Talk:Circumcision/Archive 48

This is an archive of past discussions about Circumcision. Do not edit the contents of this page. If you wish to start a new discussion or revive an old one, please do so on the current talk page.

Archive 45

Archive 46

Archive 47

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Reasons for the totallydisputed tag

Instead of the above list of quotes and sources, I'll provide a quick summary of factual problems. The reader of Wiki’s Circumcision is actively denied (or mislead about) the following (see links to source references above) facts:

A neonate has a 27-33% chance of getting a frenectomy along with his circumcision. This frenectomy will effectively remove one of the boy’s two primary erogenous zones. If circumcision is required for religious purposes, there are circumcision procedures that minimize the chance of frenular damage (mogen clamp properly aligned with the glans, or the authentic covenant procedure).

Reducing frenular damage also reduces the chance of meatal stenosis, which is a complication to circumcision found in 9-10% circumcised as a neonate, with an average presentation age of 4 years old. Meatal stenosis is treated with surgical meatotomy. Meatal stenosis can be prevented (post circ) if parents are given care knowledge.

Traditional circumcisions of both Jews and Muslims are currently radical (tight circs that removes all the covering of the glans, most of the mucosa, and much of the frenulum), though the covenant procedure (“commandment of God”) was minor (removing the tip of the foreskin that extended beyond the glans).

Circ’s are done at a relatively dangerous age (5 months old is much safer than neonatal), are evidently unsanitary when “traditional,” and are dangerously extremely painful … especially when the frenulum is cut. Circumcisions are generally done without anesthesia. The reader is mislead about dangers, complications, sexual effects, and is hyped on health benefits (versus meta cost/benefit find no medical or costs gains).TipPt (talk) 18:03, 19 September 2008 (UTC)

Did you see the recent study (Krieger 2008) that demonstrated that circumcised men had MORE sexual pleasure/satisfaction than uncircumcised men? The article covers both positions, there is no need to emphasize one over the other (unless you are more interested in soapboxing which, of course, is forbidden). -- Avi (talk) 19:17, 19 September 2008 (UTC)

Did you know Krieger 2008 men were circ'd as adults by medical personel only, and that the technique used would have preserved the frenulum. Those results cannot be applied (said the AAP)[1] to neonatal circ's, especially traditional circ's.

Hey, that's another fact that's been deleted from Circumcision!TipPt (talk) 19:43, 19 September 2008 (UTC)

I don't see anything in TipPt's justifications for the tag beyond personal opinion and soapboxing. Recommend removal of tag. Nandesuka (talk) 20:55, 19 September 2008 (UTC)

If an editor thinks there is a problem and places a tag, then comes here to talk about it, we should respect that. Once again tags do not deface articles. They are improvement mechanisms used to draw attention to talk debates. Garycompugeek (talk) 21:14, 19 September 2008 (UTC)

Tip don't you think the one tag already on the article is enough? It covers title and subject matter. Garycompugeek (talk) 21:18, 19 September 2008 (UTC)

The issues I bring (deletions from prior versions of Circumcision, or critical facts actively denied from inclusion) are specific and easily fixable when we agree on wording. Again Nandesuka, I'm providing very specific significant factual faults with Circumcision. It's not POV, it's missing facts; so there's a different tag. I have expressed no personal opinion; facts (quotes) I've presented are backed up by respected encyclopedias or published peer reviewed research.TipPt (talk) 14:48, 20 September 2008 (UTC)

Please note that the meatal stenosis article finding 9-10% incidence was a review of the literature, not a meta analysis (as I stated above)[2]TipPt (talk) 14:48, 20 September 2008 (UTC)

Female circumcision in hatnote

I agree with this edit: [3] which inserts "for the practice sometimes known as" before "female circumcision" in the hatnote, because "female circumcision" is not a NPOV term, i.e. it's rejected by some POVs. OK, maybe all possible terms are rejected by some POV or other, but some terms may be more NPOV than others, and inserting "sometimes known as" makes it NPOV in my opinion: it's not disputed that the term is sometimes used. I know there's been previous discussion of this, but I can't find it. ☺ Coppertwig (talk) 14:33, 21 September 2008 (UTC)

No consensus for this obvious POV change. "Female circumcision" is as neutral a term as "male circumcision." Attempts to direct the reader to immediately believe that female circumcision is somehow "not circumcision" (such as this, and the disputed title of this article) are related to pro-male circumcision and anti-female circumcision activism and POV, contradict reliable sources[4], and are therefore unwelcome in this encyclopedia. See also [5]. Blackworm (talk) 19:13, 21 September 2008 (UTC)

How about "see also female genital cutting" in the hatnote? (Or "see also female circumcision (female genital cutting)". We need to avoid implying that the term "female circumcision" is incorrect, and we also need to avoid implying that it's correct: either implication would be un-NPOV. The sources collectively don't treat male and female circumcision equally: "circumcision" is commonly used for the male, but other terms are frequently used in the female case. ☺ Coppertwig (talk) 19:38, 21 September 2008 (UTC)

No, we do not need to avoid implying that it is correct. It is used in reliable sources. The only reason "other terms are frequently used in the female case" is because of pro-male circumcision and anti-female circumcision advocacy, dating back only about 30 years at most. I do not support Wikipedia adopting activists' terminology over lexicographical and professional sources. "Circumcision" is not "commonly used for the male" -- it is "commonly performed on males." "Male circumcision" itself is a euphemism for "cutting the foreskin off the penis," and yet we don't call this article "Cutting the Foreskin Off the Penis - Sometimes Known as Male Circumcision." Blackworm (talk) 19:56, 21 September 2008 (UTC)

High quality external links

We've been restricting the external links to only the highest quality ones, and keeping a balance between pro and con, per NPOV. Low quality personal websites are a dime a dozen, please don't add them. Jayjg ^(talk) 00:22, 18 September 2008 (UTC)

This is an important website and it is not low quality. The website is based on a very important published study by O 'hara which can be seen here. If there are more anti-circ websites than there are pro-circ websites on the internet then we should reflect that. And anyway i already said you can add another if you want - oh and who is "we" - you and your pro-circ gang? Tremello22 (talk) 12:46, 18 September 2008 (UTC)

The study may be interesting, though it appears highly subjective, but the website is low quality. Also, Comment on content, not on the contributor. Don't violate WP:CIVIL again. Jayjg ^(talk) 23:22, 18 September 2008 (UTC)

It isn't clear that info presented on the site is based on O'Hara and O'Hara. Also, the site in question contains an abundance of advertisements. I propose that we remove the following links based on the quality of the information conveyed:

Sex as Nature Intended It - see above thread.
Visualisation of amount of skin removed - seems like an arbitrary categorization of adult circumcision "styles". Little educational information is provided.
Jewish Circumcision – Brit Milah - most of the claims (about pain, in particular) are unsubstantiated.

The other links present information with an obvious bias, but at least they are supported (mostly) by reliable sources. AlphaEta 00:45, 19 September 2008 (UTC)

Makes sense to me. Jayjg ^(talk) 00:48, 19 September 2008 (UTC)

I still think that it warrants inclusion. There is only advertisements because the website and the book are about the same thing. It is a good circumcision opposition site which looks at the sexual effects of circumcision in some detail - the other sites do not do this. If we are going to make an issue over the valaidity of the claims then Schoen should go too. Again it is not about validity it is about sites promoting their point of view. The O hara site is most definitely the most informative site on the sexual effects of circumcision from an anti-circ point of view - therefore it should stay. I think we are being too pedantic about this anyway - the way it is now seems fine. Tremello22 (talk) 10:06, 19 September 2008 (UTC)

It's difficult to see how debating unsourced and improperly sourced external links is pedantry. If we start removing ELs because they promote a point of view, I guess we should just remove ALL of them! If the site is blatantly pro- or anti-circ, it can stay, so long as the information it contains is verifiable, and the bias is clearly labelled in the Wikipedia article (as it currently is). CIRP, NOCIRC, DOC, Morris' site, and Shoen's site cite or post (with or without copyright permission?) sources when they make MOST of their arguments. The "sex as nature intended" site does NOT! Furthermore, it is the only of these sites which aims to sell the reader something for a profit. AlphaEta 13:37, 19 September 2008 (UTC)

