Monthly Archives: November 2012

Should we trust birth?

Here is the first blog post stepping outside the topic of circumcision and into other pseudoscientific territory. Enjoy!

“Trust birth” is a phrase that I’ve commonly heard among those in the natural or home birth advocacy movement. There are even Trust Birth groups springing up advocating this. Such groups may state that trusting birth is natural, and fearing or distrusting birth is unnatural and has simply been taught through our culture. Is this correct? Fear of childbirth has in fact been common throughout history, in all times and cultures. Why? Because while birth is a natural process, it is also naturally a dangerous process. Childbirth in humans is an evolutionary bottle neck, where the advantageous feature of large, well developed brains conflicts with the advantageous feature of narrow pelvises, to aid bipedalism. It is also a complex process, to which no other natural process can be an adequate comparison. Pregnancy itself precariously balances the needs and health of the fetus against the needs and health of the mother. The result is historically high rates of both perinatal (around the time of birth) mortality for the babies involved and maternal mortality. This has the evolutionary purpose of keeping head and pelvis size in check, yet as a human event each loss represents a tragedy. We are not willing to accept the death of a human being as simply “evolution in action.”

Improved sanitation and nutrition and modern medicine — including antibiotics, safer cesarean sections, improved ability to monitor the health of mom and baby during pregnancy and childbirth, and developments in neonatal resuscitation and life support, among many others — have dramatically decreased the perinatal and maternal mortality rates, although attempts to further reduce it are constantly being made. We now take these improvements in mortality rates for granted. We assume that mother and child will come through birth and be fine. Ironically, it is these very improvements that allow us to assume that birth is low risk and worthy of trust.

If we cannot trust birth, should we then fear birth? Are all interventions good and necessary, with no harmful side effects? Is the best response to make birth a completely medicalized event, attempting to remove all uncertainty? This position forgets that birth, as a natural physiological process, is not fully understood by science. We know of what can go wrong, but still often do not know why it goes wrong. We don’t fully understand the purposes of the natural physiology of birth — we can’t know for certain what elements in the process of birth serve a purpose in the health of the mother and child, and we don’t always know the long term effects of medical interventions.

I propose the best attitude of a birth attendant is not “trust birth,” nor is it “fear birth,” but rather is “respect birth.” That is, respect birth both as a natural physiological process which goes well much of the time, AND respect birth as a complex event with inherent and natural risks. Birth attendants need both to allow labor and birth to unfold, and to exercise vigilance and intervene when deviations from normal begin to put mother and child at risk. This balance isn’t easy, it likely takes significant training both in normal births and potential complications. It means accepting and responding to the scientific evidence on birth practices and interventions without prejudiced ideology. It means abandoning simple catch phrases or black and white positions and truly grappling with what we know, and what we don’t know.

Can’t you just take antibiotics? Circumcision and UTIs.

One of the most well grounded benefits of neonatal circumcision is a 90% reduction in the incidence of urinary tract infection (UTI) in boys in the first year of life. This benefit seems to raise a lot of questions for anti-circumcision advocates. One example can be seen in this response to the new AAP guidelines,

The AAP report inflates the benefits by stating in its summary, for example, that circumcision “prevents” urinary tract infection (UTI). The report text states, “Given that the risk of UTI among this population [boys under age 2] is approximately 1%, the number needed to circumcise to prevent UTI is approximately 100.” Therefore, 99 boys out of 100 receive no UTI “benefit” from circumcision. UTI is treatable with antibiotics. Good medical practice requires the least intrusive form of effective treatment. All the claimed “preventive health benefits” are debatable and insignificant.

There are numerous other arguments made against circumcision to prevent infection, one common claim is that that UTIs are “several times commoner” in girls, yet we aren’t considering surgical alteration to prevent their rate of infection. Sometimes the grounds for the claim in reduction itself are challenged, although this has become less frequent as the claims have become better and better supported by evidence. Do these arguments undermine this benefit?

The first thing to establish is what exactly we are talking about when we speak of a UTI in an infant boy. A UTI in an infant is a very different beast to a bladder infection in an older child or adult. The primary symptoms are not burning pain and discomfort, but instead a prolonged fever and irritability with no other obvious cause. The majority of UTIs in infancy involve the upper urinary tract, the kidneys, and not merely the bladder as is more common in older children and adults. It poses the very real risks of kidney damage or the development of sepsis, a blood infection, although these have become less common as better antibiotics have been developed.  Mortality was once a real danger from a UTI in infancy although this is now extremely rare. While antibiotics are an essential part of the treatment of such a urinary tract infection, treatment is not as easy as going and taking an oral medication. Hospitalization and the use of IV antibiotics are common  and unfortunately antibiotic resistance is becoming common among the pathogens in these UTIs. Even if response to the antibiotics is good, imaging follow up to look for urinary tract abnormalities and damage will often be necessary.

