Talk:Circumcision

Should we have both absolute RR and relative RR for the HIV benefit from circumcision?

The following discussion is closed. Please do not modify it. Subsequent comments should be made on the appropriate discussion page. No further edits should be made to this discussion.

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Should we have the text "circumcision reduced the infection rate of HIV among heterosexual men by 1.8% over 24 months, a reduction of between 38–66%" rather than " circumcision reduced their acquisition of HIV by 38–66% over a period of 24 months."?

Support

• Support Absolute risk reduction is also useful in addition to relative risk reduction. Both these are supported by the Cochrane review in question and the ARR takes into account the overall risk in the population. Thus many people find ARR useful for interpreting prevention measures. We could also state 18 out of 1000 which is the same as 1.8%. Doc James (talk · contribs · email) (if I write on your page reply on mine) 03:53, 11 April 2014 (UTC)

• Comment - Hi James here 18 out of 1000 is not conveying the full information. If you were explaining in terms of absolute numbers you have to say that if 1000 people received circumcision and 1000 did not, AND if in the group that did not get circumcision 100(10% baseline risk assumption) contracted AIDS, only 34 to 66 people in the circumcision group will contract HIV/AIDS. If you assume a different baseline risk you would get a different ARR. But you need to state both the relative and absolute risks. Manu Mathew (talk) 10:07, 24 April 2014 (UTC)

• Support For my full reasoning see above discussion. My reasoning is similar to Doc James. Tremello (talk) 07:08, 11 April 2014 (UTC)
• Support. Suggest we add wikilinks to absolute risk reduction and relative risk reduction so that the statement reads "circumcision reduced the absolute infection rate of HIV among heterosexual men by 1.8% over 24 months, a relative risk reduction of between 38–66%" so that readers without a knowledge of stats have a way to reconcile these two stats. --LT910001 (talk) 22:28, 11 April 2014 (UTC)

• Comment I would be happy with that. Are those who oppose happy with this alternative? Tremello (talk) 11:22, 13 April 2014 (UTC)
• I always thought it was generally bad writing to use terms where the reader has to follow multiple wikilinks due to WP:JARGON to understand a sentence, especially in the lead. Yobol (talk) 13:28, 13 April 2014 (UTC)

• Support - Relative comparison is valid. I think the statement wording could be improved so that it doesn't sound like the act of getting circumcised creates the benefit. Suggest: "A 2009 Cochrane meta-analysis of studies done on in Africa found that over a period of 24 months, sexually active heterosexual men who had been circumcised acquired HIV at a rate 38–66% lower than comparable uncircumcised men." ~KvnG 02:14, 21 April 2014 (UTC)

Neutral

• Neutral - I don't mind the proposed wording much as it includes both the RRR and ARR to put things in context. But I have minor concern about the inclusion of ARR in the lead for the same reasons as Alexbrn below. EvergreenFir (talk) 16:44, 13 April 2014 (UTC)

Oppose

• Opppose (in the lede at any rate) - as is well-shown in the discussion below, this is not effective communication (i.e. it's bad medical writing for a lay audience). Alexbrn ^{talk|contribs|COI} 14:35, 11 April 2014 (UTC)
• Oppose in the lead. As always, we should follow the emphasis of the source. While the 1.8% statistic is in the paper, it is not discussed in the "Discussion" section at all, so the only statistic the authors put any weight on is the 38-66%, so this should be what we place weight on as well. To say use of the statistic is "sensationalizing" when the authors of the paper only discuss that statistic in the Disucssion section is bizarre. As evidenced below, is also not clear to the average lay reader what this means; if we are to include it, we have to include a significant discussion/explanation, which is only reasonable in the body. Yobol (talk) 13:20, 13 April 2014 (UTC)

