Some Statistics For You (redux)

Copy of one of my first posts – I wanted to put it up again, because it’s way at the back, and I want people to see some of these statistics.

This will probably take a while for me, because I’m going to attempt to provide the claims provided by intactivists and then counter them for  you.  I’d like to add a note here that I am very against RIC.  That does not mean that I support the position to lie and twist facts in order to convince other people to join your cause or convince them not to circumcise.

The NYT Article:

Here’s the NYT article.   They even admit in the article that the numbers are not definitive and are reported from hospitals:

A little-noted presentation by a federal health researcher last month at the International AIDS Conference in Vienna suggested that the rate had fallen precipitously — to fewer than half of all boys born in conventional hospitals from 2006 to 2009, from about two-thirds through the 1980s and ’90s.

Last week, officials at the Centers for Disease Control and Prevention cautioned that the figures in the presentation were not definitive. But they are already stirring a sharp debate on the Internet.

Well, yeah.  They stirred a sharp debate that’s based on a very specific presentation of numbers.  Then they admit just how they performed this slight of hand in the following paragraph:

The slide portrays a precipitous drop in circumcision, to just 32.5 percent in 2009 from 56 percent in 2006. The numbers are based on calculations by SDI Health, a company in Plymouth Meeting, Pa., that analyzes health care data; they do not include procedures outside hospitals (like most Jewish ritual circumcisions) or not reimbursed by insurance.

Andrew Kress, the chief executive of SDI Health, cautioned that the data had not yet been published and was still being analyzed, but he confirmed that the trend had been toward fewer circumcisions each year.

That’s right.  That’s circumcisions done in hospitals, based on calculations (so no raw numbers are given) and do not include procedures outside of the hospital or self-pays (procedures not reimbursed by insurance).  The data hasn’t even been published, but here it is in a newspaper article.

So, from reading the above paragraphs, does it seem as though this is a legitimate statistic to use?  I think not.  Now, lets take a look at some different numbers.

HCUP

Here’s a neat little chart from HCUP (Health Cost and Utilization Project),  which is not just about circumcision, but procedures for children done in the hospital.  The provide a nice little table that I’ll post here for you.

Table 3. Most common all-listed procedures received by children in U.S. hospitals, 2009*
All-listed procedure	Number of procedures	Rate of discharges per 10,000 population†
1. Prophylactic vaccinations	1,329,600	1,783.5
2. Circumcision	1,147,700	1,539.5
3. Respiratory intubation and mechanical ventilation	226,700	304.1
4. Enteral and parenteral nutrition	165,100	221.5
5. Blood transfusion	109,400	146.8
6. Appendectomy	89,800	120.5
7. Repair of obstetric laceration	54,600	73.2
8. Cancer chemotherapy	47,900	64.3
9. Artificial rupture of membranes to assist in delivery	35,700	47.9
10. Incision and drainage of skin and subcutaneous tissue	35,600	47.8
* Excludes diagnostic testing. † Calculated using resident population for July 2009 from the U.S. Bureau of the Census, accessed on February 28, 2011. From: http://www.census.gov/popest/national/asrh/NC-EST2009-sa.html. Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Kids’ Inpatient Database(KID), 2009

Lets do a little simple math, and then I’ll provide some statistics from the CDC to  back that up (You watching, Intactivists?) The birth rate in 2009 was 4,136,000.  51.5% of that is 2,130,040, which would be the number of males born in 2009.   Divide 4,136,000/2,130,040 and you get .5388 which equals 53.88% or around 54%.   Now, I’m really really bad at math, but I’m pretty sure that 54.8% =/= 32.5%.  You saw how I got my numbers.  Even then, that’s counting in-hospital procedures, and does not include circumcisions done in-office, in an outpatient surgery center, or ritually, such as a Bris.  Which means that number could be anywhere from 57% (3% Jewish population) to 65%, depending on how many in-office, outpatient surgery center or ritual circumcisions done that year, which we don’t know.  So a conservative estimate is 54%, and we know that number is too low.

Now, to verify my numbers.
The CDC

Here is the MMR (morbidity mortality report) from 2009.  It’s discussing trends in in-hospital circumcision rates.  Again, this is not including ritual circumcision, in-office or outpatient surgery circumcisions.

All three data sources underestimate the actual rate of NMC because none of the datasets include NMC performed in the community. Rates of NMC through the first 28 days of life were calculated for the most recent 10 years of available data from each data source (i.e., 1999–2008 data from NHDS and NIS, and 2001–2010 data from CDM), and a Poisson regression model was used to calculate the average annual percentage change (AAPC). The changes in incidence estimated from the three data sources were compared using the trends homogeneity test.

Even here they admit it’s an underestimation.  Let’s read further.

For the period 1999–2010, the weighted analysis yielded 11,789,000 (59.1%; 95% confidence interval [CI] = 59.1%–59.2%) of 19,933,000 and 12,347,096 (57.8%; CI = 57.8%–57.8%) of 21,359,690 newborn males circumcised in the United States from NHDS and NIS, respectively. Of 2,339,760 newborn males recorded in CDM, 1,306,466 (55.8%; CI = 55.7%–55.9%) were circumcised.

