Infants lack capacity, so the state assigns parents the authority to grant permission on behalf o... more Infants lack capacity, so the state assigns parents the authority to grant permission on behalf of their child for interventions that are routine, non-emergent interventions, or emergent/life-preserving. For the infant who is severely compromised medically and for whom any intervention would be considered futile, a dialectic between preserving “life at all costs” and the infant’s interest in avoiding unnecessary suffering emerges, prompting potential schisms between parents, physicians, the medical facility, and the state—each of which brings its own biases. Physicians are charged with compassionately providing accurate disclosure that is free of bias and refraining from exerting coercive influence. Parents need to be allowed the space and support to thoughtfully deliberate. Medical facilities, through ethics committees, can provide a path to resolving conflicts without resorting to adjudication in courts. Deliberation should focus on the principles of the infant’s best interests an...
The introduction is a historical article in and of itself. As interesting as it is, it adds littl... more The introduction is a historical article in and of itself. As interesting as it is, it adds little to the scientific paper. It would be useful as a whole separate article. It can be shortened to a single paragraph without detracting from the substance of the article. R: The introduction is shortened to a single paragraph The authors compare their results to that of other series on similar papulation circumcized in a similar tradition, however, it would be helpful if their results were compared to a western population of traditional newborns circumcized by trained pyhsicians or for that matter mohels. Right or wrong, this is the standard that the results needs to be compared to for validation. R: The 1989 review of the American Academy of Pediatrics' Task Force on Circumcision reported that the rate of postoperative complications of male circumcision was approximately 0.2% to 0.6% in the United States. The majority of complications were minor, the most common being local infection and bleeding. Needs some language corrections before being published R: Language corrections have been made.
The recent report by Wayant and colleagues on the fragility index 1 did not include the African r... more The recent report by Wayant and colleagues on the fragility index 1 did not include the African randomized clinical trials on HIVand adult male circumcision. 2-4 Analysis of these trials may provide insight into the interaction between p values and fragility in overpowered studies. The three trials shared nearly identical methodologies, the same sources of differential bias (lead-time bias, attrition bias, selection bias, and confirmation bias), and nearly identical results. All three trials were powered to demonstrate an absolute risk reduction of 1%. All three were discontinued prematurely following interim analyses that satisfied pre-established early termination criteria. Of interest, the fragility index for the three trials were 4, 5, and 6 for the Ugandan, 2 Kenyan, 3 and South African 4 trials, respectively. This suggests that 4 to 6 patients with an event
Background: In 2017 Ploug and Holm argued that anonymizing individuals in the Danish circumcision... more Background: In 2017 Ploug and Holm argued that anonymizing individuals in the Danish circumcision registry was insufficient to protect these individuals from what they regard as the potential harms of being in the registry (overreaching social pressure, stigmatization, medicalization of a religious practice, discrimination and promoting polarized research). Discussion: We argue that Ploug and Holm's fears in each of the areas are misguided, not supported by the evidence, and could interfere with the gathering of accurate data. The extent of the risks and harms associated with ritual circumcision is not well known. The anonymized personal health data supplemented with the circumcision registry will enable more precise research into the medical consequences of ritual circumcision, and allow parents to make more fully informed decisions about circumcision with minimal, if any, adverse consequences.
The Journal of law, medicine & ethics : a journal of the American Society of Law, Medicine & Ethics, Jun 1, 2016
The foreskin is a complex structure that protects and moisturizes the head of the penis, and, bei... more The foreskin is a complex structure that protects and moisturizes the head of the penis, and, being the most densely innervated and sensitive portion of the penis, is essential to providing the complete sexual response. Circumcision-the removal of this structure-is non-therapeutic, painful, irreversible surgery that also risks serious physical injury, psychological sequelae, and death. Men rarely volunteer for it, and increasingly circumcised men are expressing their resentment about it.Circumcision is usually performed for religious, cultural and personal reasons. Early claims about its medical benefits have been proven false. The American Academy of Pediatrics and the Centers for Disease Prevention and Control have made many scientifically untenable claims promoting circumcision that run counter to the consensus of Western medical organizations.Circumcision violates the cardinal principles of medical ethics, to respect autonomy (self-determination), to do good, to do no harm, and ...