The decision to put that statistic in the lede is sensationalising things because it doesn't account for the rarity of HIV in most developed populations (never mind In the African trials), nor does it account for the rarity in acquiring HIV for a man having intercourse with an HIV infected woman (about 1 in 2000 per act in high income countries according to these transmission rates). So the question must be how much of a big deal do we make out of this statistic. My concern is that people will think that circumcision is definitely a worthwhile thing and that they are in danger of catching HIV if they aren't circumcised. If Europeans increased their circumcision rate, would their HIV rates go down by 38-66% exactly? I also fail to see how it is a bad thing to tell the reader what the statistic means. I would rather they learnt the difference between relative and absolute risk reduction than they be misled. As the 3 scholars I linked to have pointed out, the relative reduction statistic can be misleading. Also, the discussion section of the Cochrane report only briefly mentions the 38-66% statistic - there isn't much discussion at all regarding rates. Tremello (talk) 21:06, 13 April 2014 (UTC)

In cases of dispute, it is best to follow the sources. In this case, which, if any, statistics to emphasize should be guided by the source in question. The source singles out the 38-66% statistic in the abstract and discussion, and ignores the 1.8% statistic. To me, what we should emphasize and what we should not is clear based on this. Yobol (talk) 01:37, 14 April 2014 (UTC)

Yobol is exactly right, per WP:DUEWEIGHT we need to reflect the emphasis found in the best-available sources. How do the reliable sources handle it? I have pulled reliable secondary sources on the subject:

PMID 23775468, a 2013 MEDLINE-indexed review, in the abstract: RRR: "showed a reduction in the rate of acquisition of HIV by up to 66 % over 24 months"; ARR: not covered.

PMID 22797745, "Voluntary Medical Male Circumcision: An HIV Prevention Priority for PEPFAR"; section "The scientific evidence for voluntary medical male circumcision": RRR: provided for all data summarized; ARR: not covered.

PMID 22926175, the AAP Technical Report: RRR: often used "reported protective effect of 40% to 60%", "average efficacy of 60%"; ARR: doesn't appear to be mentioned in the article body.

PMID 22014096, "Male circumcision for HIV prevention: current evidence and implementation in sub-Saharan Africa": RRR: Review section, "efficacy of greater than 60%"; ARR: doesn't appear to be mentioned in the article body.

PMID 19370585, Cochrane review, "Male circumcision for prevention of heterosexual acquisition of HIV in men": RRR: abstract, Authors' Conclusions, "There is strong evidence that medical male circumcision reduces the acquisition of HIV by heterosexual men by between 38% and 66% over 24 months"; IRR: not mentioned in abstract, but is embedded inside a detailed technical analysis in the body of the article, "At the end of the studies (21 or 24 months), the risk difference dropped further to -1.80% with 95% CI from -2.48% to -1.12% with minimal statistical heterogeneity (X² = 1.00, df = 2; p = 0.61; I² = 0%) (see Analysis 1.6). This can be interpreted as a significant absolute risk reduction of 0.83% at 12 months and of 1.80% at 21 or 24 months, following circumcision."

I support adding the ARR in the body, as per the emphasis found in the sources, and because in the body there is room to explain the statistics. Zad68 04:39, 14 April 2014 (UTC)

• Oppose 1.8% makes no mathematical sense whatsoever. It gives the reader absolutely no information at all unless they understand what the 38-66% means, mathematically. Now, if you were to list the starting and ending percentage, that would make sense. Saying "reduced from 3% to 1.8%" makes logical sense. Absolute percentage reductions are meaningless without a starting and ending %. In fact, the relative reductions give redundant information. Only the absolute starting and ending percentage is needed. As a side comment, this article has certainly improved a lot over the last year and then some. Been keeping an eye on it. Rip-Saw (talk) 04:19, 14 April 2014 (UTC)

  It means that if one is circ in Africa their risk of getting HIV decrease 1.8%. How is this "no information"? Doc James (talk · contribs · email) (if I write on your page reply on mine) 07:02, 19 April 2014 (UTC)