Contrary to the repeated claims that UTI is more common in girls, in early infancy it is in fact several times more likely in an uncircumcised boy than in a girl. This early period, under three months or so, is also the time of greatest risk overall for a febrile UTI. Within a few months, the prevalence of UTI in an uncircumcised boy is equal to that in girls, and soon the risk in girls surpasses the risk in boys. The most prevalent form of UTI also changes, as bladder infections become more common than the more serious kidney infections that are seen in early infancy.

Studies consistently show that circumcision reduces the risk of UTI significantly, with an overall reduction in risk of nearly 90%. Considering that what is being prevented is a serious infection and not a minor issue, is this alone sufficient reason to circumcise? A recent review determined that it would require 111 circumcisions to prevent one urinary tract infection, and assuming that the complications of circumcision are about 2%, concluded that this wasn’t sufficient to recommend routine circumcision. However, for certain subpopulations at greater risk of infection, the benefits would more clearly outweigh the risks. Moreover, if any of their assumptions about the complication rate of circumcision or the severity of the morbidity associate with UTI or circumcision were wrong, the numbers needed to treat might be quite different. The review didn’t consider any other potential benefits of circumcision besides the risk of UTI, so this might be only one piece to consider when making this decision.

Some New Stuff!

Ok ok ok, first things first.  We have two new contributors to the blog, and a part time author.  One contributor will be working with me on the issues with intactivism specifically, with occasional commentary on other topics of woo, and the other will give us a weekly blog about various topics of woo interest, sure to piss off those in the homebirth movement, anti-vaccination movement and the uber boobers.

Unfortunately, most of my comments are coming from the same people or same kinds of people.  People who, when I look up their email address, are active in assaulting virtually any web page, article or blog post that has anything remotely to do with circumcision.  I honestly wish I would hear more from other people, but perhaps it’s because I’m not writing in a way that seems inviting to parents who are questioning this issue.

With the new statement out from the AAP, I think it’s more clear than ever that the decision to circumcise or not circumcise is really up to the parents.  There are risks and benefits to either decision, and while for me, I don’t find the procedure necessary and therefore decline it, I’ve been moving further and further away from the idea that circumcision causes harm (other than the immediate harm of the procedure).

I know that intactivists are really banking on the coming-of-age of the boys circumcised after the anti-FGM legislation, but I really don’t think that equal protection can or would be applied in that way.  They’re very very convinced of this, but I think that’s a product of their echo chamber.  When you choose to surround yourself only with those of a like mind and a like opinion, who’ve accepted the same assertions as facts, then those assertions start to look more and more rock solid, as though they’re indisputable, widely known facts.  The truth is that this is an illusion, caused by limiting yourself to those sources of information.  As you become more and more involved, it becomes harder and harder to to accept any outside or dissenting source of information.  The fact is that the only people who consider FGM and RIC comparable ARE intactivists.  Virtually everyone else sees this for the nonsensical gross over-reaction that it is.  They’re hardly comparable, except on levels that enormous mental gymnastics are required to reach.  I’ll write a new blog post about this tomorrow, cross my heart and hope to die.

I also recently saw a post in STFUParents with a woman whose husband said he was thankful for all the babies who still had their foreskins left.  I think, to me, this is so absurdly representative of the movement and how it’s just really missing the mark.  Though again, it goes back to the echo chamber environment, and the almost religious zeal it causes.   Are children who are kidnapped and sold into slavery EVEN MORE victimized if they were subject to RIC?  Should they be thankful all they have to deal with is daily rape, and not the horror that their most intimate parts were hacked away at birth by a doctor who only cared about the paycheck (rhetoric of the movement, not my opinion).

I recognize this blog post is sort of all over the place, there’s not much of a unifying theme to it, other than my belief that the online communities of intactivism are innately crippling.  If you were truly interested in the truth and empirical, evidence-based information, then you absolutely would not dismiss EVERYTHING that doesn’t bolster your viewpoint.  The only intellectually honest position is one that recognizes that there are pros and cons, or at the least that there is compelling information in the decision to circumcise; after all, if there wasn’t, why would anyone choose to?

Does the AAP Really Have “No Ethics”?

In the September issue of their journal Pediatrics, the American Academy of Pediatricians published a newly revised policy statement on circumcision. This was the first new statement on circumcision since 1999, and it took a much more strongly procircumcision stance, arguing that the benefits of circumcision outweighed the risk, and that the procedure should be covered by medical insurance so that parents were free to choose it regardless of their finances. The outcry from the intactivist community was loud indeed. Critiques were written of the policy, it was criticized as unethical and unscientific and the AAP was accused of being biased. See here, and here. In addition an initiative was begun which collected pictures of individuals with the phrase “AAP No Ethics” written on their palms.