I think you may have missed the fact that Edgar Schoen's site promotes his book too. It is on the front page linking to this page. As far as I am aware circumcision promotion is a minority view. In countries where circumcision isn't done there isn't really any circumcision promotion because it is only Jews and Muslims get it done and they don't need to promote it. Edgar Schoen makes a living out of it and also is Jewish. So according to NPOV policy WP:UNDUE then maybe there needn't be symmetry. The Sexasnatureintendedit site is based on this published study. Everything that is said is demonstrated via video and pictures and is fairly self-explanatory. So I don't think that is even an issue. Anyway this isn't about validity this is about circumcision opposition and O Hara is major circumcision opponent. You could find non-sourced material on each of the sites but that is to be expected. Each site has a particular point of view because they are under the heading " Circumcision opposition" or "Circumcision promotion" so there is no point debating if there is a bias because there obviously is. I still think it should be included. Tremello22 (talk) 14:28, 19 September 2008 (UTC)

You are correct, I did miss the fact that Schoen is peddling a book as well. The sales pitch is clearly less pervasive, as, contrary to the "sex as nature intended" site, Schoen's site is not comprised primarily of book excerpts, but lets focus on overall link quality first. The principal issue is that each EL should contain educational content that is supported by reliable information. Again, it's possibly an oversight on my part, but I don't see material on the "as nature intended" website that is derived from O'Hara and O'Hara. The presentation of the links (NOCIRC, DOC, CIRP, Morris and Schoen) appear to be compliant with the undue policy for ELs, but maybe I'm missing something. AlphaEta 15:08, 19 September 2008 (UTC)

To be honest I don't see why people are trying to exclude this site. If I and other people think it is important on this side of the debate then our view should carry. I haven't complained about the quality of the Jewish site that was recently added that gives some random rabbi's views on circumcision, have I? i have addressed the symmetry issue above. It is not that important and if you feel that worried about it - add another link. You will find it hard too though as circumcision advocacy isn't as popular as circumcision opposition. Tremello22 (talk) 09:13, 23 September 2008 (UTC)

Nothing in Wikipedia's policies supports the notion that external links can be selected on the basis of whether editors on one side of the debate happen to like them. Instead, they should be chosen on the basis of whether the content is high-quality, and should be reasonably symmetrical. For example: are they well-referenced? Are they notable? Or are they primarily an advertising vehicle? Jakew (talk) 12:49, 23 September 2008 (UTC)

Again, the big problem is that there's no obvious source for the info posted on this particular EL. AlphaEta 13:57, 23 September 2008 (UTC)

Problematic paragraph in 'complications'

The following paragraph, from 'Complications from circumcision', is problematic:

An Australian study in 1970 entitled Circumcision - a continuing enigma[ref] found that 9.5 per cent of patients had repeated circumcisions for inadequately performed initial operations. A year after this study was published, the Australian Paediatric Association announced it's first official recommendation on circumcision. It recommended newborn babies not be circumcised.[ref]

The first problem is that the first sentence is misleading. It states that "9.5 per cent of patients had repeated circumcisions". The authors did not make this assertion, however. The figure reflects the reason for the procedure in a series of consecutive circumcisions - in 9.5% of cases, it was to revise an earlier circumcision. It would thus be more accurate to say "9.5 percent of the circumcisions performed were revision procedures", or as the source puts it, "Recircumcisions constituted 19 (9.5%) of the 200 operations.". To establish the percentage of patients who required revisions, it would be necessary to identify a group of patients who had undergone initial circumcision, and monitor what proportion of those were re-circumcised. Such studies do exist. For example, in a study of 66,519 boys, Cathcart et al. report a revision rate of 0.5% within 6 months ("Trends in paediatric circumcision and its complications in England between 1997 and 2003". Br J Surg 2006;93:885-90.)

The second problem lies in the second and third sentences. What is the relevance of these sentences to complications? It might conceivably be relevant in the section entitled 'Policies of various national medical associations', though even that is questionable (a 1971 policy statement - actually a single sentence - is somewhat outdated). However, there is no obvious relevance to complications, and only a tangential relationship to Leitch's paper (the follow-up letter from Belmaine briefly refers to Leitch's paper, but does not suggest that it influenced the original statement).

Unfortunately I have no idea of the purpose of this paragraph, so it is difficult to see how it can be fixed. Jakew (talk) 18:40, 22 September 2008 (UTC)

If we can find a review study about re-circumcision rate, we could replace that paragraph with a single sentence based on that study (if there's enough room for it in this article at all).☺ Coppertwig (talk) 23:36, 22 September 2008 (UTC)

The first point is probably a good one. If you have more (better sources?) then add them too. As for the second you can take it out then - I only added the bit about it because I thought it was interesting. I realise it probably doesn't belong there as there is limited space in this article. Tremello22 (talk) 10:09, 23 September 2008 (UTC)

I've removed the paragraph in question, and have added Cathcart to the following paragraph (since recircumcision is closely related to the removal of too little skin). I think this could probably be condensed further, perhaps just noting that it can occur rather than giving in-depth information about reported rates. Medical analysis of circumcision is a more suitable place for detailed information. Jakew (talk) 11:03, 23 September 2008 (UTC)

Paring back the WHO info, ROUND II

(I'm bringing this back from Archive 43. Not because I think my revision is great, but because discussion stalled on what was a good move towards consensus. I agree with Tremello that the WHO info in the HIV section has become a bit bloated. This was my recommendation for streamlining the section.)

Proposed re-write of the HIV section (refs in italics):

While more than 40 epidemiological studies have suggested that circumcision provides a protective effect for men against HIV infection,(Szabo & Short, 2000) early meta-analyses of observational and epidemiological data differed as to whether there was sufficient evidence for an intervention effect of circumcision against HIV.(Weiss, et al., 2000)(Siegfried, et al. Cochrane review) However, randomized controlled trials conducted in South Africa,(Auvert, et al., 2005) Kenya(Bailey, et al., 2007) and Uganda(Gray, et al., 2007) found that male circumcision reduced vaginal-to-penile transmission of HIV by 60 percent, 53 percent, and 51 percent, respectively. All three trials were stopped early by their monitoring boards on ethical grounds, because those in the circumcised group had a lower rate of HIV contraction than the intact group.(Bailey, et al., 2007) A meta-analysis of the African randomised controlled trials and other observational studies confirmed that using circumcision as a means to reduce HIV infection would, on a national level, require consistently safe sexual practices to maintain the protective benefit. According to this particular meta-analysis, 72 circumcisions would need to be performed to prevent 1 HIV infection.(Mills et al., 2008)

As a result these findings, WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that male circumcision is an efficacious intervention for HIV prevention when done by well trained medical professionals and under conditions of informed consent.("New Data on Male Circumcision and HIV Prevention... WHO)("WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention... WHO)("Male circumcision: Global trends and determinants of prevalence... WHO/UNAIDS) Both the WHO and CDC indicate that it may not reduce HIV transmission from men to women, and that data is lacking for the transmission rate of men who engage in anal sex with either a female or male partner, as either the insertive or receptive partner.("New Data on Male Circumcision ... WHO)("Male Circumcision and Risk for HIV Transmission and Other Health Conditions... CDC) The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should never replace known methods of HIV prevention.("WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention... WHO)

Other reports have indicated that circumcision has little to no effect on HIV transmission.(Carael, et al., 1988)(Grosskurth, et al., 1995)(Barongo, et al., 1992) Furthermore, some have challenged the validity of the African randomized controlled trials, prompting a number of researchers to question the effectiveness of circumcision as an HIV prevention strategy.(Mills & Siegfried, 2006)(Dowsett, et al., 2007)

Thoughts? Criticisms? Grievances? Accusations of pro- or anti-circumcision bias (/sarcasm)? Overt or subtle insults? AlphaEta 00:44, 7 September 2008 (UTC)

If you keep the introduction that I added then yes I think that is a big improvement. Nice work. Tremello22 (talk) 02:14, 7 September 2008 (UTC)

I like it; but going forward and working and looking towards overall improvements to the article, the problems I see on it are that the WHO/UNIADS statement was very specifically about:

young adults and adolescents
countries with high prevalence and generalized heterosexual HIV epidemics that currently have low rates of male circumcision - in other words, it was targeted very much at sub-Saharan Africa where a combination of resources and climate make wetness (genital hygiene) a general problem

