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Circumcision, part 2 August 29, 2012

Posted by drolarn in Medical musings.
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I first blogged about circumcision in 2009, I was surprised how many people read it and kindly commented, thank you all who took to time to read it. Re-reading it after 3 years it seems to me my blog was mostly ranting with personal opinion and bias. I haven’t changed my opinion on the subject but when I talk to parents and others I try harder to present as much available factual data as I can, and keep my personal opinion to a minimum, which is not easy when discussing a topic with so much controversy. I also confine my opinion to medical aspects, I know I am not qualified to discuss religious practices.

Lately there has been a number of new published studies on circumcision which are quite interesting and so I feel it is time I chime in again.

The American Academy of Pediatrics now officially endorse circumcision as a procedure that provides health benefits. They cite research that show that circumcision reduces the risk of contracting HIV-AIDS, other STD’s particularly genital warts. Circumcision also is associated with reduction in incidence of penile cancer, and urinary tract infection in young children. The APA does however stop short of recommending making circumcision a routine, universal procedure, saying that it is up to families to decide.

Here’s my take on the subject: first of all medical research data when obtained by observational studies (as opposed to blinded clinical trials), are open to different interpretations. For theoretical example let’s say that in England research shows that among circumcised men, the incidence of HIV-AIDs is proportionally less than in uncircumcised men. It would be wrong to then conclude that in England, circumcision helps prevent AIDS. In medical language the only acceptable conclusion of this data is to say that circumcision is associated with less incidence of AIDS, and not to draw conclusion on causality. May be circumcision does prevent AIDS, but then again it could be that men from families that practice circumcision, such as jews and muslims, practice less unprotected, multi-partner  sex than the Christian and atheist population, accounting for the research data.

On the subject of AIDS prevention, the consensus of medical opinion is now to accept that circumcision does significantly reduce the risk of HIV-AIDS in the studied population of Africa. It would be wrong however to then extrapolate that the same must apply to the rest of the world. May be it does, but one cannot really know until good research has been conducted in other populations.

In another research study out of America, the researchers concluded that wider practice of circumcision would result in cost savings in the long term because of the protective benefits of circumcision against the diseases mentioned. The bulk of this saving would be from lower incidence of HIV-AIDS, other diseases like infant urine infection, penile cancer etc account for only a small part of the savings that could be made from lowering the risk of these diseases.

If one was to accept, despite the lack of irrefutable evidence, that circumcision directly reduces the risk of all STD’s including HIV-AIDS, it would make sense for governments to recommend or adopt as national policy the routine circumcision of all boys. Projections have been made as to how many cases of HIV-AIDS would be prevented, and how much money would be saved, if all boys are circumcised and this may well seem compelling. But let’s look at it from a much smaller scale. If you have a little son, look into his eyes, do you think when he grows up he will engage in risky sexual practice with multiple partners? You hope not! And what would be the best ways to reduce the chance that one day he will catch AIDS? Teach him about safe sex! Proper use of condoms virtually eliminate the risk of catching AIDS. Circumcising him may reduce the risk, not sure by how much, but for sure not enough that you could safely rely on it. If circumcision prevents AIDS 100%, or close to it, every boy and every sexually active men should be circumcised, but not even the most radical proponent of circumcision would dare to have unprotected sex with an HIV positive partner.

So if you want to not catch AIDS, you would use a condom, you would not go and have a piece of flesh cut out of you, would you then do different for your son?