  It's no information because it gives no starting point. If your risk went from 99% to 97.2%, no one in the world could make the case for circumcision. That's not even a significant decrease. And if it went from 1.9% to 0.1%, well that would be absolutely massive, wouldn't it? Saying a risk decreased by an absolute amount is absolutely ridiculous, and only a fool would do so without context. Rip-Saw (talk) 01:51, 6 May 2014 (UTC)

  If my chance of death when from 99 to 97.2% yes that is great. So is 1.9% to 0.1%. Different people wish the numbers in different ways. Doc James (talk · contribs · email) (if I write on your page reply on mine) 03:15, 6 May 2014 (UTC)

Comment I disagree with Yobol's and zad's logic. Your logic is we should follow what the abstract of the source says. But this cochrane an article about circumcison and HIV. Whereas this Wikipedia article is about circumcision alone/in general. So you have decide the weight to give it and how to put it in context.

Unfortunately ripsaw, they do not give the starting and ending percentage. I think they did some statistical stuff weighting some studies more than others to get the 1.8% - which I don't umderstand.

I have some problems with the 38-66%. What if a lot of those who got HIV also had genital ulcers for example? What if the protection percentage varies upon type of circumcision. My question to those who are in favour is - is this a definite percentage?

Also is this relevant from WP:MEDRS: "However, when it comes to actually writing a Wikipedia article, it is misleading to give a full citation for a source after reading only its abstract; the abstract necessarily presents a stripped-down version of the conclusions and omits the background that can be crucial for understanding exactly what the source says." Tremello (talk) 18:09, 14 April 2014 (UTC)

Our logic is that we do what the Wikipedia content policy says. The Wikipedia content policy says that we summarize the scientific consensus of the best-available sources, giving weight proportionate to the weight given by the sources. If you want to see what the most important points are, look to the abstract or conclusions, as it is precisely the purpose of an abstract or conclusion section to summarize the most important points. In my comment above I provide the relevant WP:MEDRS-compliant reliable secondary sources and show they weight the RRR heavily, and the ARR very little.

Re I have some problems with the 38-66%. What if a lot of those who got HIV also had genital ulcers... Tremello, your personal issue with the subject of this article should be irrelevant. Your argument has been nothing more than your own original research based on anonymous self-published activism sites. If you disagree, you're welcome to go try to change Wikipedia content policy to say that it's OK for Wikipedia articles to reflect the original research put forth by single-purpose accounts. Zad68 19:16, 14 April 2014 (UTC)

• Oppose - Per Alexbrn's logic. Information might be helpful for more educated readers, but probably just confusing for the common Joe. NickCT (talk) 20:15, 14 April 2014 (UTC)
• Oppose - I have been following this for a little while now and tend to agree with the above commentators. Best to keep it simple in the lead and follow the emphasis from the sources. Have no issues with the 1.8% being explained in the body though. AIRcorn (talk) 23:14, 14 April 2014 (UTC)

Comment: Oppose and Oppose Firstly, the lede in this article is ludicrous. If it were on a less hysterically contentious subject I would climb in and split it into a five-line real lede plus one or more introductory overview sections, but I suspect I would be wasting my time. The numeric topic under discussion certainly does not belong in the lede anyway and most certainly not in that form. It does of course belong in the article, in an appropriate context, but also appropriately discussed, not quoted out of context without analysis of its significance. Until that is corrected it does not in fact belong in the article at all, being in effect incoherent, of use neither to naive nor advanced readers. To plead WP policy in defence is the purest legalistic window dressing; to summarize the most important points is useless out of context, if not positively misleading. JonRichfield (talk) 06:31, 19 April 2014 (UTC)

Agree with you that the lede is an unreadable mess. Neither of the warring factions can be bothered to write for readers. That is the reason why I no longer mingle in this ant hill, see also my comment here.82.113.99.92 (talk) 20:46, 19 April 2014 (UTC)