If we can work that in, then we also:

explain why WHO / UNAIDS justifiably ignored the evidence that circumcision would have no impact in countries / regions where other factors prevail
explain why it isn't a worldwide recommendation
make it clear that it is a very different set of ethical arguments to those in the infant circumcision debate Finn (talk) 08:31, 7 September 2008 (UTC)

It sounds well-written and well-organized: it flows much more smoothly than the current version. Thank you, AlphaEta! ☺ The only piece of information I notice that you've added or removed is that you've removed the mention of keratin as a hypothesis as to the reason for circumcision's preventive effect. I oppose the removal of this information, as I think it adds significant meaning to what is otherwise just statistics as numbers without explanation. I've changed the keratin sentence as I had suggested at the bottom of the thread Talk:Circumcision/Archive 42#HIV. I suggest that this modified sentence be retained; I suggest adding it as the last sentence of the first paragraph of your draft. Coppertwig (talk) 12:36, 7 September 2008 (UTC)

Except that Szabo's keratinised glans theory is hotly disputed; so if we keep that section, then it needs to be rewritten to make it reflect that and cite the opposing views (as acknowledged in Szabo's very own paper). The test for me is whether reference to it actually helps understading. I would suggest it doesn't, so my vote says we just get rid of it. Finn (talk) 15:46, 7 September 2008 (UTC)

In fact, do I read that right and is Szabo & Short being used as a direct replacement for the McCoombe paper? If so, that would be a mistake; because one speculates about keratinised glans and the other speculates about poorly keratinised glans - which just goes to show that whatever process is going on just isn't understood at all - something happens on the penis, but we don't actually know exactly what it is - and that we would be better off without it, before we sink in a sea of conflicting citations. Finn (talk) 16:20, 7 September 2008 (UTC)

I agree with Finn. All of the mechanistic explanations are speculative at this point. This info would be more suitable in the "Medical aspects" sub-article, or in a new HIV/circ sub-article. AlphaEta 18:08, 7 September 2008 (UTC)

I thought both papers were saying something similar: that the inner surface of the foreskin lacks keratin. I don't have time to re-check at the moment. We could keep the statement, and add a brief statement like "though others dispute this" or whatever, for NPOV. Good to describe the controversy. We don't delete stuff just because there's controversy. Are there any other theories as to why circumcision might prevent HIV? ☺ Coppertwig (talk) 22:11, 7 September 2008 (UTC)

I don't have time to re-read the sources right now, but assuming I previously cited them correctly, one is saying the inner surface of the foreskin has only a thin keratin layer, the other is saying it has no keratin layer: that's essentially the same thing, it lacks the thick keratin layer of most normal skin including the glans, and thus is hypothesized as a viral entry point. ☺ Coppertwig (talk) 22:17, 7 September 2008 (UTC)

I recently read that removal of preputal Langerhans cells may play a more important role than keratinization. Give me a little while to dig up the source. Of course, these two concepts aren't mutually exclusive, but it seems like most of the explanations are guesswork at this point. AlphaEta 22:23, 7 September 2008 (UTC)

I agree with Coppertwig. We shouldn't relegate controversies to subarticles. What a refreshing change! Blackworm (talk) 23:39, 7 September 2008 (UTC)

Dealing with it in its proper context isn't relegation - it is giving it the attention it deserves and in a context in which it makes sense.Finn (talk) 07:38, 8 September 2008 (UTC)

Look, here is an example of the real importance of the Langerhans' cells debate: Observational studies in a clinic in South Africa shows a 50% tendency to moisture beneath the foreskin in uncircumcised men. Do the same study in a similar clinic in an ethically varied part of London and there is an overall 7% tendency to moisture beneath the foreskin (but look at the detail of the study and you see that it differs dramatically along ethnic and cultural lines and that the tendency is down to 3% amongst men of African descent). Moisture is important because, above a certain level, it creates an environment in which HIV can survive outside of the body (HIV dies instantly when exposed to the air, but not when it is trapped in a moist airtight ridge below the glans with loads of immune system cells to lock onto and do battle with). Model the theory at 7% and , from an HIV prevention point of view, it is a very slight advantage to being uncircumcised. Model the theory at 50% and, from an HIV prevention point of view, it is a distinct advantage to circumcised. The research is mentioned in the article; but not in the context of the Langerhans' cells debate and only (until I reworded it) to try to make a banal point about uncircumcised men being dirty because they don't wash as frequently as circumcised men. What the series of research papers said, as an aside from the main objective of understanding HIV transmission and the function of Langerhans' cells, was that the sample of circumcised men were slightly more likely to wash their penis more than once a day and that in temperate climates – and temperate climates only – washing your genitals more than once a day left you more vulnerable to diseases (because it leaves you short of the Langerhans' cells that will normally afford a degree of protection from diseases other than HIV, but which HIV can piggyback). In other words, the citation was used to make a point that the research wasn't even making and to draw original conclusions that was potentially totally contrary to that of the research. That is very far from being the only example tortured use of HIV citations in this article that both Schoen and Boyle would be proud of.Finn (talk) 08:41, 8 September 2008 (UTC)

I've put this version in for now as it is a lot better and more concise than the previous version. Tremello22 (talk) 14:24, 23 September 2008 (UTC)

Is this relevant?

This was recently tucked into the HIV section:

According to Valiere Alcena [4], it was he who first hypothesised that low rates of circumcision in Africa were partly responsible for the continent's high rate of HIV infection.[102] He did this via a letter to the New York State Journal of Medicine in August 1986.[103] He also alleges that the late Aaron J. Fink stole his idea when Fink published a letter to the New England Journal of Medicine entitled A possible explanation for heterosexual male infection with AIDS, in October 1986.[104]

Any objections to moving this to one of the subarticles? I guess it's interesting, but is it notable enough for the main circ article? More importantly, if these people are still alive, are the refs up to par? Thoughts? Complaints? Accusations of pro- or anti-circ bias? AlphaEta 19:22, 4 September 2008 (UTC)

Who added it? I don't think removing the arguments as to who was responsible for the hypothesis that circumcision reduces HIV risk is a problem, as long as the discussions (and supporting evidence to the discussion) remains. However, I agree with you that it would be an appropriate addition to the Medical Effects sub-article. -- Avi (talk) 19:37, 4 September 2008 (UTC)

I added it. I think it is a good intro to the HIV section because it marks the beginning of the link between the 2 things. What links are not up to par? How can it be pro-circ or anti-circ , it is what happened.Tremello22 (talk) 21:12, 6 September 2008 (UTC)

Sorry, the pro- anti-circ thing was an attempt at sarcasm. It never plays well on the internet. Also, it wasn't directed at any particular editor. AlphaEta 22:07, 6 September 2008 (UTC)

I also think that the views of the WHO which currently take up 3 quite big paragraphs is excessive. It maybe violates some kind of NPOV policy. 1 paragraph would be sufficient. Tremello22 (talk) 21:58, 6 September 2008 (UTC)

I'm all for making things more concise. What did you have in mind? AlphaEta 23:02, 6 September 2008 (UTC)

The problem I have with the WHO is that they aren't the original source. So they are just providing conclusions and acting on those conclusions, in doing so, implying a result to the trials that might differ from the conclusions other readers would draw. I was just thinking of the wiki policy "let the reader decide". That is all. Tremello22 (talk) 23:39, 6 September 2008 (UTC)

Looking it over, the WHO info may be a bit excessive! AlphaEta 23:49, 6 September 2008 (UTC)

Intro to HIV section

Why was the intro taken out coppertwig? What exactly do you object to? How does it go off on a tangent? Is it not important when and who originated this theory? I would say it is very important and should be included. Tremello22 (talk) 16:29, 7 September 2008 (UTC)

I apologize: perhaps I should not have deleted this without discussing it first. If this paragraph has been discussed previously on this talk page, please put a link to it. I've self-reverted and restored the paragraph because of your message, though I still oppose its inclusion as currently formulated.