I hope to devote future blog posts to a more thorough critique of each of the arguments against the AAP’s statement. There are so many allegations that I can’t address them all in one blog post, and I hardly know where to begin. Suffice to say that I don’t find the arguments against the science convincing; the evidence has been growing for real but moderate benefits to circumcision. Many of the criticisms show an ignorance about common scientific language or technique that invalidates their arguments. Some  don’t seem familiar with the AAP’s accompanying technical report which explained their reasoning and fleshed out the recommendations in the official policy statement. I plan to go through some of these objections to the statement in later posts, and point out where the objections are flawed and why. However, I want to start by touching on where I agree with the intactivist criticisms. This doesn’t mean that I think the AAP statement is invalidated, but I do think there are some legitimate complaints about it.

So, some criticisms which I believe have some merit:

The AAP has a cultural bias. 

Now, some of these criticisms claim that the AAP committee has a bias due to a reliance on scientific thinking, which I do think is absurd. In contradiction to the Circumcision Resource Center’s post, I think that the possible benefits and harms of circumcision are absolutely discernible through scientific inquiry, and controlled, replicable and falsifiable studies are a much better gauge of the truth than either feelings or common sense, which are far more subject to cultural bias. However, the researchers DO have a cultural bias: circumcision and the circumcised state are viewed as normal and acceptable, unless there are proven harms. I think that intactivists are somewhat correct in saying that scientists wouldn’t even be investigating circumcision and possible benefits if it weren’t already acceptable to a degree in Western society. However, just because this preexisting bias makes American doctors more willing to consider circumcision doesn’t mean that it doesn’t have real benefits, it just means that the researchers are more open to those benefits. And while there might be concern that this normalcy encouraged the researchers to be more procircumcision in their review of the scientific data, it is also possible that the cultural distaste for circumcision leads other groups to overlook or minimize possible benefits of circumcision. Bias goes both ways. It is definitely possible, however, that this bias influenced how much benefit the committee believes that one needs to see before circumcision is justifiable, and that leads to my next point.

The AAP placed no value on bodily integrity.

I think that this statement is true. I have seen this stated in a few sites or a few different ways, some more inflammatory than others. I agree that the AAP seemed to place no value on keeping the child’s body whole, rather they looked only for objective evidence of harms and benefits. Since the committee members view circumcision as normal and the circumcised state as normal as the intact state, they didn’t seem to require a large benefit to justify the procedure, evidence of  greater lifetime benefits than lifetime harms seems to be sufficient for them. However, in this document they also stress parental choice, and acknowledge that different parents will bring different values to their decision making. I also do not believe that this means that the AAP does not care about ethics or about the well being of boys, it just means that in their decision making system the presence or removal of the foreskin had no value, no decision making weight, in and of itself. The value was determined solely on the effects, positive and negative, on the child’s health and well being. This is certainly different to the philosophy of ethics of intactivists, but it is not an absence of ethics. It is perhaps a more utilitarian ethics.

The AAP does not make clear the magnitude of the benefits of circumcision.

Although the AAP does try to quantify the magnitude of any benefits and likewise the magnitude of any risks, I don’t believe that it provides sufficient evidence for parental decision making.  The most useful number is the “number needed to treat,” which indicates how many circumcisions are necessary to prevent one negative outcome in comparison to the intact state. This could be more easily compared with the numbers available on complication rates. The AAP technical report provided numbers needed to treat for the issues of urinary tract infection and penile cancer. For most other benefits, it provided information on relative risk ratios only. For instance, the report cites a CDC study which estimated a 15.7% reduction in the individual’s lifetime risk of HIV with neonatal circumcision but doesn’t provide information on the absolute risk of infection. A 16% reduction in a 1.87% absolute risk of contracting HIV may seem much less than persuasive to many. The CDC study did provide estimated numbers, which vary based on race. “The number of circumcisions needed to prevent one HIV infection was 298 for all males, and ranged from 65 for black males to 1,231 for white males.” This is the kind of information that is truly needed for a decision on the benefits of this procedure, and they suggest that the benefits for each individual are far from equal.

These listed criticisms are not minor. They are not, however, criticisms of the science itself, which I believe the AAP Technical Report shares in a fair manner. They are instead related to the application of those scientific findings to the decision of whether or not to circumcise. If one is going to argue against routine circumcision, then I feel that these are the points to focus on. I think it is important, however, to keep in mind that the question of “how much benefit is necessary to justify circumcision” is a question based on the parents’ own philosophy, and that different parents can make different decisions based on the same evidence, all while desiring the best for their son’s well being.