Small comes to play.

What happens when a MINI Cooper S collides with a Chevy Tahoe?

Dr. Sheldon Cooper would respond that it’s a simple matter of physics. And Dr. Cooper would be right. Getting t-boned in an accident is not the best position. But it’s also a reminder that, if you drive like an ass, your car’s size can be a disadvantage. Today’s scientific lesson is “center of gravity.”

Today’s unscientific lesson is MINI’s are full of awesome. Link via MotoringFile.

There is no do-over in surgery.

I’m still catching up on some of the circumcision-related news items form the last few weeks. Sometimes, I step away from the topic for short periods to recharge my tolerance for the inevitable frustration that arises when considering the various ways the rights of the circumcised are ignored, and the manner in which every breathless proclamation seems to instill even more determination that every male will just love being surgically altered shortly after birth. Stepping away eliminates reduces the number of verbal tirades I feel compelled to unleash. I always come back, though.

This story, forwarded to me by a loyal reader who forwards me useful material that I too often fail to translate into entries, is worth mentioning. Now that I’m looking, I can find a few references to it, but most media seems to have ignored it. Probably because it directly challenges the cheerleading for infant circumcision in the recent past. Anyway, the gist:

A quarter of a century after the outbreak of Aids, the World Health Organisation (WHO) has accepted that the threat of a global heterosexual pandemic has disappeared.

In the first official admission that the universal prevention strategy promoted by the major Aids organisations may have been misdirected, Kevin de Cock, the head of the WHO’s department of HIV/Aids said there will be no generalised epidemic of Aids in the heterosexual population outside Africa.

This is the appropriate point to remind everyone – the unethical scientists at WHO specifically – that the recent research we’ve been bombarded with repeatedly for the last two years suggests that voluntary, adult male circumcision reduces the risk of HIV transmission from female-to-male through heterosexual intercourse. Those infants who’ve been circumcised in the mad rush to embrace fear unsupported by at least the anecdotal evidence any mildly observant individual in a Western society could pick up? Ooops. But, hey, women will dig it, so there’s that.

In case you think this might cause the media to apply any critical thinking to the way they’ve reported on circumcision, fret not, they’re fully prepared to let you down if you get optimistic. In the same article, this:

Critics of the global Aids strategy complain that vast sums are being spent educating people about the disease who are not at risk, when a far bigger impact could be achieved by targeting high-risk groups and focusing on interventions known to work, such as circumcision, which cuts the risk of infection by 60 per cent, and reducing the number of sexual partners.

Interventions known to work. Process that for a moment. It’s known to work¹ at reducing the risk of HIV transmission from female-to-male through heterosexual intercourse! Isn’t the point of this story to report on the possible exaggeration of an epidemic among heterosexuals? I can imagine the editorial review of this article. “Everyone, shake your pom poms with me. Give me a “C”! Give me an “I”! Give me an “R”! Give me a “C”!

I won’t put it in print, but I’m swearing right now.

¹ There is room to debate this, primarily on methodology. Another time, perhaps.

Do a child’s eyes belong to the child’s parents?

As a thought experiment, consider:

LASIK surgery in children.

AIMS: To report success in the treatment of high myopia in children with LASIK. To report the visual results, complications and postoperative management of children with high myopia. METHODS: Six children (seven eyes) with high myopia were included in this series. Preoperative and postoperative refraction, visual acuity, and pachymetry were compared. RESULTS: Six children with high myopia ranging from -5.00DS to -16DS were treated. There were three males and three females. Five children had improved refraction and visual acuity post-LASIK. Age ranged from 2 to 12 years. Five of the children had unilateral amblyopia preoperatively. One had bilateral high myopia. CONCLUSION: High myopia in children may be treated safely and effectively with LASIK.

Now consider this story, via Amy Alkon:

Most Lasik recipients do walk away with crisper vision, and the American Society for Cataract and Refractive Surgery reviewed studies showing about 95 percent of patients say they’re satisfied with their outcome.

But not everyone’s a good candidate, and an unlucky fraction do suffer life-changing side effects: poor vision even with glasses, painful dry eyes, glare or inability to see or drive at night.

How big are the risks? The FDA agrees that about 5 percent of patients are dissatisfied with Lasik. How many struggle daily with side effects? How many are less harmed but unhappy that they couldn’t completely ditch their glasses? The range of effects on patients’ quality of life is a big unknown — and the reason the FDA help a public hearing Friday as part of its new move.