Same arguments apply to other STD’s, and also penile cancer which is linked to STD. That leaves urinary tract infection in young boys. the APA says that circumcision reduces the risk and incidence of UTI in boys and I would accept that this it true. But it is a big leap to then conclude that circumcision should be advocated for all boys for this reason. Again let’s look at individual boys instead of making sweeping generalisations: how might the presence of the foreskin increase risk of UTI? It’s not always easy being a boy. Little baby boys, especially newborns, much more frequently have problems related to the urinary tract than little girls, (for men and women it’s different, women very much more often have UTI’s than men, because of their shorter urinary tract). For boys and men our plumbing is much more complicated than in females and the incidence of congenital abnormality of the urinary tract and sexual organs are much higher as a consequence. All congenital, anatomic abnormalities of the urinary tract increase the risk of UTI, and the most common of these is probably phimosis. This is when the opening of the foreskin is so small that it obstructs the flow of urine to such a degree that the bladder fails to completely empty, the residual urine then could become infected. Phimosis therefore, is one of the medical indications for circumcision (it is worth noting though that phimosis can sometimes be effectively treated without surgery). Phimosis isn’t difficult to diagnose, and when diagnosed should be treated, this would then reduce the risk of UTI in boys. Does it then make sense to circumcise all boys, including those without phimosis, in order to reduce the risk of UTI’s? By routinely performing circumcision, how many cases of UTI would be prevented? Look at it another way, how many normal boys must be circumcised to prevent one case of UTI? I don’t have the number, I imagine it’s a very large number. It makes a lot more sense to me to educate people on how to spot phimosis, and just circumcise the targeted group.

Not long ago, I think it was around June 2012, the district court of Cologne (Köln), Germany ruled that circumcision of infant boys other than for medical reasons constituted grievous bodily harm. I believe it was after a case where a baby suffered serious complications after being circumcised, something that can happen with any kind of surgery, even the most minor ones. This would make it a criminal offence to perform non-medically indicated circumcision on a person who cannot give consent. Religious groups protested that this ruling infringes on religious rights. The counter-argument is then what about the rights of the child to the integrity of his own body? How does secular authority weigh the spiritual needs of ethnic minorities against what the larger part of society consider to be a more universal human right? I would be interested to hear other people’s opinion.

 

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Overtreated July 1, 2009

Posted by drolarn in Medical musings, Rants.
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One question that is being asked frequently about Michael Jackson’s death is: did he die because he took too many prescription drugs?

I believe that many people have died, or suffered ill health, from being over-medicated. Some because the drugs are addictive, or induce psychological or physical dependency. Sleeping pills and painkillers are common and well know examples of these. But many suffer simply because they are taking too many medicines which are not addictive, and are prescribed to treat symptoms and conditions that the patient is suffering from or complaining of.

There are many reasons why patients may be prescribed too many medicines, to the point where the medicines make them sicker. Firstly the patient himself may be fond of taking pills, and doctors who are willing to indulge are not uncommon. Secondly many doctors feel that if they more drugs, especially the newest strongest drugs, that makes them more proactive in their treatment than others who judiciously use tried and tested therapies. Thirdly, and I have seen this happen many times and in conjunction with the other two scenarios, the doctor and patient get in to a vicious cycle of drugs and symptoms. This is how it happens:

Imagine a patient comes in with a rash that itches and irritates but otherwise not serious. A doctor gives him steroids which he finds is effective in controlling the rash. Long term steroid use cause him to be hypertensive, so the patient goes to see a cardiologist who gives him blood pressure medicine. This controls his blood pressure but causes him to have insomnia so he goes to see a neurologist who gives him sleeping pills. This helps him sleeps but causes him to be anxious, so he goes to see a psychiatrist who gives him anxiolytic drugs, which gives him nausea and heartburn, the treatment of which gives him diarrhoea, and meanwhile the steroid is giving him diabetes and so on and so forth.

All drugs have undesirable side-effects. Treating the side effects with more drugs lead to more side effects. If one doctor was in overall control of one patient’s treatment, things may not get out of hand but in situations where the patient has a free choice of doctors and doctors fail to communicate with each other, patients could be receiving drugs that work against each other, or duplicate each others effects and side effects, or otherwise interact adversely. In countries where the government provides universal health coverage and drug consumptions are kept under control, this situation is less likely to arise. But in a situation where the patient can freely shop for health care and doctors compete for business, it is common place. In (good) medical schools prospective doctors are taught to limit drug treatment to a minimum. The elderly particularly, are rarely able to cope with more than 4 different drugs in a day. In private hospital it is common place for patients to be on 12-15 different drugs at the same time, prescribed by up to half a dozen different doctors, and costing the monthly wage of the average man in the street.

If you are taking more than four different drugs everyday, chances are you are overtreated. Ask yourself are  you really feeling better ,overall, on these drugs than before you were started on them.