For most of this century, physicians have been performing procedures and surgeries on newborns wi... more For most of this century, physicians have been performing procedures and surgeries on newborns without anaesthesia under the mistaken notion that newborns were not neurologically complex enough to experience pain. Although this myth has been dispelled, the most commonly performed surgery in the newborn period, circumcision, continues to be performed, in the majority of cases, without any attempt at pain relief. In 1994, only 4% of obstetricians under 34 years of age used an anaesthetic for neonatal circumcision. Overall, the rate of anaesthetic use was 14% among obstetricians, with 20% of the female obstetricians using anaesthetic. A subsequent survey, distributed in 1996, found that anaesthetic use had increased to 25% among obstetricians. As routine circumcision comes under attack and its frequency declines, proponents of mass circumcision have begun advocating the use of anaesthesia in an attempt to reverse the professional and popular shift against routine neonatal circumcision. Like most of the information that is used to perpetuate neonatal circumcision, the literature on anaesthesia contains a mixture of truth and hyperbole. This article will review the medical research regarding topical and local anaesthesia for neonatal circumcision and its effectiveness.
... of the Committee on Bioethics, is also a member of the current task force addressing male gen... more ... of the Committee on Bioethics, is also a member of the current task force addressing male genital ... male genital cutting to evade an evaluation of the human rights issues associated with ... 27: 3 Fall 2011 Van Howe/Female Genital Cutting 173 differences of opinion that need to be ...
The authors wish to thank Menstuff.org and TheMensCenter.com for their cooperation in providing a... more The authors wish to thank Menstuff.org and TheMensCenter.com for their cooperation in providing access to their men's communities through their websites. We would also like to thank Graeme J. Taylor, MD, for providing the TAS-20 checklist, supportive documents, and assistance with our survey design.
nor painful. He could not recall any trauma, infestation, or insect bites to the area. There was ... more nor painful. He could not recall any trauma, infestation, or insect bites to the area. There was no history of any recent new exposures. Physical examination revealed Tanner 1 genitalia with a circumcised penis. The shaft exhibited a marked area of circumferential swelling that was pink rather than erythematous, resembling urticaria. There was increased swelling in the area between the circumcision scar and the corona. No evidence of trauma, infestation, or insect bites was found. He
Cancer Epidemiology, Biomarkers & Prevention, 2006
To the Editors: Physical examination is the consensus gold standard for determining circumcision ... more To the Editors: Physical examination is the consensus gold standard for determining circumcision status in men. In their study of Mexican military men, Lajous et al. (1) found that self-report of circumcision status had a sensitivity of 57.14% and a positive predictive value of 8.33% when compared with physical examination. In other words, of the men who were considered circumcised, only 8.33% of them actually were. If the authors had physical examination data on their subjects, why did they use self-report as measure of circumcision status when they knew it could not be as accurate as the physical examination data? The increase in statistical power using the 95 men who reported themselves as circumcised as opposed to using the 14 men who were actually circumcised is more than offset by using an invalid measure. It would have been helpful if the authors had presented their analysis using the gold standard. As it stands, the authors' conclusion that circumcision was protective against human papillomavirus (HPV) infection is misleading. The more appropriate conclusion is that the mistaken belief of being circumcised is protective. Can the extremely low positive predictive value of selfreport of circumcision status be a result of lack of familiarity with the term ''circumcision'' that has been reported in Spanish speakers in the United States (2)? Does this mean that the 88 men who misidentified themselves as circumcised were less educated or less literate than men who correctly identified themselves, or did they have a ''short'' foreskin as described in South America mestizos (3)? Finally, the authors should be congratulated on obtaining cultures from a broad array of genital sources. One large study of HPV prevalence failed to obtain specimens from the shaft of the penis (4), which has subsequently been found to be the only location to yield evidence of HPV in the majority of circumcised men with the infection (5). The failure to obtain shaft samples renders the results of this highly publicized New England Journal of Medicine study meaningless. Newer studies have found HPV DNA in the seminal vesicles, epididymis, vas deferens, Leydig cells, Sertoli cells, and probably germinal cells (6). Consequently, the validity of any future study of HPV infection in male genitalia will depend on the thoroughness of search for evidence of HPV.