“Clearly there is a group who are not satisfied and do not get the kind of results they expect,” said Dr. Daniel Schultz, the FDA medical device chief. The study should “help us predict who those patients might be before they have the procedure.”

Doctors advise against Lasik for one in four people who seek the surgery, said Dr. Kerry Solomon of the Medical University of South Carolina, who led a review of Lasik’s safety for the ASCRS. Their pupils may be too large or corneas too thin or they may have some other condition that can increase the risk of a poor outcome.

Solomon estimates that fewer than 1 percent of patients have severe complications that leave poor vision.

Should parents have an unchallenged option to choose Lasik surgery for their children for any reason?

Bonus question: Should they have that unchallenged option for only their children of one gender, with the exclusion based on a societal belief such as the (non-)desirability of glasses?

Rights, Science, Tradition. Not Tradition, Science, Rights.

Last week I wrote about baby tossing, making a comparison to infant male circumcision. Today, via Kevin, M.D., here’s a story that includes a debate among doctors.

“Of course there is risk of injury in this practice. Missing the stretched cloth might be fatal and even landing on it wrong might cause a limb fracture,” said Dr. Joseph R. Zanga, past president of the American Academy of Pediatrics and a professor at the Brody School of Medicine, Greenville, N.C.

Objectively identifiable risk for a subjective, perceived benefit. End of discussion. Yet:

“I would not suggest that we try it in the U.S., but if they have been doing it for 500 years without any injury I’d be wary of stopping them,” Zanga said.

When faced with a tradition of stupidity, it’s best to focus on the stupidity, not the tradition. Science over superstition.

Dr. Michael Wasserman, of the Ochsner Health System in New Orleans, felt the same pull toward cultural sensitivity. “It is hard for one to disagree with religious rituals, as they are private choices, at the same time, there is a real danger?” Wasserman said.

This is not about disagreeing with religious rituals. If people want to toss themselves over a building’s edge in a “controlled” manner, have at it. This is not that. This is people intentionally endangering another person – a child – for no objective gain to the person being tossed. Jumping and being tossed are quite distinct. The former is a ritual. The latter is madness.

However, some doctors thought the health risks trumped cultural sensitivity in this case.

“The idea that parents would participate in such a harmful practice and that no one would point out the dangers to them seems inconceivable,” said Dr. Astrid Heppenstall Heger, professor of clinical pediatrics and executive director of the Violence Intervention Program at the University of Southern California, Los Angeles.

While this sentiment is based in logic, it’s not really inconceivable. American parents participate in a harmful practice that disregards risk in favor of cultural sensitivity more than one million times each year. The parents have “rights”, you know. As long as the tosser¹ finds value in the act, the tossed is merely the necessary pawn assumed to value the subjective gain more than the objective risk. He or she² isn’t completely worthy of individual protection because the group finds some benefit.

¹ No derogatory pun intended.

² Except for genital cutting, of course. There the comparison allegedly breaks down. Cutting healthy boys is valid tradition, but cutting healthy girls, that’s barbaric, even when it’s tradition. Half of that rationale is wrong. Would doctors suggest it’s okay to toss only male children from a building?

I wouldn’t use the word “debate”.

Following on today’s earlier entry, how many pro-circumcision myths does this short essay, “The Debate Over Circumcision,” inadvertently expose as flawed?

My first son had what can only be described as a bad circumcision. While he was still in diapers, the skin at the tip of his penis started to get sticky and when we changed him, we were unable to pull the skin back to do an adequate cleaning. “It’s a problem,” the pediatric urologist explained. I am sure there is some medical term for the condition, but all I can remember is that it required a trip to Boston’s Children’s Hospital where, in the office, my little boy had to get “re-snipped.”

This was very, very difficult to for me watch. Despite receiving a local anesthetic, my son cried a lot. So did I. When I found out I was expecting another boy, I did more research on circumcision and stumbled across countless websites arguing both for and against the procedure. Given that my husband and I are not of the Jewish or Islamic faith, where circumcision is customary, there was no real reason to choose circumcision other than family tradition. The medical arguments don’t really hold all that much weight, in my opinion.