If you are consulting with more than one doctor, and your doctors are not seen to be communicating and cooperating, no matter how disparate their specialties, you are running a high risk of overtreatment. Find a doctor who is happier giving you explanations rather than pills, with luck he will help you stop the vicious cycle.

A life saved June 29, 2009

Posted by drolarn in Medical musings, Uncategorized.
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Baby J.

Baby J.

 

This little boy was born with a haemoglobin level of 3, which roughly speaking means he had lost 75% of his blood, prior to delivery. He was literally white as a sheet, this picture was taken after he was treated. He looked like a ghost and was well on his way to becoming one.

Because his blood was too thin to carry adequate oxygen to his vital organs, his heart was working over time and was on the verge of failing. He could not breath fast enough and with all the effort, his blood was turning acid.

I could not just pour blood into him, transfusing him too quickly would have overloaded his already stressed circulation. Giving him blood too slowly and he might have gone into shock.  A risky procedure that is sometimes indicated in this situation is to perform an “exchange transfution”, whereby baby’s blood is removed and replaced simultaneously with donor’s blood. The procedure requires twice or three times as much donor’s blood as baby’s total blood volume, and even though most of the time this procedure is safe if performed with great care, it is never without considerable risk. Instead I gave him blood as fast as I dared, in the meanwhile he had to be put on a breathing machine as he was too exhausted to breath by himself. I had to give him a big slug of bicarbonate to counteract his acidic blood.

The hours I spent watching him turn from white and gasping to pale pink and relaxed were anxious hours indeed. Luckily he had just enough resilience left to turn the corner and now, a day later, is out of intensive care and breast-feeding.

A bit of shameless bragging on my part, but heck, I’ve earned the right!

Circumcision June 28, 2009

Posted by drolarn in Medical musings, Rants, Uncategorized.
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Of all the things new parents request from me, the most irritating is  circumcision for their son.

The practice of surgical removal of the foreskin without medical indication is widespread in the world. It is of course the norm in Muslim societies. In America it is widespread enough to be the rule rather than the exception. The practice has spread into other countries and societies. Here in Thailand, at least in Bangkok, it is common, even among non-Muslims.

OK look, I don’t want to offend Muslims and Jews, I am proud to say I count many Muslims and Jews among my friends past and present, but this aspect of jewish and islamic practice impresses me not at all. I don’t know why your God mandate circumcision for all male faithfulls, but it seems to me if He feels males should not have foreskin, he would not have created it in the first place. The fact that the Judeo-Christian-Islam God created men with foreskin logically should mean He has a purpose in mind for it. Could God’s only purpose for the foreskin be for it to be cut off as a mark of the faithfull?  Seems to me He might prefer other kinds of marks, such forms of dress, prescribed rituals, any number of other things. As proof of faith, having to get one’s dick out in the open for demonstration, is frankly ludicrous.

But all right, it’s not my place to tell muslim or jewish parents not to practice their religion as their traditions dictate, and indeed when parents request circumcision for religious reasons, I always make the arrangements without demur. What makes me mad though is when non-muslims and non-jewish parents make this request.

Most likely, ritual male circumcision arose as a practice from the middle east, as the cradle of the judeo-christian-islamic faith. It probably originated from a jewish tribe, spread around the world with the diaspora, and into the related islamic faith. Why has it become almost normal, routine practice in America? I really don’t know. Could it be because jews in America, especially jewish doctors, extolled the benefits of this practice (in all sincerity and in all good faith I’m sure), and convinced the gentiles of America that it is the smart thing to do?

Certainly in America, medical practitioners and researchers list many health benefits of circumcision. Better hygiene, lower risk of urinary tract infection, lower risk of penile cancer (an exceedingly rare cancer), lower risk of transmission of genital wart virus (HPV) which causes cervical cancer in women and lower risk of HIV-AIDS transmission are among the most frequent health benefit claims. Research papers are cited to support these claims enthusiastically. Meanwhile in Europe, Australasia, and other areas where the practice has not taken hold, equally eminent physicians, surgeons and researchers deny that there is good evidence to justify removal of the normal foreskin. Again research papers are brandished, tables are thumped and beards are muttered into.