• Oppose per above, in particular Rip-Saw and JonRichfield. The amount of medical detail in the bloated lede is given totally undue weight, and is directly confusing to the reader by throwing it like that in their face instead of being introduced in the appropriate sections (Circumcision#Effects and Circumcision#Adverse_effects). Material from the lede should be trimmed and moved to these sections, so that it is more in line with wp:lede. ^walk victor falk ^talk 16:29, 4 May 2014 (UTC)

Discussion

Is the RFC for text in the body, the lede, or both? Alexbrn ^{talk|contribs|COI} 05:26, 11 April 2014 (UTC)

Both, I presume. Can't have it in lede without it being in body also. My view is that to include just the 38-66% in the lede would be undue weight and sensationalising things. See my reasoning above. I am not sure I prefer the non- statistics proposal you offered above as I identified problems with it.Tremello (talk) 07:03, 11 April 2014 (UTC)

• Okay as someone is asking for outside input, presumably from those unfamiliar with the article and perhaps topic, could someone explain the meaning of the above statement "circumcision reduced the infection rate of HIV among heterosexual men by 1.8% over 24 months, a reduction of between 38–66%" How can it reduce it by 1.8% and 38-66%? AIRcorn (talk) 10:34, 11 April 2014 (UTC)
  • Exactly, for the general reader it is just confusing. (But see discussion in section above for elucidation). Alexbrn ^{talk|contribs|COI} 10:38, 11 April 2014 (UTC)

• Question Where is the 1.8% figure coming from? I don't see it in the abstract of the source.

Comment As someone also unfamiliar with the topic, I agree with AIRcorn in finding the sentence showing both figures difficult to understand (in its current form). It's not clear to a lay reader what each percentage is a percentage of. : 94.193.139.22 (talk) 10:55, 11 April 2014 (UTC)

Comment Re WP:UNDUE: The source makes a very strong statement ("strong evidence that male circumcision prevents men in the general population from acquiring HIV from heterosexual sex"). If the source is reliable (and it does look reliable to me) then quoting the 38-66% alone, while it is a strong statement, would be justified by the source IMO.

To explain: So let's us say for arguments sake, the HIV rate for the non circumcised group after 24 months was 3% and for the circumcised group it was 1.5%. That would be a 1.5% reduction in the rate of HIV, but comparing the 2 groups it would be a 50% reduction because 1.5 is 50% of 3. So which percentage should we use? The absolute reduction (1.5%), the relative reduction (50%) or both? See Goldacre, Welch, and Earpe for the merits and reasoning behind the absolute reduction statistic. Tremello (talk) 13:51, 11 April 2014 (UTC)

Got it. If we do go with the two figures then IMO what each one stands for does need further explanation, or at the very least a wikilink to an explanation elsewhere on wikipedia. So is the 1.8% from the body (but not the abstract) of the source? I'm seeing " At the end of the studies (21 or 24 months), the risk difference dropped further to -1.80% with 95% CI from -2.48% to -1.12% with minimal statistical heterogeneity ... This can be interpreted as a significant absolute risk reduction of 0.83% at 12 months and of 1.80% at 21 or 24 months, following circumcision." - is that where the 1.8% is coming from? Why are we not using the 1-year figures? Balaenoptera musculus (talk) 14:20, 11 April 2014 (UTC)

And should the 1.8 perhaps be denoted in percentage points rather than percent? Balaenoptera musculus (talk) 14:23, 11 April 2014 (UTC)

Yes the figure is located in the Effects of intervention > primary outcome> sensitivity analysis of the full article not the abstract. Generally it is seen as more reliable if the reduction holds true over a longer period. Yes maybe the use of percentage points with inline link could improve things. Tremello (talk) 14:34, 11 April 2014 (UTC)

? Is the issue here really one of presentation (i.e. which of the two ways to present the figures is clearest and most informative) or is it one of how much weight we should allot to the African studies (and the Cochrane meta-study), given the scientific debate that seems to be going on (example) about the validity of the studies (e.g. alleged selection bias, inadequate blinding etc)?