The complications the author’s son experienced are easily explained. At birth, the foreskin adheres to the glans thanks to synechia. The inner foreskin is mucosal tissue, just like the nose, mouth, and female genitals. It doesn’t magically stop being mucosal tissue after circumcision. It only stops acting like mucosal tissue through years of keratinization. Until that occurs, any loose foreskin will tend to re-adhere because it is moist mucosal tissue. As the author discovered, this can require further surgical intervention. It can also lead to complications (NSFW – graphic images).

This is objective harm. Even when parents understand some of the risks – through the experience of their previously healthy sons – from medically unnecessary infant circumcision, they’re willing to proceed again. The risk of it becoming reality for the boy is inherent in every infant circumcision. No one has the right to impose this risk on him without medical need. No one should have the legal option to impose this risk on him, either.

Delicate Decision: Post 4 of 4

On Monday the Los Angeles Times offered a typical analysis of infant male circumcision. There are many points to address from this story, so I’ve broken them up into multiple posts. (Posts 1, 2, and 3.)

Point four:

FOR nearly all of Nada Mouallem’s pregnancy, she and her husband, Tony, had a running argument. She wanted to have their son circumcised. He didn’t. “Many days, I’d go off and research all the pros. He’d go and research all the cons. Then we’d get together at night and fight,” she says.

For the Mouallems, family tradition and religion were not factors. “We kept those separate and focused only on the scientific reasons,” says Tony Mouallem, who was against circumcising his son because he didn’t think it was necessary. Plus, he’s not circumcised. “You have to work a little harder to keep it clean, but that’s not a big deal.”

His wife, Nada, however, worried about the responsibility of keeping her newborn’s penis clean. She thought circumcision would help reduce the risk of infection and disease. “I wasn’t keen on my baby having a surgical procedure, but then I thought, why not if we can offer him more protection?”

In the end, Tony sided with his wife. Their son was born Feb. 10, and was circumcised the next day. Tony held him during the procedure. “There was no bleeding and he didn’t even cry,” he says. “I’m still not convinced it was medically necessary, but I didn’t want to burden my wife with the worry of cleaning it. And maybe it will be easier for him in the locker room.”

Choosing surgery over responsibility is the abdication of an obligation when having children. No one states that an intact penis can’t be kept clean. Even ignoring the absurdity that it’s more difficult to clean in his early years when his foreskin adheres to his glans and shouldn’t be retracted, keeping your children clean and eventually teaching them to care for themselves is parenting. Anything else is the selfish subjugation of the child’s needs to the parents’ whims. In this case, that whim is further discredited because the father presumably understands how to keep an intact penis clean.

Post Script: This most fits the “typical” analysis. These “balanced” articles always contain a couple who can’t decide. And the couple always chooses “yes”.

More analysis of this article and the CDC’s obtuse approach can be found here and here at Male Circumcision and HIV.

Delicate Decision: Post 3 of 4

On Monday the Los Angeles Times offered a typical analysis of infant male circumcision. There are many points to address from this story, so I’ve broken them up into multiple posts. (Posts 1, 2, and 4.)

Point three:

Robert and Cara Moffat of Los Angeles, who are expecting their first child, a boy, in May, had no trouble deciding, and plan to have their son circumcised. Robert, who is 30 and circumcised, said, “I grew up with it, and my wife has a preference for it, so that’s what we’ll do. We’re doing what the family is comfortable doing.”

His father is happy being circumcised, so the boy will be happy with it. This is an unverifiable assumption at birth. His mother prefers having sex with circumcised partners. This is irrelevant because I presume she does not intend to have sex with her son. So it leaves the conclusion that his future sex partner(s), who they apparently know will be female, will prefer that he be circumcised. This is an unverifiable assumption at birth. Finally, “what the family is comfortable doing” is hardly a principle of ethics, liberty, or science.

Also note that the parents have said nothing about (potential) medical benefits in forcing this on their son. Yet, they’re allegedly qualified to decide that their son will want this. And legally we’re all supposed to think this is reasonable.

As parents and task forces sort through the variables surrounding this intimate decision, [Dr. Andrew] Freedman offers parents in turmoil this comforting advice: “Rest assured. No matter what decision parents make for their son, most men think whatever they have is just fine.”

There are four potential realities for an adult male when he is finally legally protected to make his own genital decisions the way females are protected from birth. He can be intact and happy. He can be circumcised and happy. He can be intact and unhappy. He can be circumcised and unhappy. In the first scenario, he could do something but he wouldn’t. In the second, he can’t do anything but he doesn’t care. In the third, he can do something and he will choose either the perceived benefits of circumcision he seeks or not facing the drawbacks from adult circumcision. In the fourth, he can do nothing and society rejects his opinion as an individual.