Australian and New Zealand Journal of Public Health, 2011
Objective: To conduct a critical review of recent proposals that widespread circumcision of male ... more Objective: To conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection.
Vogelstein cautions medical organizations against jumping into the fray of controversial issues, ... more Vogelstein cautions medical organizations against jumping into the fray of controversial issues, yet proffers the 2012 American Academy of Pediatrics' Task Force policy position on infant male circumcision as 'an appropriate use of position-statements.' Only a scratch below the surface of this policy statement uncovers the Task Force's failure to consider Vogelstein's many caveats. The Task Force supported the cultural practice by putting undeserved emphasis on questionable scientific data, while ignoring or underplaying the importance of valid contrary scientific data. Without any effort to quantitatively assess the risk/benefit balance, the Task Force concluded the benefits of circumcision outweighed the risks, while acknowledging that the incidence of risks was unknown. This Task Force differed from other Academy policy-forming panels by ignoring the Academy's standard quality measures and by not appointing members with extensive research experience, exten...
J S Mill used the term 'dead dogma' to describe a belief that has gone unquestioned for so long a... more J S Mill used the term 'dead dogma' to describe a belief that has gone unquestioned for so long and to such a degree that people have little idea why they accept it or why they continue to believe it. When wives and children were considered chattel, it made sense for the head of a household to have a 'sovereignal right' to do as he wished with his property. Now that women and children are considered to have the full complement of human rights and slavery has been abolished, it is no longer acceptable for someone to have a 'right' to completely control the life of another human being. Revealingly, parental rights tend to be invoked only when parents want to do something that is arguably not in their child's best interest. Infant male circumcision is a case in point. Instead of parental rights, I claim that parents have an obligation to protect their children's rights as well as to preserve the future options of those children so far as possible. In this essay, it is argued that the notion that parents have a right to make decisions concerning their children's bodies and mindsirrespective of the child's best interests-is a dead dogma. The ramifications of this argument for the circumcision debate are then spelled out and discussed. We all declare for liberty; but in using the same word we do not all mean the same thing. With some the word liberty may mean for each man to do as he pleases with himself, and the product of his labor; while with others the same word may mean for some men to do as they please with other men…. Here are two, not only different, but incompatible things, called by the same nameliberty. And it follows that each of the things is, by the respective parties, called by different and incompatible names-liberty and tyranny. The shepherd drives the wolf from the sheep's throat, for which the sheep thanks the shepherd as a liberator, while the wolf denounces him for the same act as the destroyer of liberty.
I am grateful to the Editor-in-Chief of Global Public Health for offering me the opportunity to r... more I am grateful to the Editor-in-Chief of Global Public Health for offering me the opportunity to respond to the critique (Morris, Barbosa, Wamai, & Krieger, 2016) of my meta-regression analysis of t...
Infants lack capacity, so the state assigns parents the authority to grant permission on behalf o... more Infants lack capacity, so the state assigns parents the authority to grant permission on behalf of their child for interventions that are routine, non-emergent interventions, or emergent/life-preserving. For the infant who is severely compromised medically and for whom any intervention would be considered futile, a dialectic between preserving “life at all costs” and the infant’s interest in avoiding unnecessary suffering emerges, prompting potential schisms between parents, physicians, the medical facility, and the state—each of which brings its own biases. Physicians are charged with compassionately providing accurate disclosure that is free of bias and refraining from exerting coercive influence. Parents need to be allowed the space and support to thoughtfully deliberate. Medical facilities, through ethics committees, can provide a path to resolving conflicts without resorting to adjudication in courts. Deliberation should focus on the principles of the infant’s best interests an...