If the reliability of these studies is debatable, then should we not move them out of the lede entirely and deal with them in the body of the article, where the arguments for and against could be spelled out in more detail? Balaenoptera musculus (talk) 15:02, 11 April 2014 (UTC)

It is best practice to use both RR and AR for the benefits and harms of treatment. I find AR to be much better. 1.8% means that if you are circ in Africa your chance of getting HIV decrease 1.8%. The RR is less informative. Doc James (talk · contribs · email) (if I write on your page reply on mine) 06:59, 19 April 2014 (UTC)

It means no such thing.Doc James(User Jmh649) is at best misguided or ill informed in making the following statement

"1.8% means that if you are circ in Africa your chance of getting HIV decrease 1.8%"

In fact, if you were circumcised in Africa- if you survived the often crude and often forced process of Tribal Circumcision you may have all sorts of complications,scarring, or malfunction from having the top of yer willy lopped off.

What it DOES mean is that for a small cohort of subjects( all of whose foreskins were cut off in clinical settings) in a questionable study in a part of one country on the continent of Africa (a study which was halted on ethical grounds) that there may be some support for the idea that being cut eliminates or reduces one route of entry for HIV into the male body through th moist envelope of the inner of the still attached foreskin which unfolds during intercourse.

The moist envelope of the foreskin normally protects the penis head and helps retains its sensitivity preventing the hardening and coonsequent desensitization of the penis head which is a result of every circumcision worldwide. There exists a counter argument to the one extolling the protective virtues of the chop. That is that the mucous membrane of the intact foreskin is a vital part of the immune system. Perhaps circumcision will, (like many gung-ho knife based procedures in medicine -like cutting out tonsils and appendix too readily) fall out of fashion when this aspect receives more attention .--— ⦿⨦⨀Tumadoireacht ^Talk/_Stalk 21:45, 22 April 2014 (UTC)

@Tumadoireacht: mind saying that not in all caps and in a more understandable way? EvergreenFir (talk) 02:04, 23 April 2014 (UTC)

The discussion above is closed. Please do not modify it. Subsequent comments should be made on the appropriate discussion page. No further edits should be made to this discussion.

Pro circumcision bias

This article still has a pro circumcision bias. Given the prevalence of circumcision of the penises of the contributors to Wikipedia and the US origins of this organisation I wonder if this is unavoidable. I hope not.

The pro circ argument around possible std prevention is absolutely shameful, and it's a dangerous idea to circulate. By that I mean, there should be no material that encourages sexually capable men of all ages to practise sex without a condom because of any slight perceived protection by having a calloused glans on their penis. It's also dangerous to circulate this idea with parents who think it's their right to circumcise their son.

What ever happened to the section in this article around the negative side effects of routine penile modification?

Perhaps some more competent editor could put the identity of the editor who made the above comment at the end of it. Or the editor concerned could do it .--— ⦿⨦⨀Tumadoireacht ^Talk/_Stalk 11:41, 3 June 2014 (UTC)

Sexual impact

The article states in the third paragraph "Circumcision does not appear to have a negative impact on sexual function.", citing a study done by Pediatricians, who I believe have a questionable at best knowledge of adult human sexuality. I have a study which presents clear evidence to the contrary that circumcision leads to a loss of pressure sensitivity, but since I am a new editor I would like to bring the topic up for discussion before I go ahead with the edit. Here is the whitepaper: http://www.ncbi.nlm.nih.gov/pubmed/17378847 Santacide (talk) 01:40, 7 June 2014 (UTC)

Hi Santacide, you didn't propose a specific edit but the general idea of using a primary study to contradict the conclusions of multiple secondary sources is contraindicated by WP:MEDREV. If you're interested in editing Wikipedia biomedical content, please start by reading WP:MEDRS carefully.