In the first two scenarios, we conclude that the child validates the parents’ decision. We mistake an unrelated outcome for causation. In the third scenario, whatever we conclude, we’ve achieved the minimum standard of liberty that the male retains his right to choose (or reject) medically unnecessary procedures. In the fourth scenario, we either deny its validity or babble on about the rights of the parents. This generally involves some hand-wringing about parents making lots of tough choices while actively missing that none of the other choices involve removing parts of his anatomy. (You didn’t forget that parental rights are greater when speaking of sons, did you?)

Dr. Freedman’s opinion tells every man in scenario four his parents’ opinions about his penis matter more than his own. Anyone who argues this refuses to reconcile the complete lack of medical need with any notion of ethics and individual rights. Just because science can (allegedly and potentially) achieve an outcome does not mean it should try to achieve that outcome. That is a slippery slope unbounded by any consistent rule or principle.

More analysis of this article and the CDC’s obtuse approach can be found here and here at Male Circumcision and HIV.

Delicate Decision: Post 2 of 4

On Monday the Los Angeles Times offered a typical analysis of infant male circumcision. There are many points to address from this story, so I’ve broken them up into multiple posts. (Posts 1, 3, and 4.)

Point two:

In the first year of life, 1 in 100 uncircumcised [sic] boys will develop a urinary tract infection. Only 1 in 1,000 circumcised boys will. “While that’s a tenfold reduction, you have to keep in mind that the risk was only 1% to begin with,” says Dr. Andrew Freedman, pediatric urologist at Cedars-Sinai Medical Center. Proper hygiene can prevent most infections.

When considering potential benefits, context matters more than an isolated statistic. For example:

The downside of letting the child make the decision later is that adult circumcision is more expensive, painful and extensive. During an infant circumcision, practitioners numb the site with local anesthesia, then attach a bell-shaped clamp to the foreskin and excise the skin over the clamp. The clamp helps prevent bleeding. In adults, the procedure involves two incisions, above and below the glans (tip of the penis), stitches and a longer recovery. The cost is about 10 times that of a newborn procedure.

Let’s ignore the rights of the individual for the moment. I don’t, but the hypothetical does, so I’ll stick with it. The cost is about 10 times that of a newborn procedure. So what? As a fact on its own, it means nothing. How likely is it that an intact male will need circumcision in his lifetime? If it’s less than 10%, and it is, then a basic cost-benefit analysis shows that we will spend less overall by circumcising only those males who medically require circumcision. The “ten times more expensive” meme is worthless upon minimal inspection.

Dr. Freedman seems to understand this:

“The HIV data is the most compelling to date that circumcision can help prevent the transmission of the virus in male-female sex,” Freedman says. “While this is important to sub-Saharan Africa, the question is how many infant boys need to be circumcised in the United States to prevent one case of HIV transmission 25 years from now? Factoring in even the rare complication that can occur with circumcision may render this study insignificant.”

No kidding. Aside from not being able to predict who (or if) circumcision will help prevent HIV, we can also not predict who will suffer a complication. I seriously doubt the few children who suffer a significant mutilation of the penis care that most circumcisions are “successful”. Nor do I suspect the few boys who die from circumcision care about the general outcome. Of course, this should matter now, even before reducing a child to his (unknown) place in the statistical herd.

But he might not get it:

If parents do opt for the procedure, Freedman advises that they do it when the baby is a newborn, have someone trained and experienced perform the procedure, and use pain control. “The older a child gets, the less benefit there is, and the greater the risk,” he says. “I would ask parents of an older child to strongly reconsider if the only reason they’re doing this is cosmetic.”

The parents of a newborn who choose circumcision for cosmetic reasons? Those are somehow okay? Again, the individual – the patient – matters. When he is healthy, every other outside opinion is meaningless to the consideration of his body.

More analysis of this article and the CDC’s obtuse approach can be found here and here at Male Circumcision and HIV.

Delicate Decision: Post 1 of 4

On Monday the Los Angeles Times offered a typical analysis of infant male circumcision. There are many points to address from this story, so I’ve broken them up into multiple posts. (Posts 2, 3, and 4.)