"According to Valiere Alcena [6], it was he who first hypothesised that low rates of circumcision in Africa were partly responsible for the continent's high rate of HIV infection.^[1] He did this via a letter to the New York State Journal of Medicine in August 1986.^[2] He also alleges that the late Aaron J. Fink stole his idea when Fink published a letter to the New England Journal of Medicine entitled A possible explanation for heterosexual male infection with AIDS, in October 1986."^[3]

I don't oppose the inclusion of this information somewhere in this article or in a subarticle. It might be better to put most of it in a subarticle or footnote, to save space. The way the paragraph is now, I think it loses the reader's attention and doesn't give the reader a clear idea of what this section of this article is supposed to be about. This article is supposed to be about circumcision, not about who published what article in a scientific journal when.

I suggest replacing this paragraph with a single sentence as follows, and putting the rest of the information in a footnote: "A hypothesis that low rates of circumcision in Africa were partly responsible for the continent's high rate of HIV infection was proposed in 1986." As long as a footnote is given explaining who claims to have proposed it, I don't think this counts as weasel words.

There are problems with this paragraph. Please propose new material on the talk page first so that problems can be worked out before putting it into the article. The Alcena reference needs to be formatted correctly. The Alcena reference doesn't seem to support the statement: I see nothing about HIV on that web page. The Alcena reference may or may not count as a reliable source: it seems to be self-published: we would have to discuss this.

Thanks for contributing interesting material to the article, though, and I apologize for just deleting it rather than moving it to the talk page, moving it to a subarticle or modifying it; I'm glad you were watching. ☺ Coppertwig (talk) 12:33, 8 September 2008 (UTC)

The Alcena link above is his own personal webpage. This is just to show who he is. The other references are all published in medical journals so there shouldn't be a question over their reliability. here is where he first proposed the hypothesis that HIV infection had something to do with Africa's high HIV rates in the new york state journal of medicine in August '86. Here is Aaron J. Fink's letter in October '86. Here is a letter Alcena wrote in response to the South Africa randomised control trial in PLOS medicine journal in 2006, 20 years after his original idea. I think it is important for the reader to understand where this idea originated. Tremello22 (talk) 10:19, 10 September 2008 (UTC)

I agree that this is excessive detail for this article. It doesn't tell the reader anything about circumcision. Instead, it tells the reader about a dispute about who first published a hypothesis. In the detailed article, it seems reasonable to discuss this as part of discussion of the history of circumcision & HIV research, but I can't really see why this is important. Given that more than 500 articles have been published about circumcision and HIV, I think we need to be a little more selective. Jakew (talk) 18:49, 22 September 2008 (UTC)

I disagree. I am going to re-add it. If anything should stay it is how this theory started. —Preceding unsigned comment added by Tremello22 (talk • contribs)

Questionable assertion, for two reasons. First, we can't really say that "it is how this theory started" without carefully checking the references to every study and verifying that we can trace a path back to the supposed origin. There may in fact be multiple origins: it is perfectly possible that Fink and Alcena generated the hypothesis independently, and for that matter it is equally possible that the investigators who performed later studies were unaware of either. All we can say is that X was the first time that circumcision and HIV were linked in print (and the possibility remains that some as-yet undiscovered paper may have been published previously).

Second, assuming that there is a single origin, if the history of HIV/circumcision research should be discussed, then why only the origin of the hypothesis? Surely, if the history is to be considered, then the first ecological study is just as historic, as is the first case-control study, the first cohort study, the first meta-analysis? And why should an allegation that someone "stole" an idea get half (one of two sentences) of the discussion of the history? As currently presented, the article implies that Alcena had an idea in 1986, Fink allegedly stole it, and then - boom!! - three randomised controlled trials were published. To put it mildly, that's somewhat misleading. Jakew (talk) 11:33, 23 September 2008 (UTC)

Well because the journal Alcena printed his letter in wouldn't have accepted it otherwise. So I think we can assume that he was the first to do it - to have printed it anyway. Whether Fink knew of Alcena's study I don't know - Alcena seems to think so. That allegation by Alcena can be removed if you want. If you want to add a sentence or 2 of what led up to the randomized control trials then fine - i was about to do it but have not got round to it. AlphaEta revised this section anyway which can be seen here in a discussion that was recently archived. The studies in between were either found to be flawed/biased in methodology or contradicted each other anyway according to Van Howe's survey study - which is partly why the RCT's were conducted. Tremello22 (talk) 12:14, 23 September 2008 (UTC)

I'm afraid it's unclear what you mean by "Well because the journal Alcena printed his letter in wouldn't have accepted it otherwise". I think you mean that PLos Medicine wouldn't have published Alcena's 2006 letter unless he actually was the first, but I think you're placing a lot of faith in their review process. Even if we assume that PLoS use a rigorous peer-review process for letters, it would be asking a lot of the reviewers to confirm that none of the millions of journal articles published before Alcena's 1986 letter mentioned such a hypothesis!

It seems unwise to state Van Howe's review as fact, since it was itself the subject of criticism; see Moses et al and O'Farrell and Egger, for example. Later meta-analyses differed somewhat in their assessment of the value of observational data (see refs 111 and 112 in the article). If you read the 'Introduction' to Auvert et al., you'll see that both of these refs (12 [Weiss 2000] and 13 [Siegfried 2005]) are cited as background information. In particular ref 13 is cited in support of the need for experimental (ie., RCT) data.

Regardless, even if the observational studies were flawed/biased/etc., that seems a poor reason to overlook their existence in a discussion of the history of this research. This brings me back to my main point: if we're to discuss history of circumcision and HIV at all, then we need to do so properly. But to do that properly and neutrally would require several paragraphs, and given the limited space available here it seems far more appropriate to do so in the detailed article. Jakew (talk) 13:19, 23 September 2008 (UTC)

I've shortened the intro section and followed Alpha Eta's re-write on the archived talk page. Tremello22 (talk) 14:19, 23 September 2008 (UTC)

Thank you. I think the current version is reasonable: "The origin of the theory that circumcision can lower the risk of a man contracting HIV is disputed.^[4]^[5]^[6] " This acts as a brief introduction to the idea of the whole section. I still think it puts too much emphasis on that dispute here (where the reader may be more interested in the theory and results than in who originated them) but only two words, so not too bad. I think it may be better to mention the RCTs earlier, perhaps as early as the first sentence, with the current first sentence perhaps becoming the second sentence; the RCT results are the most important and interesting information so they should be presented where the reader is most likely to notice them. It would also make more sense that way: the current first sentence talks as if the reader has already heard of the theory (i.e. "the theory", as opposed to "a theory") which doesn't seem the right narrative flow to me. ☺ Coppertwig (talk) 12:51, 25 September 2008 (UTC)

That is the point - the theory came first - then the study. I have to disagree with you about the order. I think chronologically is best. Tremello22 (talk) 17:21, 25 September 2008 (UTC)

I agree with Coppertwig. The very first question that the reader is likely to ask after (s)he sees the "HIV" heading is, "what the *!*& does this have to do with circumcision", or to put it another way, "what is the relationship between circumcision and HIV". So let's start with that. The background to the RCTs, if this information belongs at all, should be discussed afterwards. Jakew (talk) 18:06, 25 September 2008 (UTC)

Jakew, re:your comment "The very first question that the reader is likely to ask after (s)he sees the "HIV" heading is, "what the *!*& does this have to do with circumcision" Can I ask which sentence it is you are referring to? If you are referring to the half of a line that mentions the origin of the theory then I think you are wrong to assume the reader thinks that, for one - he would have read it before he would have had time to think that. It seems to me that introducing the theory is the logical way to structure a topic about which the majority, or at least some of the readers are unaware of. Also ask yourself, what is the heading of the topic? - is it "circumcision lowers the risk of contracting HIV" or is it "how circumcision relates to HIV"(i.e medical analysis in relation to circumcision) It is the second obviously. Now for all the reader knows, circumcision could raise the risk. I personally think taking only a few lines to explain the back story doesn't make the reader wait too long before he gets to the (as you seem to think) important bits. It also means that they understand the whole picture - why the trials needed to be conducted etc. Tremello22 (talk) 20:29, 26 September 2008 (UTC)

On meta-analyses

In the 2nd paragraph of 'complications':

One meta-analysis found hemorrhage and infection to be the most common complications of circumcision, occurring at a rate of about 2%.[ref]

The reference cited is Singh-Grewal 2005. This sentence is misleading for several reasons. Firstly, as written, the sentence implies that the authors performed a meta-analysis of complication rates. In fact, their meta-analysis was of the association between UTI and circumcision. Their study did not "confirm" that haemorrhage and infection were the most common complications, they merely stated it (in the text, they cited Williams & Kapila's review in support of the statement). Nor did they confirm the rate. In fact, the authors explicitly stated that the rate used was an estimate: "we have used a conservative estimate of circumcision complications of 2%". And in an accompanying editorial, they received criticism for using this figure: "The 2% complication rate mentioned is high. In a 1999 report,[6] the American Academy of Pediatrics stated that complications of newborn circumcision are "rare and usually minor" and that complications occur at a rate of 0.2% to 0.6%—3 to 10 times lower than the rate cited by Singh-Grewal et al." (Schoen EJ. Circumcision for preventing urinary tract infections in boys: North American view. Arch Dis Child. 2005 Aug;90(8):772-3)

So, to be more accurate, we'd need to say something like: "In one study, the authors used an estimate of the complication rate of 2%". When put like this, though, it is questionable whether the material belongs in the article. I mean, if it had been a meta-analysis then it would have some value, but an estimate barely seems notable, especially since it is in turn based upon the reviews (W&K and Kaplan) that are already cited.