As a side note: First, you are discussing sexual impact, but the study you've provided in your proposal to update the Wikipedia article's content in this area did not investigate sexual impact and makes no statement about sexual impact in its conclusions. Second, you state that you believe pediatricians "have a questionable at best knowledge of adult human sexuality" but the lead author of the study you provided is a pediatrician--Why would you propose to change content because it was done by a kind of investigator you question and then offer to replace it with a study done by the same kind of investigator? Zad68 14:05, 9 June 2014 (UTC)

I support Santacide; posting that circumcision does not effect sexual pleasure is a lie to the people of the public and is not considered as good faith. — Preceding unsigned comment added by Enlightened one088 (talk • contribs) 03:43, 11 June 2014 (UTC)

This was discussed a month and a half ago:
https://en.wikipedia.org/wiki/Talk:Circumcision/Archive_79#Summarizing_the_effects_of_circumcision_on_sexual_function

I agree that currently the way we summarise the sexual effects does not accurately reflect the secondary sources or current scientific consensus. Tremello (talk) 07:53, 11 June 2014 (UTC)

Do you have some new secondary sources to discuss? Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:25, 11 June 2014 (UTC)

Thank you all very much for helping me with trying to improve this article, even though I am new here. I will try to look up relevant secondary sources to support this thesis in my spare time, and for the record we currently only have one secondary source stating that circumcision has no negative sexual repercussions, if I recall correctly. Once again, I appreciate your honest and helpful feedback! Thank you! Santacide (talk) 00:35, 12 June 2014 (UTC)

You're welcome. But, a few important things: First, you state that you want to support your "thesis". So you are coming to the article with a preconceived view (your "thesis") and will now scout around to look for sources to support your belief--this is backwards. Per Wikipedia content policy we review the available sources and summarize them with due weight: the sources need to lead you to the content, not the other way around.. That, plus the advocacy website you first used to attempt to support the content, explain why you might be here; please see WP:NOTADVOCACY. Second, your statement "we currently only have one secondary source stating that circumcision has no negative sexual repercussions"--No, please look again. Zad68 04:10, 12 June 2014 (UTC)

By "my thesis" I was simply referring to, as Tremello stated, the current scientific consensus, which I believe is that circumcision, since it removes erogenous tissue, decreases erogenous sensation... And the NIH is not an advocacy website... Secondly, by one secondary source I was referring to source 18 which, on second glance, does contain several citations therein, so my apologies. However, none of these citations are links or URLs, so how is a reader supposed to look them up and verify them? Thank you! Santacide47eb06a9@opayq.com (talk) 06:04, 12 June 2014 (UTC)

By the way this [1] is a primary source as thus we do not really allow its use. We want secondary sources that provide a general overview of primary sources. Doc James (talk · contribs · email) (if I write on your page reply on mine) 07:25, 12 June 2014 (UTC)

• I have found a recent secondary source [2] which I will add. It is freely available. Doc James (talk · contribs · email) (if I write on your page reply on mine) 07:26, 12 June 2014 (UTC)

Primary sources

For medical content such as this we do not use primary sources but instead use secondary sources. This has been made clear in the edit summaries such as this one [3] Doc James (talk · contribs · email) (if I write on your page reply on mine) 04:45, 11 June 2014 (UTC)

Summarizing the effects of circumcision on sexual function

Zad68 recently reverted one of my edits with the reason: "restore well-supported content, Crooks been discussed before, as a source & what it actually says doesn't overwhelm the many strong sources we have that are in close agreement"

I'm afraid it's not that simple, so allow me to explain. (I will continue to use "Crooks" for continuity of discussion, but for those reading this, the book in question is "Our Sexuality" by Crooks & Baur). I see that Crooks has been discussed here in the Circumcision talk archives. Zad68 summarized what reliable secondary sources have said about sexual function as follows:

AAP Tech Report 2012 - PMID 22926175 - "Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction."

Sadeghi-Nejad 2010 - PMID 20092446 - "most recent articles do not show evidence of adverse effects on sexual function"

Doyle 2010 - PMID 19913816 - "Adult male circumcision does not seem to have an adverse impact on sexual function."