Incidence of NMC decreased from 62.5% in 1999 to 56.9% in 2008 in NHDS (AAPC = -1.4%; p<0.001), from 63.5% in 1999 to 56.3% in 2008 in NIS (AAPC = -1.2%; p<0.001), and from 58.4% in 2001 to 54.7% in 2010 in CDM (AAPC = -0.75%; p<0.001) (Figure).

When compared using the trends homogeneity test, the decreases in incidence were statistically different (p<0.01) for the 8 years of commonly available data (2001–2008); however, the maximum difference in absolute incidence did not exceed 5.9 percentage points for any given year.

So…haven’t intactivists been telling us that the circumcision rate is dropping precipitously, and has been for years?  Well, that’s not what this article says, which examines rates from 3 different sources.  All they have is the NYT article.

So now I’ve (in detail) shown that they prefer to twist facts about the rate circumcision is being performed.  Even if they don’t want to find these easily available statistics, they could at least read more than just the 32.5% part of the NYT article, which shows it’s a very lowball estimate.

Lets move on.

Death by Circumcision

Do I think it’s possible?  Absolutely, yes.  Do I think we have any hard numbers on it?  No.  Neither do the men who published this “study“, or more appropriately, an article, in my opinion.  Let’s look at the abstract:

Author Dan Bollinger presents a study regarding circumcision deaths. Baby boys can and do succumb as a result of having their foreskin removed by circumcision. Circumcision-related mortality rates are not known with certainty; this study estimates the scale of this problem. This study finds that approximately 117 neonatal circumcision-related deaths (9.01/100,000) occur annually in the United States, about 1.3% of male neonatal deaths from all causes. Because infant circumcision is elective, all of these circumcision deaths are avoidable. This study also identifies reasons why accurate data on these deaths are not available, some of the obstacles to preventing these deaths, and some solutions to overcome them.

Well, that’s not a promising start.  An approximation?  But it’s quoted as a fact!  How many times have you seen ’117 boys die every year from circumcision’ or ‘over 100 boys die every year due to that elective procedure’.  However, lets look at what this article actually says:

About 1.3 million boys are circumcised each year in the United States (HCUP, 2007); however, the number of boys who died from those surgeries has not been reported or estimated in any credible way. Some reasons include record-keeping practices,
indifference, and—no doubt—concerns about liability. Death certificates typically do not list circumcision as the immediate or leading
cause of death and rarely list circumcision as an underlying cause. Incomplete and inaccurate death certificates for children are a common phenomenon (Cunniff, Carmack, Kirby, & Fiser, 1995). Thus, many circumcision-related deaths are more often reported
as surgical mishap, infection, hemorrhage, cardiac arrest, stroke, reaction to anesthesia, or even parental neglect.

So basically he’s saying he has no way to come to the number he came to.  I’m not going to spend a bunch of time on pointing out the flaws of this paper, since this blog does it for me.

According to Dan Bollinger, who I’ve spoken to personally (and operates this site…and if you look at this part of his site, he again uses inaccurate statistics to quote a 32% circumcision rate.  Again, if you can’t be accurate about something as basic as the percentage of boys being circumcised, how can you be trusted to provide an accurate ‘guesstimate’ of deaths?)  he’s had professional epidemiologists examine his paper and found no problem with the methodology.  The issue is, that doesn’t mean much.  First, how do I know he’s telling the truth?  He’s misleading visitors to his website about the percentage of circumcisions performed.  Secondly, it’s now obvious intactivists will say just about anything to make their case seem stronger, if he did have an actual epidemiologist examine it, I have no doubt they are an intactivist.

This is about all I can get through for right now.  I may add some more later today, for instance, about attributing a hard number to retractability.
What I want you to get from this blog is not that I think circumcision is wonderful, or that I support RIC.  I definitely support circumcision for Jews, because it’s so integral.  I support it for medical necessity, or personal desire…for the person who the penis is attached to.  I think it’s understandable that parents choose to circumcise, considering the cultural attitude about the intact penis.  Understanding why they would make that decision is very different from supporting it, however.  That doesn’t mean I feel that it’s appropriate to bully parents who circumcise or are considering circumcision.  I think using emotionally loaded words like ‘mutilation’ or ‘victimization’ does nothing to get people to listen to what we have to say.  I think that twisting facts or using inaccurate sources (that say they’re inaccurate in the same article you selectively quote) is just flat wrong.  It’s lying.  So for that reason, I’m not an intactivist, and I have a problem with intactivists.  Because those are the methods they demand you use.  And if you’re not quoting the same 10 sources or pieces of information, then you’re the enemy.

Circumcision is legal.  It’s the parents choice.  Is it a choice that more parents could research better?  Yes, on both sides.  Is circumcision the ideal choice for an anatomically normal, non-Jewish infant?  Not in my opinion.  However, I’d prefer to use as accurate information and as I can.  I’d prefer to use reasonable words instead of emotional rhetoric.

Who am I?  I’m not an intactivist, but I did not circumcise my own sons.