Point one:

Dr. Peter Kilmarx, chief of epidemiology in the CDC’s division of HIV/AIDS prevention, says the CDC is looking at how the findings apply here. “The early opinion from the consultants — and not the position of the CDC, which involves a peer review process and public comment — is that, given all the previous data on circumcision plus the recent HIV African studies, the medical benefits of male infant circumcision outweigh the risks and that any financial burden barring parents from making this decision should be lifted,” he said.

Nationalizing health care will no more end routine infant male circumcision in America than the elimination of Medicaid funding has ended it in the states where Medicaid no longer pays for the unnecessary procedure. There is a political constituency that strongly supports imposing this on children. Until the universal principle that each individual owns his or her body is codified into law for males the way the Female Genital Mutilation Act now protects female minors, medically unnecessary circumcision will continue. And the state will pay for it when parents can’t (or won’t). Any protection of the individual based on entrenching an existing, or establishing a new, collective will fail.

Here’s a half-point in which I doubt Kilmarx understands the missing half:

“The procedure is so ancient, and steeped in cultures, I’m not surprised that the rate of adult circumcision in civilized countries doesn’t track with medical evidence,” Kilmarx says. “But as scientists, we don’t solely rely on what other countries do as a guideline.”

But as Americans, we don’t (mustn’t) solely rely on what science tells us as a guideline. Ethics matters. The rights of the individual matter, particularly the healthy individual. There is a hierarchy for decision-making concerning surgery on children. Kilmarx, among many, does not start at the beginning (i.e. medical need). That leads to mistakes, as clearly shown by the million-plus unnecessary infant circumcisions performed every year in America.

More analysis of this article and the CDC’s obtuse approach can be found here and here at Circumcision and HIV.

Denial versus Rejecting Sociological Science Experimentation

Filling in for Andrew Sullivan, Jim Manzi writes about conservatives and science:

The debate about evolution is a great example of the kind of sucker play that often ensnares conservatives. Frequently, conservatives are confronted with the assertion that scientific finding X implies political or moral conclusion Y with which they vehemently disagree. Obvious examples include (X = the Modern Synthesis of Evolutionary biology, Y = atheism) and (X = increasing concentrations of atmospheric CO2 will lead to some increase in global temperatures, Y = we must implement a global regulatory and tax system to radically reduce carbon emissions). Those conservatives with access to the biggest megaphones have recently developed the habit of responding to this by challenging the scientific finding X. The same sorry spectacle of cranks, gibberish and the resulting alienation of scientists and those who respect the practical benefits of science (i.e., pretty much the whole population of the modern world) then ensues.

In general, it would be far wiser to challenge the assertion that X implies Y. Scientific findings almost never entail specific moral or political conclusions because the scope of application of science is rarely sufficient. In fact, for the two examples that I provided, I have tried to show in detail that X does not come close to implying Y.

This maps to the circumcision debate perfectly. Too many advocates against medically unnecessary, routine circumcision of male children make the exact same fallacy. Many Americans, with the unquestioning aide of nearly every mass media outlet, has already made the connection: X = voluntary, adult circumcision reduces the risk of HIV infection, Y = we must circumcise all males, adult and child, willingly or unwillingly. We’re losing intellectual ground that need not be ceded.

Regardless of what advocates for the rights of children as individual human being state, the battle for X in the example above is already lost. It will be lost for a generation or more. That does not mean X is true. But to pretend that we’re going to win through mere denial is counter-productive. It’s possible to qualify any such recitation of X with a challenge to possible methodological flaws, for example. That should be done. It’s just not going to change the public perception that X is true.

The key, as Mr. Manzi demonstrates, is that any validity in X does not require Y. This is our strength. Logic demands that we leave healthy children intact. Individual rights demands that we leave healthy children intact. Medical ethics demands that we leave healthy children intact. Easy access to condoms demands that we leave healthy children intact. Until the child can consent or needs medical care, his (and her) healthy body is the only proof we need that proxy consent must be limited.

The facts are what they are. We cannot change that, to the extent that the findings are valid. Although it’s useful to remind anyone who misinterprets the scope of those findings that all benefits from genital surgery on healthy children are merely potential, with a very low likelihood of ever being necessary, we do not need to change that. Every study surrounding HIV and male circumcision already involves the two key components we need to demonstrate our case: voluntary and adult. Going beyond those two words requires our reason and intellect to figure out the appropriate application of those facts. We must demand that society use them.