Perera 2010 - PMID 20065281 - "The evidence suggests that adult circumcision does not affect sexual satisfaction and function."

Crooks 2013 - "questions about the relationship between circumcision and male sexual arousal remain to be answered" (It also goes on to say "Data concerning the effect of circumcision on erotic function are limited and inconclusive.")

Tian 2013 - PMID 23749001 - "These findings suggest that circumcision is unlikely to adversely affect male sexual functions."

Zad68 then said: "Based on this, I'm not sure Crooks 2013 changes what the article needs to say."

It's not just what Crooks is saying though. Other sources not mentioned on the above list have also analyzed the studies on sexual function, and came up with different conclusions. Here are the more recent ones:

RACP Circumcision statement 2010 - "The effects of circumcision on sexual sensation however are not clear, with reports of both enhanced and diminished sexual pleasure following the procedure in adults and little awareness of advantage or disadvantage in those circumcised in infancy."

KNMG Circumcision statement - "complications in the area of sexuality have also been reported"

So it's actually 3 sources cautiously stating that circumcision likely does not affect sexual function, 2 sources stating that adult circumcision likely does not affect sexual function, 2 sources saying the question is unclear (given the sometimes polarized results of various studies, this is technically the most accurate view), and 1 source stating that circumcision can have sexual complications. The wording before my edit, which is "Circumcision does not appear to have a negative impact on sexual function," only accurately summarizes 3 of the above 8 sources (AAP Tech Report 2012, Sadeghi-Nejad 2010, Tian 2013), since the others either refer only to adult circumcisions, or reached different conclusions entirely. A more neutral and succinct summarization of all sources is the one I suggested: "The impact of circumcision on sexual function is unclear."

I hope this clarifies why my changes are a more neutral and accurate summarization of what the sources say on the subject. Since WP:NPOV states that the views of all relevant reliable sources be represented, I will be re-adding my previous changes. --kyledueck (talk) 18:23, 18 April 2014 (UTC)

Kyledueck, one thing to keep in mind is that WP:Neutral states "representing fairly, proportionately, and, as far as possible, without bias, all of the significant views that have been published by reliable sources on a topic." It does not state "relevant" in that sentence, and this because, per the WP:Due weight (including subsections) aspect of WP:Neutral, not all relevant material should be included (reliable or not). Flyer22 (talk) 19:31, 18 April 2014 (UTC)

There are more strong secondary sources available that are unequivocal in their assessment of no negative effect, I can provide those later this weekend if necessary. The KNMG statement only mentions individual reports, which is the weakest form of evidence. Curiously Crooks only mentions a study from the 1990s, if I remember right, and ignores the large amount of good quality evidence from the large RCTs. The overwhelming consensus from the reliable sources is that there does not appear to be an effect. The weights of the views are not equal, we cannot pretend they are equivalent. Zad68 19:56, 18 April 2014 (UTC)

A textbook will sometimes okay is not as good as a position statement or a systematic review and meta analysis. Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:03, 12 June 2014 (UTC)

Is the lede summary on sexual effects adequate?

The lede of the wikipedia article says: Circumcision does not appear to have a negative impact on sexual function.

The idea that "Circumcision does not appear to have a negative impact on sexual function." as said in the above secondary sources that Zad cites (and in the wiki article) is obviously mainly due to the thinking that RCT trials are the gold standard and because the Ugandan and Kenyan RCTs showed no effect, there is no effect.