A similar problem exists in 'HIV':

A meta-analysis of the African randomised controlled trials and other observational studies confirmed that using circumcision as a means to reduce HIV infection would, on a national level, require consistently safe sexual practices to maintain the protective benefit. According to this particular meta-analysis, 72 circumcisions would need to be performed to prevent 1 HIV infection.

The second sentence is ok, but the first is erroneous. A meta-analysis can estimate a summary NNT, but cannot confirm that consistently safe practices would be required. A mathematical model could be used to predict the assertion in the first sentence, but in this case it appears to be the authors' conclusion. Additionally, there appears to be an error: the article says "A meta-analysis of [...] and other observational studies", but the abstract indicates that only RCTs were included: "We conducted a systematic review of medical literature, and included any RCTs assessing male circumcision to prevent heterosexually acquired HIV infection among males. [...] We identified three RCTs that met our inclusion criteria, involving a total of 11 050 men." Finally, I cannot understand why we mention the meta-analysis but omit the result of the meta-analysis - a relative risk of 0.44 (95% CI 0.33-0.60). I included a summary of this, and two other meta-analyses including RCT data, here.

I realise that this may seem rather pedantic, but the term "meta-analysis" has a very precise meaning in epidemiology, and if we use it incorrectly it reflects poorly on the article. Jakew (talk) 14:12, 23 September 2008 (UTC)

Not everyone reading this will understand statistical terms like relative risk and confidence interval. How about "the meta-analysis found that circumcision reduces the overall risk of contracting HIV by 0.44%." Tremello22 (talk) 14:59, 23 September 2008 (UTC)

I think that must be a typo! A relative risk of 0.44 means that the risk among circumcised men is 44% of (or 0.44 times) the risk among uncircumcised men. Jakew (talk) 15:06, 23 September 2008 (UTC)

No not a typo , just me not being acquainted with relative risk. But I am now, you just divide the amount of men infected in the uncirc group by the ones in the circ group, right? However articles such as this which state "circumcision can reduce the transmission of HIV in heterosexual men by as much as 65 percent." is kind of misleading and deliberately sensationalising the results. If you take the results of the Ugandan trial:

22 of the 964 retained in the circumcised group got HIV. Which gives a risk of 22/964 X 100 = 2.28 (infected with HIV per 100 people)
45 of the 980 retained in the uncircumcised group got HIV. Which gives a risk of 45/980 X 100 = 4.59 (infected with HIV per 100 people)
4.59%-2.28%= X 100 = 2.31 <----

So the chances of African men contracting HIV has only increased by ~2%. But of course that wouldn't be as impressive a way of presenting the findings. Also there have been many criticisms of the trials; I'm sure if confounding factors were limited and some of the flawed methodologies were rectified then that 2% could easily be accounted for.

You mention you have a problem with the author's conclusion yet you don't seem to have a problem with the WHO giving their conclusion? Either way I am sure you will find the best way to put a positive spin on it.Tremello22 (talk) 19:42, 23 September 2008 (UTC)

I've warned you about this before, Tremello22. Comment on content, not on the contributor. Jayjg ^(talk) 00:12, 24 September 2008 (UTC)

Tremollo, that is the difference between absolute and relative risk, and is one of the fundamental problems of any statistical study. In this particular study, on an absolute percentage basis, the difference is 2.31%. However, uncircumcised men were still more than twice as likely to get HIV than circumcised ones. The incidence of HIV worldwide is still very low, thank G-d. There could be many other factors that contribute to why more than 95% of the population does not contract HIV. From a frequentist's perspective, as most people are, the only way to compare the two groups is to compare their relative rates, which is why the 44% (or 2.27 multiplier) is accurate. If you were subscribed to the Bayesian school of thought, we would need some more data, I reckon.

Just to compare, the Hemorrhage bullet in the "immediate complications" section of Medical analysis of circumcision brings as its source Hiss and Horowitz (2000) which describes one case of hemorrhage. Which, out of the estimated 1.2 million circumcisions in the US (as per that very paper) is a rate of .000083%. Yet that was significant enough to get its own section. The 2.31% savings in HIV is over 270,000 times as significant, if you would like to look at it that way. -- Avi (talk) 01:42, 24 September 2008 (UTC)

Small²

I have no problems making quotes even smaller, Tremollo. However, you do know that the refs are already in smaller fonts due to the{{reflist}} template, and also, Firefox and other browsers render the refs as a scrollable list, so space is not an issue in the refs. -- Avi (talk) 18:57, 25 September 2008 (UTC)

no I didn't know that. Tremello22 (talk) 21:47, 25 September 2008 (UTC)

According to that page the reflist|colwidth code "will allow the browser to automatically choose the number of columns based on the width of the web browser. Choose a column width that is appropriate for the average width of the references on the page." It doesn't say anything about scrollable and it is not a scrollable list for me and I am using firefox. Also the quotes are bigger for me if I don't use the "small" code. Tremello22 (talk) 19:54, 26 September 2008 (UTC)

Same here, Tremello. My firefox doesn't default to a scrollable ref list, and the text size is not automatically reduced when quotes are compiled using the reflist format. I prefer using small font for quotations, but I guess it could negatively affect the browsing experience of others. AlphaEta 21:10, 26 September 2008 (UTC)

Then maybe something is different by me, but both at work and at home, I get the scrollable refs. -- Avi (talk) 21:39, 26 September 2008 (UTC)

Lead

Recent edits have added some problematic material to the lead. This addition is problematic from an NPOV perspective. In the previous version, we include four claims by proponents and four claims by opponents. Depending on how one counts claims, the changes result in dedicating either six or seven claims to opponents.

In one of the edit summaries for these changes, the reason is given that the length of the text differs. To accomodate this concern, we need to change the length of the text, not the number of arguments. We could dedicate six claims to each, but why not seven or eight? At some point, we have to say enough, and four seems a good choice if we're to keep the lead reasonably short.

I've therefore edited each sentence, to try to make them approximately equal in length. (Clarification: I haven't actually edited the sentences in the article yet, but have edited the versions presented here for discussion.)

Opponents of circumcision claim that it violates the bodily rights of the individual, is medically unnecessary, has an adverse effect upon sexual pleasure and performance, and is a practice defended by myths. [208 characters, 32 words]

Advocates for circumcision claim that it provides important health benefits which outweigh the risks, has no substantial effects on sexual function, has a low complication rate, and is best performed on neonates. [212 characters, 32 words]

Can anyone improve on this? Jakew (talk) 12:23, 26 September 2008 (UTC) (clarification added 13:06, 26 September 2008 (UTC))

I have restored this to beginning of the para. "There is scientific evidence supporting both sides of the circumcision controversy." Garycompugeek (talk) 13:50, 26 September 2008 (UTC)

I feel like word count is irrelevant, so I'll stick with number of points made to support each side, and their relative gravity.

The risk of complications should be included in the opposition sentence. It should displace the "myths" clause, which is a minor argument that is infrequently used. The following sentence includes 4 arguments that support the opponent's viewpoint.

Opponents of circumcision claim that it violates the bodily rights of the individual, is medically unnecessary, has an adverse effect upon sexual pleasure and performance, and may incur post-procedural complications.