So what is the truth, are there health benefits of male circumcision that would justify routine use? Why can’t researchers agree?

The problem with medical research into circumcision is that it cannot be conducted in such a way as to eliminate all researcher bias, and the effects of other factors on the analysis of data cannot be totally excluded. In a good drug trial, to test the efficacy of a new drug, research conducted using the double blind technique (whereby neither the drug prescriber nor the recipient know if the drug given is the new research drug on an older established drug against which comparison is saught, or placebo). If properly done the result of such a trial can be totally compelling. Obviously this kind of research technique cannot be applied to circumcision and doctors (at least the smarter ones) are aware of the pitfalls and limitations of non-blinded medical research.

The world concensus seems to be that yes, circumcision can help reduce the spread of HIV-AIDS, at least in Africa, and there has been moves to increase the practice in Africa for this reason. There is no world concensus on the balance of risks/benefits of circumcision in relation to any other health claims.

And so the status quo in American and Europe looks set to continue, Americans will continue to circumcise most newborn boys, and Europeans will continue to circumcise only jews, muslims, and the few boys who have problems with their foreskins.

Let’s talk a bit about female circumcision. This ritual practice is common in parts of Africa. There are strong tribal beliefs that uncircumcised females will die prematurely, or suffer diseases, or are impious and unfit for marriage. Not all circumcised African females are forced to it against their will. Strong tribal beliefs means many have it done quite voluntarily. The exact methodology of female circumcision varies from tribe to tribe, particularly as to which parts and how much of the female genitalia should be removed.

The western world regards female circumcision as a barbaric act. In many (perhaps all?) western countries the practice is banned, that is doctors cannot perform it on any girl regardless of parental request or background. To me this really begs the obvious question: if female circumcision is barbaric, senseless and despicable, why is male circumcision ever wise, commendable, and acceptable? In both male and female circumcision, the genitalia is mutilated by removal of varying amounts of skin. In both the precedure is commonly performed without anaesthetics. In both the disfigurement is permanent and may affect sexual function thoughout life. Is there really any difference between male and female circumcision in terms of logic and reasoning other than religious beliefs? What about the benefits of female circumcision? If male circumcision provides health benefits as some research shows, could not female circumsion also have health benefits? Just because no research is (or can) be done does not mean female circumcision can’t possibly have any health benefit. And if those African tribes that practice it are barbaric and cruel, why, by the same yardstick, are not the middle eastern tribes that first practiced male circumcision?

Here in Thailand I have come across, all too frequently, parents (mostly fathers) who have no religious or cultural justification for circumcision who are almost desperate to have their newborn son’s genital mutilated at the earliest opportunity. For some of them the first two questions they ask the paediatrician when their son is born are 1) how much does he weigh? and 2) when can he be circumcised?

I have had arguments with parents like this. Sometimes I manage to persuaded them out of it (mothers are often much less keen on the idea) and other times the parents never want to see or speak to me again (and good riddance to them to, the despicable excuses for parents). I also not infrequently alienate the surgeons who perform the procedure who stood to benefit financially.

But here is where I stand: if parents have been deluded into thinking that circumcision is good and necessary but not for religious reason, I will patiently explain the pros and cons. If they see reason, wonderful! I shall be happy to care for their son through out his childhood. If they are unreasonable, and will subject their baby boy to a barbaric, painful, and cruel procedure to permanently mutilate is penis, and all this without the boy himself ever having a chance to chose what is done to him, well then I won’t be a party to it. I took an oath not to deliberately harm my patients, and I don’t care for parents who won’t listen to reasons. There are many other doctors out there eager and willing (for a fee of course) to help torture and scar innocent baby boys so go to one of them and may you all one day weep for the errors of your way.

Swine ‘flu June 26, 2009

Posted by drolarn in Medical musings, Uncategorized.
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For the past few weeks I have seen many cases of ‘flu. No doubt some were the much talked about swine flu, H1N1 flu, 2009 flu, what ever the latest nomenclature is. A ‘flu bug, by any other name, would give you fever and headache.