The introduction is a historical article in and of itself. As interesting as it is, it adds littl... more The introduction is a historical article in and of itself. As interesting as it is, it adds little to the scientific paper. It would be useful as a whole separate article. It can be shortened to a single paragraph without detracting from the substance of the article. R: The introduction is shortened to a single paragraph The authors compare their results to that of other series on similar papulation circumcized in a similar tradition, however, it would be helpful if their results were compared to a western population of traditional newborns circumcized by trained pyhsicians or for that matter mohels. Right or wrong, this is the standard that the results needs to be compared to for validation. R: The 1989 review of the American Academy of Pediatrics' Task Force on Circumcision reported that the rate of postoperative complications of male circumcision was approximately 0.2% to 0.6% in the United States. The majority of complications were minor, the most common being local infection and bleeding. Needs some language corrections before being published R: Language corrections have been made.
The recent report by Wayant and colleagues on the fragility index 1 did not include the African r... more The recent report by Wayant and colleagues on the fragility index 1 did not include the African randomized clinical trials on HIVand adult male circumcision. 2-4 Analysis of these trials may provide insight into the interaction between p values and fragility in overpowered studies. The three trials shared nearly identical methodologies, the same sources of differential bias (lead-time bias, attrition bias, selection bias, and confirmation bias), and nearly identical results. All three trials were powered to demonstrate an absolute risk reduction of 1%. All three were discontinued prematurely following interim analyses that satisfied pre-established early termination criteria. Of interest, the fragility index for the three trials were 4, 5, and 6 for the Ugandan, 2 Kenyan, 3 and South African 4 trials, respectively. This suggests that 4 to 6 patients with an event
Background: In 2017 Ploug and Holm argued that anonymizing individuals in the Danish circumcision... more Background: In 2017 Ploug and Holm argued that anonymizing individuals in the Danish circumcision registry was insufficient to protect these individuals from what they regard as the potential harms of being in the registry (overreaching social pressure, stigmatization, medicalization of a religious practice, discrimination and promoting polarized research). Discussion: We argue that Ploug and Holm's fears in each of the areas are misguided, not supported by the evidence, and could interfere with the gathering of accurate data. The extent of the risks and harms associated with ritual circumcision is not well known. The anonymized personal health data supplemented with the circumcision registry will enable more precise research into the medical consequences of ritual circumcision, and allow parents to make more fully informed decisions about circumcision with minimal, if any, adverse consequences.
The Journal of law, medicine & ethics : a journal of the American Society of Law, Medicine & Ethics, Jun 1, 2016
The foreskin is a complex structure that protects and moisturizes the head of the penis, and, bei... more The foreskin is a complex structure that protects and moisturizes the head of the penis, and, being the most densely innervated and sensitive portion of the penis, is essential to providing the complete sexual response. Circumcision-the removal of this structure-is non-therapeutic, painful, irreversible surgery that also risks serious physical injury, psychological sequelae, and death. Men rarely volunteer for it, and increasingly circumcised men are expressing their resentment about it.Circumcision is usually performed for religious, cultural and personal reasons. Early claims about its medical benefits have been proven false. The American Academy of Pediatrics and the Centers for Disease Prevention and Control have made many scientifically untenable claims promoting circumcision that run counter to the consensus of Western medical organizations.Circumcision violates the cardinal principles of medical ethics, to respect autonomy (self-determination), to do good, to do no harm, and ...