Schoen's claim that circumcision is best perforned during the neonatal period is also a minority viewpoint, and should be removed. The claim that circumcision provides important health benefits which outweigh the risks is so inclusive that it I think it should allow the advocate's position to be supported by only 3 arguments and still balance the opponent's position.

Advocates for circumcision claim that it provides important health benefits which outweigh the risks, has no substantial effects on sexual function and has a low complication rate.

Finally, the newly-readded introductory sentence is redundant and confusing in its current form. It reads: There is scientific evidence supporting both sides of the circumcision controversy. At this point in the article/lede, it isn't obvious that a controversy exists, but we refer to the circumcision controversy as though it has already been defined. Part of the problem is that it isn't clear what the "advocates" and "opponents" listed in the subsequent sentences are advocating or opposing. Circumcision in general, or neonatal circumcision, specifically. Perhaps a minor re-wording of the introductory sentence would be helpful. AlphaEta 15:18, 26 September 2008 (UTC)

I disagree Alpha, however it is a matter of perspective. We state there is a controversy then illustrate it. The other way seems backwards to me. I also believe circumcision is largely defended by myths. Garycompugeek (talk) 15:42, 26 September 2008 (UTC)

I partly agree and partly disagree, AlphaEta.

On one hand, I agree with your argument that the number and nature of the points is more important than the exact word count (though, having said this, we don't want to dedicate vastly more text to one side than the other).

On the other hand, I agree that the "myths" argument is infrequently used in its exact form, but I think that opponents frequently dispute the reasons that are often given for circumcision, and from their point of view, these reasons may seem little different from myths. Since the purpose of this paragraph is to illustrate the debate in general, the "myths" argument may thus be more representative than it would seem at first.

I would also question your classification of Schoen's claim re the neonatal period as a minority viewpoint. This argument appears quite regularly in pro-circumcision opinion pieces, and I'm not sure that it is a minority viewpoint in that context. As you note, there is some ambiguity over the nature of the controversy. If we consider voluntary adult circumcision (in HIV prevention, for example), then Schoen's argument is irrelevant, but so too is the "bodily rights" argument from the opponents. If we consider neonatal circumcision, then both arguments are relevant.

I agree with your comment about the sentence that has recently been added. In addition to your comments, I'd add that it has no apparent relationship to the text that follows. The sentence discusses evidence, whereas the following text discusses claims. Jakew (talk) 16:59, 26 September 2008 (UTC)

HIV section

The following sentences from the HIV section require further thought:

Since the idea was first mooted, over 40 epidemiological studies have been conducted to investigate the relationship between circumcision and HIV infection,[116] mostly in Africa.[117] The authors of meta-analyses performed on these studies reached differing conclusions. Two recommended against circumcision being used as a prevention method against HIV in Africa,[117][118] however another recommended it should be used.[119] Because of the questions over the reliability of previous studies, 3 randomized controlled trials were commissioned as a means to reduce the effect of any confounding factors.

Let me explain some of the problems:

There is a synthesis of two facts in the first sentence. "More than 40" comes from one source and "mostly in Africa" from another. Setting aside issues of OR, extrapolating from one sample to another is potentially problematic.
The next two sentences raise some interesting questions. These are:
- Why do we include Siegfried 2003, which wasn't a meta-analysis?
- Why do we exclude Moses et al 1999 and O'Farrell & Egger 1999, both of which contained results of meta-[re]analysis of data gathered by Van Howe?
- More generally, what are the inclusion criteria? This is an important because, since we enumerate the papers, we imply that exactly three papers of class X exist (compare "the solar system contains one gas giant, Jupiter" with "the solar system contains a gas giant, Jupiter" - the second does not imply that there is exactly one, and is hence more accurate).
- Since we're ignoring the results of meta-analysis, might it make more sense to introduce these papers as systematic reviews or even just "reviews"?
- Why do we say "recommended against circumcision being used as a prevention method against HIV in Africa", when the sources don't make that statement? For example, Siegfried et al don't mention Africa in their conclusions, and their conclusion is closer to an absence of a recommendation for rather than a recommendation against: "We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men". Would it not be better to remove the second of these two sentences, and add the refs to the end of the first?
- Similarly "recommended [circumcision] should be used [as a prevention method against HIV in Africa]" seems an imprecise summary of "consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised", which seems closer to a recommendation that we should think about it, rather than urging that it should be done.
The final sentence is unsourced, and seems to imply that the observational studies were problematic. But as Auvert et al explain, the main problem with the observational studies was simply that they were observational (as opposed to experimental): "All of these studies were based on observational data, and, in the absence of experimental studies, a causal relationship between MC and protection against HIV infection could not be determined [13]. Direct experimental evidence is needed to establish this relationship and, should a protective effect of MC be proven, to convince public health policy makers of the role of MC in reducing the spread of HIV [7,13,14]."[15] I'd therefore suggest something like: "Because experimental evidence was needed to establish a causal link..."

Jakew (talk) 12:12, 30 September 2008 (UTC) (updated 13:24, 30 September 2008 (UTC))

Good points. The problem is while editing it is hard to fit everything you want to say without it being too long. So Ive just left it as saying reviews of the studies reached differing conclusions on whether to use circ as prevention strategy. I've added the o farrell one but couldn't find Moses. Tremello22 (talk) 21:32, 30 September 2008 (UTC)

Lead again

There are some serious problems with material recently added to the lead:

"In most of Europe, both the rate and prevalence of circumcision is low;" - this is extrapolation beyond the sources.
"The concept of circumcision as a preventive, and then routine, procedure emerged in the mid-nineteenth century, in Britain." - according to Darby. Why do we favour Darby's chronology, as opposed to that of Gollaher, say, who begins with a Manhattan physician? It is extraordinarily non-neutral to assert one viewpoint as fact. Given that there are multiple viewpoints, it's best to leave such detail out of the lead.
"Circumcision was cited to prevent or cure such things as impotence, phimosis, sterility, priapism, masturbation, venereal disease, epilepsy, bed-wetting, night terrors, " precocious sexual unrest" and homosexuality." - what is the purpose of listing these claims, and why are these particular claims chosen? And why do they belong in the lead?
"Despite originating in Britain," - again, favouring Darby's chronology.
"the practice of routine infant circumcision (RIC) only lasted there from the 1870s to the 1940s and probably affected no more than a third of boys at its peak points;" - two problems: first, how can something be routine if it affected no more than a third of boys? This is a description of infant circumcision, not "routine" infant circumcision. Second, "probably" according to whom? If J. Random Author says that this is "probably" the case, then why is that opinion notable enough to be in the lead?
"it did though become more widespread among it's English speaking colonies, principally the USA, Australia and New Zealand and Canada.[11] In Australia the rate of RIC has fallen in recent years[12];" - again, incorrect use of terminology. Should be "infant circumcision", not "RIC".
"in the 1970's the rate was over 50% but since that time medical organisations have discouraged the practice" - this is redundant. We already quote the AMA's comments on policies of other medical organisations in the lead.
"and health insurance has ceased to cover the procedure[13]; consequently the rate has declined to less than 15%.[12]" - how do we know that one caused the other? We don't.
"Similarly in Canada, while the rate was higher than 50% in the 1970's, the rate has fallen to less than 15%[14] due to medical organisations finding no medical indication for neonatal circumcision.[15]" - same problem: causation is asserted but not verifiable, and more redundancy.
"The United States has also seen a decline in routine infant circumcision, although to a lesser degree." - unsupported by sources.
"One study reported that approximately 32% of American boys were circumcised in 1933, rising to a peak of 85% in 1965 and dropping to 77% in 1971.[16]" - no, Laumann's study was of adult men, and determined whether they were circumcised at the time of the study. It did not determine when they were circumcised, and would include men circumcised after the neonatal period.

As a general comment, this is far too much detail for the lead. Jakew (talk) 15:33, 2 October 2008 (UTC)

According to WP:LEAD:

The lead should be able to stand alone as a concise overview of the article. It should establish context, explain why the subject is interesting or notable, and summarize the most important points—including any notable controversies that may exist. The emphasis given to material in the lead should roughly reflect its importance to the topic according to reliable, published sources. While consideration should be given to creating interest in reading more of the article, the lead nonetheless should not "tease" the reader by hinting at—but not explaining—important facts that will appear later in the article. The lead should contain no more than four paragraphs, should be carefully sourced as appropriate, and should be written in a clear, accessible style to invite a reading of the full article.