Some sufferers (and/or parents thereof) are nonchalant about it, while others are all in a tizzy. The fact is that swine flu is not all that different from the normal seasonal flu. Some sources even say that the symptoms of swine flu are often less severe than seasonal flu. Swine flu kills, but so does normal flu, and not in any lesser number. For people usually in good health, flu is not too big of a deal, with rare exceptions. For the elderly and those already weakened by chronic illness, catching ‘flu can indeed be serious, which is why they invented the ‘flu vaccine.

Some FAQ’s I’ve had to field on this topic:

I/my child has fever/flu like symptoms, should I get a ‘flu test?

It is nice to precisely identify the cause of an illness, so if the symptoms are adequately ‘flu like a ‘flu test may be useful. Also, it will help in estimating how widespread a ‘flu outbreak is. It may not however affect the treatment as most cases of ‘flu only require supportive measures (taking fever medicines, drinking lots of fluids etc). It mayaffect treatment decision if you contemplate taking Tamiflu in the event of a positive result.

Depending on your health care coverage, the cost of testing may be an issue.

Should I specifically test for swine/H1N1 ‘flu?

Again for statistical purposes this would be a good thing, but again a positive swine flu test may not affect treatment decision. Just because you have swine ‘flu does not mean you must take Tamiflu or otherwise be treated any differently from normal ‘flu

 

Should I/my child be admitted to hospital if I’ve caught ‘flu?

Not every case of ‘flu needs in-patient treatment by any means. Only cases with severe symptoms or complications need to be admitted to hospital. If you need to stay in hospital, the doctor would advise you.

 

What is Tamiflu, should I take Tamiflu?

 

Tamiflu is an antiviral drug which can mitigate the symptoms of ‘flu. It has been shown to work in normal ‘flu, bird ‘flu, and swine ‘flu. It is largely safe to use. It is not however always effective. Widespread use of Tamiflu has been shown to increase the incidence of resistance to the drug. This means that widespread use may result in the drug becoming ineffective, and since Tamiflu is the only available specific ‘flu treatment, indiscriminate usage may result in having no available effective treatment for future ‘flu episodes.

Also, even when it is effective the results are often not dramatic, perhaps shortening the illness period by a day, or reducing fever by a little. Although safe the drug can cause nausea and vomiting, and there has been reports of psychological disturbance linked to the drug, which has resulted in suicidal behaviour in some young people in Japan. The decision whether or not to take Tamiflu should be discussed with your doctor. Don’t pressure him/her for a drug you don’t need. I hate it when that happens to me.

 

I hear that supplies of Tamiflu are running short, should I stock up on Tamiflu, in case I need it?

 

Stocking up on Tamiflu is an option in countries which have poor regulation of dispensation of drugs, like here in Thailand. Although you cannot exactly buy it over the counter, you can ask/wheedle/demand that your doctor prescribe you some, and this is what happened frequently during the bird ‘flu panic a few years ago. The result of this is that shortage of Tamiflu became a self-fulfilling prophecy. A large number of people held on to their stocks of Tamiflu until the expiry date, at which point the expensive, hard to get drug became useless garbage.

 

Should I/my child be vaccinated against ‘flu?

 

The ‘flu vaccine is highly recommended for the elderly, and for those who have pre-existing conditions which makes catching ‘flu a high-risk prospect. For those in good/normal health it is debatable how necessary the ‘flu vaccine is. Flu vaccines are about 70% effective in preventing seasonal ‘flu (and 0% effective in preventing bird flu or swine flu), and its effectiveness wears off after about a year, which means you would need annual ‘flu shots to maintain immunity. Yes ‘flu vaccine can prevent the rather unpleasant symptoms of ‘flu, reduce the risk of days off school or days off work, and the risk of being stopped at an airport for running a fever whilst travelling. On the other hand the idea of having vaccine shots every year is unappealing, and there has been reports of nasty neurological complications resulting from too many ‘flu vaccine shots.

This is as much as I’ve got time for, for now. Please keep in mind this here ain’t no CDC, my opinions are my own and if you want authoritative information about ‘flu, go to official government sites.