For most of this century, physicians have been performing procedures and surgeries on newborns wi... more For most of this century, physicians have been performing procedures and surgeries on newborns without anaesthesia under the mistaken notion that newborns were not neurologically complex enough to experience pain. Although this myth has been dispelled, the most commonly performed surgery in the newborn period, circumcision, continues to be performed, in the majority of cases, without any attempt at pain relief. In 1994, only 4% of obstetricians under 34 years of age used an anaesthetic for neonatal circumcision. Overall, the rate of anaesthetic use was 14% among obstetricians, with 20% of the female obstetricians using anaesthetic. A subsequent survey, distributed in 1996, found that anaesthetic use had increased to 25% among obstetricians. As routine circumcision comes under attack and its frequency declines, proponents of mass circumcision have begun advocating the use of anaesthesia in an attempt to reverse the professional and popular shift against routine neonatal circumcision. Like most of the information that is used to perpetuate neonatal circumcision, the literature on anaesthesia contains a mixture of truth and hyperbole. This article will review the medical research regarding topical and local anaesthesia for neonatal circumcision and its effectiveness.
... of the Committee on Bioethics, is also a member of the current task force addressing male gen... more ... of the Committee on Bioethics, is also a member of the current task force addressing male genital ... male genital cutting to evade an evaluation of the human rights issues associated with ... 27: 3 Fall 2011 Van Howe/Female Genital Cutting 173 differences of opinion that need to be ...
The authors wish to thank Menstuff.org and TheMensCenter.com for their cooperation in providing a... more The authors wish to thank Menstuff.org and TheMensCenter.com for their cooperation in providing access to their men's communities through their websites. We would also like to thank Graeme J. Taylor, MD, for providing the TAS-20 checklist, supportive documents, and assistance with our survey design.
nor painful. He could not recall any trauma, infestation, or insect bites to the area. There was ... more nor painful. He could not recall any trauma, infestation, or insect bites to the area. There was no history of any recent new exposures. Physical examination revealed Tanner 1 genitalia with a circumcised penis. The shaft exhibited a marked area of circumferential swelling that was pink rather than erythematous, resembling urticaria. There was increased swelling in the area between the circumcision scar and the corona. No evidence of trauma, infestation, or insect bites was found. He
Cancer Epidemiology, Biomarkers & Prevention, 2006
To the Editors: Physical examination is the consensus gold standard for determining circumcision ... more To the Editors: Physical examination is the consensus gold standard for determining circumcision status in men. In their study of Mexican military men, Lajous et al. (1) found that self-report of circumcision status had a sensitivity of 57.14% and a positive predictive value of 8.33% when compared with physical examination. In other words, of the men who were considered circumcised, only 8.33% of them actually were. If the authors had physical examination data on their subjects, why did they use self-report as measure of circumcision status when they knew it could not be as accurate as the physical examination data? The increase in statistical power using the 95 men who reported themselves as circumcised as opposed to using the 14 men who were actually circumcised is more than offset by using an invalid measure. It would have been helpful if the authors had presented their analysis using the gold standard. As it stands, the authors' conclusion that circumcision was protective against human papillomavirus (HPV) infection is misleading. The more appropriate conclusion is that the mistaken belief of being circumcised is protective. Can the extremely low positive predictive value of selfreport of circumcision status be a result of lack of familiarity with the term ''circumcision'' that has been reported in Spanish speakers in the United States (2)? Does this mean that the 88 men who misidentified themselves as circumcised were less educated or less literate than men who correctly identified themselves, or did they have a ''short'' foreskin as described in South America mestizos (3)? Finally, the authors should be congratulated on obtaining cultures from a broad array of genital sources. One large study of HPV prevalence failed to obtain specimens from the shaft of the penis (4), which has subsequently been found to be the only location to yield evidence of HPV in the majority of circumcised men with the infection (5). The failure to obtain shaft samples renders the results of this highly publicized New England Journal of Medicine study meaningless. Newer studies have found HPV DNA in the seminal vesicles, epididymis, vas deferens, Leydig cells, Sertoli cells, and probably germinal cells (6). Consequently, the validity of any future study of HPV infection in male genitalia will depend on the thoroughness of search for evidence of HPV.
