mentioning they were also shown wrong) and POV and related to other editing problems occurring in medical content; the editors who reverted that text were later sanctioned by arbcom for other behaviors, but we hope the MEDORG lesson was learned.

Compared to my one-sentence summary; what is happening here looks like an attempt to re-argue the science, in ways that secondary sources do not, by giving UNDUE emphasis to the positions of a few organizations which differ from the mainstream. (I suppose you could add those extended discussions to the articles of those organizations, but again, not in a POV way.) Just state what their position is; let the facts speak for themselves. I think Alexbrn's summary (linked above) is a bit TOO brief, since the reader is left wondering why they differ, but all of your proposals were too broad and appear to be trying to convince the reader, and are POV. There should be a meeting ground halfway. I have supported adding alternate positions of respected MEDORGs; not using those positions as a backdoor to re-argue all the science. Keep it brief.

Also, Prcc27, I have seen you mention that the original text was added based on "strong consensus". There cannot exist "strong consensus" in a talk page discussion involving at most at various times five editors, not all of whom have weighed in on every change, and not all of whom (me) are following closely. You may have a different interpretation, but to me, "Strong consensus" is for example a widely advertised RFC in which 50 people participated, and three-fourths of those people held the same view. We don't yet have even what I call "consensus" on this page. We have evolving text and ongoing discussion-- a good thing, but not yet consensus. Several of us agree that MEDORG positions should be represented; that doesn't mean they should be used to re-argue the science. Give the reader the broad consensus of the main worldwide orgs, add the simple statement that there are different positions, with enough information to understand why (which can be done with one or two clauses), and let the facts speak for themselves. Hope this helps, SandyGeorgia (Talk) 17:36, 3 October 2020 (UTC)

Unfortunately, the proposal you had may have come off as even more POV than what I had originally wrote.. Another user actually commented on that query expressing that they didn't see any POV issues with what I originally had. Nonetheless, it is definitely not your fault that a user decided to viciously attack me over it and make absolutely false assumptions about me and my motives because they don't understand how WP:AGF works. I wasn't suggesting that the KNMG's paragraph wording had strong consensus, but rather that there seems to be consensus that the KNMG's viewpoint should be represented with DUE weight one way or another. Of course, consensus can change, and it certainly is in flux right now. Prcc27 (talk) 17:54, 3 October 2020 (UTC)

SYNTH?

Why is the recommendations section flagged as having possible WP:SYNTH violations? What are the concerns? If there are none, that warning should be removed. Prcc27 (talk) 07:52, 25 October 2020 (UTC)

We've still got issues. Text like "Circumcision has not been included in their HIV prevention recommendations" which seems to fail WP:V. More generally, we still have the requirement to get this section theme-based rather than organization-based to prevent a "dossier" approach. Alexbrn (talk) 08:51, 25 October 2020 (UTC)

Oh okay, I see how that sentence could be problematic. I think that wording was based on a proposal by another user. I'm ok with a theme-based section, but I think a lot of the information we currently have in the section is important, and I'm concerned that a theme-based section would mean removing that info. Also, I'm not entirely sure what a theme-based section would look like. I'm more of a visual learner, so it's harder for me to follow along with what exactly is being proposed. Nevertheless, I'm not sure if a SYNTH flag is necessary. WP:SYNTH doesn't seem to be a significant issue in the section. Perhaps another flag could be added in its place? Prcc27 (talk) 15:45, 25 October 2020 (UTC)

References

^ American Academy of Pediatrics Task Force on Circumcision (2012). "Technical Report". Pediatrics. 130 (3): e756–e785. doi:10.1542/peds.2012-1990. ISSN 0031-4005. PMID 22926175. Archived from the original on 2012-09-20.

Main entry point

"Excising the foreskin removes a main entry point for the HIV virus". If there is no medical source to support this claim, it should be removed. Prcc27 (talk) 03:34, 3 October 2020 (UTC)

Did you look? Seems like a fairly mundane claim, although "thought to be the main entry point" would be better wording. Start here[16] ? Alexbrn (talk) 04:57, 3 October 2020 (UTC)

@Alexbrn:Why did you revert my edit with regards to the main entry point sentence? I think you might have down it by mistake, but I don't want to revert it myself because it could come off as an edit war. Prcc27 (talk) 22:56, 3 October 2020 (UTC)

Done Sorry yes. Alexbrn (talk) 14:41, 4 October 2020 (UTC)

It is not "the" entry point. "The" entry point is via the bloodborne transmission. It is "an" entry point. Petersmillard (talk) 13:42, 29 October 2020 (UTC)

The article never said it was "the" entry point, so I'm not really sure what you're getting at.. Prcc27 (talk) 18:48, 29 October 2020 (UTC)