At the moment it gives no explanation as to how routine infant circumcision came about. Nor does it explain the fact that circumcision is hardly ever practiced in Europe and that it is more common in the USA for non-religious reasons than anywhere else. I think what I wrote is a good starting point. There may be some minor issues but there is no need to just revert all of it. Just to go over some of your points:

It is true - it is low in most of Europe. Easily verifiable - here is one such ref: [16]
Ok, easily fixed
Why not? - seems OK to me.
easily fixed
my mistake, easily fixed
easily fixed
no it is not redundant see above quote from WP:LEAD, it should bea able to stand alone
I think we do know. I can easily find a ref that states the fact that it is what caused. what else would have cause it? A little common sense?
same as above.
no, the sources follow.
easily fixed.

Here is the new paragraph in question. how would you change it?

According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, of whom 68% are Muslim.^[8]
The prevalence of circumcision varies widely between cultures. Due to religious obligations, nearly all boys are circumcised in the Middle East.^[9] In most of Europe, both the rate and prevalence of circumcision is low; for example 2% of boys are circumcised in Scandinavia and currently less than 5% of boys are routinely circumcised in Britain.^[10]

The concept of circumcision as a preventive, and then routine, procedure emerged in the mid-nineteenth century, in Britain. Circumcision was cited to prevent or cure such things as impotence, phimosis, sterility, priapism, masturbation, venereal disease, epilepsy, bed-wetting, night terrors, " precocious sexual unrest" and homosexuality. Despite originating in Britain, the practice of routine infant circumcision (RIC) only lasted there from the 1870s to the 1940s and probably affected no more than a third of boys at its peak points; it did though become more widespread among it's English speaking colonies, principally the USA, Australia and New Zealand and Canada.^[11] In Australia the rate of RIC has fallen in recent years^[12]; in the 1970's the rate was over 50% but since that time medical organisations have discouraged the practice and health insurance has ceased to cover the procedure^[13]; consequently the rate has declined to less than 15%.^[12] Similarly in Canada, while the rate was higher than 50% in the 1970's, the rate has fallen to less than 15%^[14] due to medical organisations finding no medical indication for neonatal circumcision.^[15] The United States has also seen a decline in routine infant circumcision, although to a lesser degree. One study reported that approximately 32% of American boys were circumcised in 1933, rising to a peak of 85% in 1965 and dropping to 77% in 1971.^[16] Between 1980 and 1999 the rate remained stable within the 60% range.^[17] The most current study estimated the circumcision rate to be 56%.^[18]

Tremello22 (talk) 16:37, 2 October 2008 (UTC)

(indentation omitted due to complex formatting) I'm glad that you've quoted from WP:LEAD, Tremello. To summarise, the lead should serve as an overview of the article, but should also be concise, preferably no more than four paragraphs. These are obviously conflicting goals, and finding the right balance is difficult. At present, we currently have five paragraphs, which is really a little too much. If anything, we should try to make the lead more compact. It is questionable whether adding two paragraphs will improve the situation.

To address your responses in order:

The source you cite asserts that it is true, certainly. However, if you'll read the full text, the author doesn't provide or cite any evidence in support of this assertion. Thus it appears to be an opinion.
The question is how to fix it. Given the tight space constraints of the lead, we can't really say "According to X, blah blah. However, according to Y, blah blah". It's probably safe to say that historians agree that rates of circumcision began to increase in English-speaking countries in the 1800s, however.
"Why not?" is a poor rationale for including material in the lead.
Ok.
Please could you address my questions?
Ok
Yes, it is redundant. Please see the last-but-one paragraph of the lead, which states "...Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision..."
As a practical matter, It's almost impossible to know why trends occur. We might be able to find a source that speculates that one is the reason for the other, but would such speculation belong in the lead?
Same problem.
In that case this is synthesis.
Laumann could be represented correctly, in theory.

How would I change it? Well, frankly I'm not sure that we need to add this information to the lead. If anything should be added, it ought to be as brief as possible. Firstly I'd reorganise the material to place current estimates together, followed by material briefly discussing historical and more recent trends:

According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, of whom 68% are Muslim.^[19] The prevalence of circumcision varies widely between cultures. For example, estimates of the rate of circumcision among boys include nearly all in the Middle East^[9], 2% in Scandinavia and less than 5% in Britain.^[20] Recent estimates of the rate of infant circumcision include 56% in the United States,^[18] less than 14% in Canada,^[21] and less than 15% in Australia.^[12] Neonatal circumcision is thought to have become common in English-speaking countries in the mid-nineteenth century;^[22] more recently incidence is reported to have declined in Australia and Canada.^[23] In the United States reports variously state that it is falling,^[24] stable,^[25] or increasing.^[26]

Again, I'm not saying that this material ought to be added. In fact, I think that it is better left out of the lead. Jakew (talk) 19:08, 2 October 2008 (UTC)

I disagree that the basic information not be added. As to your suggestion I think it says all I wanted to say but more concise , so I am happy to go with that. We can leave out why it became popular, but it is important we note when it became popular if we are to abide by WP:LEAD policy of the lead being able to act alone as an article. After all, this is an English speaking encyclopedia and half the page or more is taken up discussing aspects of infant circumcision (where it is popular - i.e in english speaking countries), so it would be helpful to put it in context.

In regard to length and keeping it at 4 paragraphs. Well, first of all, a lot of paragraphs are short, for instance the first paragraph is only one line long.

If we were to describe the structure of the lead: The first paragraph is 1 line long and tells us what circumcision is. The second (including your suggestion) is 8 lines long and tells us of its prevalence and history in the world. The third is 3 lines long and tells us of the debate that there is. Finally, the fourth and fifth are basically dealing with the same subject - i.e various organisations giving their views on the procedure. So in theory, the fourth and fifth could be melded into one to create one paragraph. Which would be 4 paragraphs. Tremello22 (talk) 21:24, 2 October 2008 (UTC)