Australian and New Zealand Journal of Public Health, 2011
Objective: To conduct a critical review of recent proposals that widespread circumcision of male ... more Objective: To conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection.
Vogelstein cautions medical organizations against jumping into the fray of controversial issues, ... more Vogelstein cautions medical organizations against jumping into the fray of controversial issues, yet proffers the 2012 American Academy of Pediatrics' Task Force policy position on infant male circumcision as 'an appropriate use of position-statements.' Only a scratch below the surface of this policy statement uncovers the Task Force's failure to consider Vogelstein's many caveats. The Task Force supported the cultural practice by putting undeserved emphasis on questionable scientific data, while ignoring or underplaying the importance of valid contrary scientific data. Without any effort to quantitatively assess the risk/benefit balance, the Task Force concluded the benefits of circumcision outweighed the risks, while acknowledging that the incidence of risks was unknown. This Task Force differed from other Academy policy-forming panels by ignoring the Academy's standard quality measures and by not appointing members with extensive research experience, exten...
J S Mill used the term 'dead dogma' to describe a belief that has gone unquestioned for so long a... more J S Mill used the term 'dead dogma' to describe a belief that has gone unquestioned for so long and to such a degree that people have little idea why they accept it or why they continue to believe it. When wives and children were considered chattel, it made sense for the head of a household to have a 'sovereignal right' to do as he wished with his property. Now that women and children are considered to have the full complement of human rights and slavery has been abolished, it is no longer acceptable for someone to have a 'right' to completely control the life of another human being. Revealingly, parental rights tend to be invoked only when parents want to do something that is arguably not in their child's best interest. Infant male circumcision is a case in point. Instead of parental rights, I claim that parents have an obligation to protect their children's rights as well as to preserve the future options of those children so far as possible. In this essay, it is argued that the notion that parents have a right to make decisions concerning their children's bodies and mindsirrespective of the child's best interests-is a dead dogma. The ramifications of this argument for the circumcision debate are then spelled out and discussed. We all declare for liberty; but in using the same word we do not all mean the same thing. With some the word liberty may mean for each man to do as he pleases with himself, and the product of his labor; while with others the same word may mean for some men to do as they please with other men…. Here are two, not only different, but incompatible things, called by the same nameliberty. And it follows that each of the things is, by the respective parties, called by different and incompatible names-liberty and tyranny. The shepherd drives the wolf from the sheep's throat, for which the sheep thanks the shepherd as a liberator, while the wolf denounces him for the same act as the destroyer of liberty.
I am grateful to the Editor-in-Chief of Global Public Health for offering me the opportunity to r... more I am grateful to the Editor-in-Chief of Global Public Health for offering me the opportunity to respond to the critique (Morris, Barbosa, Wamai, & Krieger, 2016) of my meta-regression analysis of t...
In September of 2012, the American Academy of Pediatrics Task Force on Circumcision released its ... more In September of 2012, the American Academy of Pediatrics Task Force on Circumcision released its report, which concluded that the benefits of the procedure outweighed the risks. A close analysis of the report reveals the Task Force used a selective, subjective and biased bibliography to support their predetermined conclusions. The Task Force neglected to discuss the anatomy, function, and normal development of the foreskin, nor did they discuss the harm or ethical consequences associated with circumcision. The Task Force deviated from standard practices in its analysis of the medical literature thereby producing a report that falls far below the quality standards set by other AAP policy statements. The report promoted expansion of the procedure as well as the revenue streams for those who perform it. Since release of the report, other national medical organizations have rejected infant circumcision as unwarranted medically and as ethically unacceptable. No organizations outside of the United States have adopted their conclusions. The report is poorly written, poorly researched, makes unsubstantiated claims, and reaches an illogical conclusion.
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Papers by Robert Van Howe