No, the article did not say so, but Alex said so above: "thought to be the main entry point" Petersmillard (talk) 18:59, 29 October 2020 (UTC)

Seems like a silly cavil. From the source I cite "The inner surface of the foreskin contains Langerhans' cells with HIV receptors; these cells are likely to be the primary point of viral entry into the penis of an uncircumcised man". The context is obvious the penis, for an article on "circumcision and HIV". Alexbrn (talk) 19:45, 29 October 2020 (UTC)

Precision in use of language is important, especially when it is read by many for whom English is not their first language. Petersmillard (talk) 21:39, 29 October 2020 (UTC)

yes, the foreskin contains Langerhans cells, which contribute to the immune system. it's intuitive that this would be a liability for HIV entry, but I'm not sure if this link is proven. Xcalibur (talk) 15:38, 2 November 2020 (UTC)

[1] Ogawa, Youichi/Kawamura, Tatsuyoshi/ Kimura, Tetsuya/Ito, Masahiko/ Blauveit, Andrew/ Shimada, Shinji 2009: Gram-positive bacteria enhance HIV-1 susceptibility in Langerhans cells, but not in dendritic cells, via Toll-like receptor activation. In: Blood, 21.5.2009, Vol. 113, Nr. 21, 5157-5166.

[2] Lot de Witte et alii: "Langerin is a natural barrier to HIV-1 transmission by Langerhans cells" http://www.nature.com/nm/journal/v13/n3/abs/nm1541.html

[3] 197-http://data.unaids.org/pub/Report/2002/brglobal_aids_report_en_pdf_red_en.pdf

[4] ttom of page, table 2 http://www.historyofcircumcision.net/index.php?option=content&task=view&id=61

[Rizvi_2009-5] Rizvi, Ali A. (2009-09-03). "Male Circumcision and the HIV/AIDS Myth". The Huffington Post. Retrieved 2016-07-11.

[UNVIERSITY_OF_OXFORD_PRACTICAL_ETHICS-6] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j Earp, Brian D. (2009-09-03). "A fatal irony: Why the "circumcision solution" to the AIDS epidemic in Africa may increase transmission of HIV". University of Oxford: Practical Ethics. Retrieved 2016-07-11.

[Weller-7] Weller SC and Davis-Beaty K, “Condom Effectiveness in Reducing Heterosexual HIV Transmission” (2002) 1 Cochrane Database of Systematic Reviews Art No CD003255.

[Green-8] [Male circumcision and HIV prevention: Insufficient evidence and neglected external validity.]. Green et al. (2010). American Journal of Preventive Medicine.

[Goyle-9] Cite error: The named reference Goyle was invoked but never defined (see the help page).

[PagePress-10] [http://www.zimeye.org/wp-content/live_images/2012/01/44-419-1-PB.pdf How the circumcision solution in Africa will increase HIV infections]. Robert S. Van Howe, Michelle R. Storms. Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Marquette, MI, USA. Cite error: The named reference "PagePress" was defined multiple times with different content (see the help page).

[Boyle-11] Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. Boyle, G. J. and Hill, G. (2011). Journal of Law and Medicine.

[Welch_2012-12] Welch, H. Gilbert (2012-06-21). "The Problem Is Relative". The Huffington Post. Retrieved 2016-07-11.

[Garenne_Giami_Perrey_2012_pp._185–210-13] Garenne, Michel; Giami, A.; Perrey, C. (2012-04-11). "Male cicumcision and HIV control in Africa : questioning scientific evidence and decision making process". Horizon (in French). pp. 185–210. Retrieved 2016-07-11.

[14] Mehta, Supriya D.; Moses, Stephen; Agot, Kawango; Parker, Corette; Ndinya‐Achola, Jeckoniah O.; Maclean, Ian; Bailey, Robert C. (2009-08-01). "Adult Male Circumcision Does Not Reduce the Risk of IncidentNeisseria gonorrhoeae, Chlamydia trachomatis,orTrichomonas vaginalisInfection: Results from a Randomized, Controlled Trial in Kenya". The Journal of Infectious Diseases. 200 (3): 370–378. doi:10.1086/600074. ISSN 0022-1899. PMC 3081655. PMID 19545209.{{cite journal}}: CS1 maint: PMC format (link)

[ethical_and_legal_concerns-15] "Sub-Saharan African randomized clinical trials into male circumcision and HIV transmission: methodological, ethical and legal concerns.", Gregory J. Boyle, George Hill, Journal of law and Medicine, 30 Nov 2011, 19 (2): 316-334, PMID: 22320006

[AAP_2012-16] American Academy of Pediatrics Task Force on Circumcision (2012). "Technical Report". Pediatrics. 130 (3): e756–e785. doi:10.1542/peds.2012-1990. ISSN 0031-4005. PMID 22926175. Archived from the original on 2012-09-20.

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