According to Morten Frisch:

"The questionnaires used to assess potential sexual problems in the two cited randomized controlled trials in Kenya and Uganda were not presented in detail in the original publications.4,5 Rather than blindly accepting such findings as any more trustworthy than other findings in the literature, it should be recalled that a strong study design, such as a randomized controlled trial, does not offset the need for high-quality questionnaires. Having obtained the questionnaires from the authors (RH Gray and RC Bailey, personal communication), I am not surprised that these studies provided little evidence of a link between circumcision and various sexual difficulties." LINK to article

Also, somewhat relevant is this letter in regard the Ugandan RCT method of circumcision:

"The most recent paper on male circumcision and its impact on sexual satisfaction [1] provided no details on the type of circumcision used in the volunteers. Correspondence with one of the authors, Dr. Stephen Watya, who is in charge of supervising and training medical personnel to do the operations, revealed that the sleeve technique was used, with the incision 0.5–1 cm from the frenulum. Further clarification with Dr. Watya confirmed that the entire frenular area, including the frenulum, was left completely intact in all of these volunteers...The current study is unique as all the volunteers had the same type of circumcision, and all were spared their most sensitive areas. " LINK to article.

See also another letter.

The point they are making is that if the sensitive areas were left intact in the circumcised group then there will be less difference. (However I will admit that the Kenyan trial and South African Trial used the Forceps guided method (which does ablate the most sensitive areas) which kind of makes this argument less strong.)

Second letter criticising the Ugandan RCT:

" However, on closer scrutiny of the data I find the authors’ conclusions rather debatable." LINK

Also I know in the abstract of the AAP report it says "Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction" but in the technical report it does say: "There is fair evidence that men circumcised as adults demonstrate a higher threshold for light touch sensitivity with a static monofilament compared with uncircumcised men (meaning they are less sensitive); these findings failed to attain statistical significance for most locations on the penis, however, and it is unclear that sensitivity to static monofilament (as opposed to dynamic stimulus) has any relevance to sexual satisfaction.132 (Own opinion's of the members of the panel). There is fair evidence from a cross-sectional study of Korean men of decreased masturbatory pleasure after adult circumcision."

Once again you might say we should just go with what they say in the abstract but I feel this isn't appropriate.

Zad your criticism of the Dutch review may be a mistake since they may have made their own judgments on which sources they thought were important on reaching a view on the sexual effects. They may have looked at the RCT studies.

Another thing to note is that in the African trials the men were questioned only 24 months after circumcision. The keratinization process may mean that men circumcised as babies are less sensitive.

Also see Circumstitions.com page on sexual effects

Tremello (talk) 09:41, 19 April 2014 (UTC)

Tremello, please stop citing self-published anonymous activist sites and letters to the editor as if they were reliable sources per Wikipedia standards. How many times do you need to be told this before you'll start respecting Wikipedia sourcing policies? Zad68 02:48, 20 April 2014 (UTC)

Zad, I am not suggesting putting the activist sources in the article. So I am not breaking wiki policy. I am merely asking the question whether the way sexual effects are presented in the wiki article match the current consensus. I don't think the current consensus is that "Circumcision does not appear to have a negative impact on sexual function.[18]". Tremello (talk) 03:56, 23 April 2014 (UTC)

Your entire comment was arguing for a change to the article content based on anonymous activist websites and letters to the editor. Are you confirming now that those sources are not reliable sources, otherwise you would argue to use them in the article?How is your response anything other than game playing? Zad68 04:57, 23 April 2014 (UTC)

The AAP report is not an a activist site or a letter to the editor. We make no mention of greater difficulty in masturbation, nor of the fair evidence Sorrels study which they bring up.

Are we saying letters to the editors which point out flaws in a trial are completely unnoteworthy? Dr Frisch is an experienced sexual epidemiologist, who has carried out his own work.

With the secondary sources we use, their conclusions depend entirely on the RCT's. You dismiss the Dutch secondary source because they don't mention the RCTs. Maybe they believe that in this case RCTs are not the best type of evidence. Yes a properly done RCT would be the best but not everyone believes that to be the case with circumcision as it stands.

I don't think the way the current article summarises the sexual affects reflects real world consensus in the scientific community - at the very least there is a little bit of doubt.Tremello (talk) 10:01, 23 April 2014 (UTC)

• We have this systematic review and meta analysis from 2013 http://www.ncbi.nlm.nih.gov/pubmed/23749001 Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:01, 12 June 2014 (UTC)