^ Alcena, Valiere (2006-10-16). "AIDS in Third World countries [letter]". response to "Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial". PLos Medicine. Retrieved 2008-08-24.
^ Alcena, Valiere (1986). "AIDS in Third World countries [letter]". New York State Journal of Medicine. 86 (8): 446. Retrieved 2008-08-24. {{cite journal}}: Unknown parameter |month= ignored (help).
^ Fink, Aaron J. (1986). "A possible explanation for heterosexual male infection with AIDS". New England Journal of Medicine. 315 (18): 1167. PMID 3762636. Retrieved 2008-08-24. {{cite journal}}: Cite has empty unknown parameter: |1= (help); Unknown parameter |month= ignored (help)
^ Alcena, Valiere (2006-10-16). "AIDS in Third World countries [letter]". response to "Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial". PLos Medicine. Retrieved 2008-08-24.
^ Alcena, Valiere (1986). "AIDS in Third World countries [letter]". New York State Journal of Medicine. 86 (8): 446. Retrieved 2008-08-24. {{cite journal}}: Unknown parameter |month= ignored (help).
^ Fink, Aaron J. (1986). "A possible explanation for heterosexual male infection with AIDS". New England Journal of Medicine. 315 (18): 1167. PMID 3762636. Retrieved 2008-08-24. {{cite journal}}: Cite has empty unknown parameter: |1= (help); Unknown parameter |month= ignored (help)
^ Boyle, Gregory J (2002). "Male circumcision: pain, trauma, and psychosexual sequelae". Bond University Faculty of Humanities and Social Sciences. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ "Male circumcision: Global trends and determinants of prevalence, safety and acceptability" (PDF). World Health Organization. 2007. Retrieved 2008-08-20.
^ ^a ^b "Insert 2" (PDF). Information Package on Male Circumcision and HIV Prevention. World Health Organization. 2007. Retrieved 2007-08-15.
^ A M K Rickwood, S E Kenny, S C Donnell (2000). "Towards evidence based circumcision of English boys: survey of trends in practice" (PDF). BMJ. 321 (7264): 792–793. doi:10.1136/bmj.321.7264.792.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Darby, Robert (2003). "The masturbation taboo and the rise of routine male circumcision: A review of the historiography - Review Essay". Journal of social history. 27 (1): 737–757. {{cite journal}}: Unknown parameter |month= ignored (help)
^ ^a ^b ^c Richters J, Smith AM, de Visser RO, Grulich AE, Rissel CE (2006). "Circumcision in Australia: prevalence and effects on sexual health". Int J STD AIDS. 17 (8): 547–54. doi:10.1258/095646206778145730. PMID 16925903. Neonatal circumcision was routine in Australia until the 1970s … In the last generation, Australia has changed from a country where most newborn boys are circumcised to one where circumcision is the minority experience. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
^ "Statements on circumcision from Australian medical organisations". circinfo.org. Retrieved 2008-10-02.
^ "Rates of circumcision slashed in past 30 years". The Gazette. march 23, 2006. Retrieved 2008-10-02. {{cite web}}: Check date values in: |date= (help)
^ Foetus and Newborn Committee (1975). "Circumcision in the newborn period". Canadian Pediatric Society News Bulletin Supplement. 8 (2): 1–2.
^ Cite error: The named reference Laumann was invoked but never defined (see the help page).
^ Cite error: The named reference nhds was invoked but never defined (see the help page).
^ ^a ^b "U.S. circumcision rates vary by region". UPI. January 21, 2008. Retrieved 2008-08-19.
^ "Male circumcision: Global trends and determinants of prevalence, safety and acceptability" (PDF). World Health Organization. 2007. Retrieved 2008-08-20.
^ A M K Rickwood, S E Kenny, S C Donnell (2000). "Towards evidence based circumcision of English boys: survey of trends in practice" (PDF). BMJ. 321 (7264): 792–793. doi:10.1136/bmj.321.7264.792.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ "Rates of circumcision slashed in past 30 years". The Gazette. march 23, 2006. Retrieved 2008-10-02. {{cite web}}: Check date values in: |date= (help)
^ Darby, Robert (2003). "The masturbation taboo and the rise of routine male circumcision: A review of the historiography - Review Essay". Journal of social history. 27 (1): 737–757. {{cite journal}}: Unknown parameter |month= ignored (help)
^ Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD (2003). "Routine circumcision practice in Western Australia 1981-1999". ANZ J Surg. 73 (8): 610–4. PMID 12887531. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
^ Mor Z, Kent CK, Kohn RP, Klausner JD (2007). "Declining rates in male circumcision amidst increasing evidence of its public health benefit". PLoS ONE. 2 (9): e861. doi:10.1371/journal.pone.0000861. PMC 1955830. PMID 17848992.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
^ "U.S. circumcision rates vary by region" (PDF). Agency for Healthcare Research and Quality. January, 2008. Retrieved 2008-08-19. {{cite news}}: Check date values in: |date= (help)
^ Nelson CP, Dunn R, Wan J, Wei JT (2005). "The increasing incidence of newborn circumcision: data from the nationwide inpatient sample". J. Urol. 173 (3): 978–81. doi:10.1097/01.ju.0000145758.80937.7d. PMID 15711354. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

[1] Alcena, Valiere (2006-10-16). "AIDS in Third World countries [letter]". response to "Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial". PLos Medicine. Retrieved 2008-08-24.

[2] Alcena, Valiere (1986). "AIDS in Third World countries [letter]". New York State Journal of Medicine. 86 (8): 446. Retrieved 2008-08-24. {{cite journal}}: Unknown parameter |month= ignored (help).

[3] Fink, Aaron J. (1986). "A possible explanation for heterosexual male infection with AIDS". New England Journal of Medicine. 315 (18): 1167. PMID 3762636. Retrieved 2008-08-24. {{cite journal}}: Cite has empty unknown parameter: |1= (help); Unknown parameter |month= ignored (help)

[4] Alcena, Valiere (2006-10-16). "AIDS in Third World countries [letter]". response to "Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial". PLos Medicine. Retrieved 2008-08-24.

[5] Alcena, Valiere (1986). "AIDS in Third World countries [letter]". New York State Journal of Medicine. 86 (8): 446. Retrieved 2008-08-24. {{cite journal}}: Unknown parameter |month= ignored (help).

[6] Fink, Aaron J. (1986). "A possible explanation for heterosexual male infection with AIDS". New England Journal of Medicine. 315 (18): 1167. PMID 3762636. Retrieved 2008-08-24. {{cite journal}}: Cite has empty unknown parameter: |1= (help); Unknown parameter |month= ignored (help)

[7] Boyle, Gregory J (2002). "Male circumcision: pain, trauma, and psychosexual sequelae". Bond University Faculty of Humanities and Social Sciences. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

[8] "Male circumcision: Global trends and determinants of prevalence, safety and acceptability" (PDF). World Health Organization. 2007. Retrieved 2008-08-20.

[WHO-Info-2-9] "Insert 2" (PDF). Information Package on Male Circumcision and HIV Prevention. World Health Organization. 2007. Retrieved 2007-08-15.

[10] A M K Rickwood, S E Kenny, S C Donnell (2000). "Towards evidence based circumcision of English boys: survey of trends in practice" (PDF). BMJ. 321 (7264): 792–793. doi:10.1136/bmj.321.7264.792.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[11] Darby, Robert (2003). "The masturbation taboo and the rise of routine male circumcision: A review of the historiography - Review Essay". Journal of social history. 27 (1): 737–757. {{cite journal}}: Unknown parameter |month= ignored (help)

[richters-12] Richters J, Smith AM, de Visser RO, Grulich AE, Rissel CE (2006). "Circumcision in Australia: prevalence and effects on sexual health". Int J STD AIDS. 17 (8): 547–54. doi:10.1258/095646206778145730. PMID 16925903. Neonatal circumcision was routine in Australia until the 1970s … In the last generation, Australia has changed from a country where most newborn boys are circumcised to one where circumcision is the minority experience. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

[13] "Statements on circumcision from Australian medical organisations". circinfo.org. Retrieved 2008-10-02.

[14] "Rates of circumcision slashed in past 30 years". The Gazette. march 23, 2006. Retrieved 2008-10-02. {{cite web}}: Check date values in: |date= (help)

[15] Foetus and Newborn Committee (1975). "Circumcision in the newborn period". Canadian Pediatric Society News Bulletin Supplement. 8 (2): 1–2.

[Laumann-16] Cite error: The named reference Laumann was invoked but never defined (see the help page).

[nhds-17] Cite error: The named reference nhds was invoked but never defined (see the help page).

[USAcircratefall-18] "U.S. circumcision rates vary by region". UPI. January 21, 2008. Retrieved 2008-08-19.

[19] "Male circumcision: Global trends and determinants of prevalence, safety and acceptability" (PDF). World Health Organization. 2007. Retrieved 2008-08-20.

[20] A M K Rickwood, S E Kenny, S C Donnell (2000). "Towards evidence based circumcision of English boys: survey of trends in practice" (PDF). BMJ. 321 (7264): 792–793. doi:10.1136/bmj.321.7264.792.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[21] "Rates of circumcision slashed in past 30 years". The Gazette. march 23, 2006. Retrieved 2008-10-02. {{cite web}}: Check date values in: |date= (help)

[22] Darby, Robert (2003). "The masturbation taboo and the rise of routine male circumcision: A review of the historiography - Review Essay". Journal of social history. 27 (1): 737–757. {{cite journal}}: Unknown parameter |month= ignored (help)

[23] Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD (2003). "Routine circumcision practice in Western Australia 1981-1999". ANZ J Surg. 73 (8): 610–4. PMID 12887531. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

[24] Mor Z, Kent CK, Kohn RP, Klausner JD (2007). "Declining rates in male circumcision amidst increasing evidence of its public health benefit". PLoS ONE. 2 (9): e861. doi:10.1371/journal.pone.0000861. PMC 1955830. PMID 17848992.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)

[25] "U.S. circumcision rates vary by region" (PDF). Agency for Healthcare Research and Quality. January, 2008. Retrieved 2008-08-19. {{cite news}}: Check date values in: |date= (help)

[26] Nelson CP, Dunn R, Wan J, Wei JT (2005). "The increasing incidence of newborn circumcision: data from the nationwide inpatient sample". J. Urol. 173 (3): 978–81. doi:10.1097/01.ju.0000145758.80937.7d. PMID 15711354. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

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