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Revision as of 23:49, 22 November 2022 editBogLogs (talk | contribs)Extended confirmed users712 edits →RFC on the Royal Dutch Medical Association: ReplyTag: Reply← Previous edit Revision as of 20:32, 23 November 2022 edit undoSnow Rise (talk | contribs)Extended confirmed users, New page reviewers, Pending changes reviewers, Rollbackers22,493 edits →RFC on the Royal Dutch Medical AssociationNext edit →
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:'''Shortened version''': I'm not sure if it's fringe or not but it is certainly a bit out of date and not needing every detail. Other out of date viewpoints in the article can also be appropriately um trimmed or replaced with newer ones if available. ] (]) 23:49, 22 November 2022 (UTC) :'''Shortened version''': I'm not sure if it's fringe or not but it is certainly a bit out of date and not needing every detail. Other out of date viewpoints in the article can also be appropriately um trimmed or replaced with newer ones if available. ] (]) 23:49, 22 November 2022 (UTC)

:'''Shorter summary of the KNMG position.''' Let me preface this by saying I think the KNMG stance is, at most, FRINGE-adjacent, not truly fringe: yes, it is a significant minority opinion in some respects
as compared against consensus medical science on the topic, but let's remember that we are talking about legitimate national-scale body representing tens of thousands of physicians, and at least some of what it has to say on the topic is not altogether controversial. The timeliness issues does raise some concerns in terms of ], but sources in Misplaced Pages articles covering this topic are kind of all over the place on the timeline of research as is.

:All of that said, the portions that come in under the extended version are definetly those which are either a) closest to fringe statements, relative to the broad corpus of research, such as the claim that "the relationship between HIV transmission and circumcision was unclear" (the particulars may be up for debate but consensus research is pretty clear about the existences of a statistically significant observable relationship), or b) so non-controversial I'm not sure it bears lengthening the article and muddying the waters to include it, as with "behavioral factors seemed to have more of an effect on HIV prevention than circumcision" (no researchers that I have ever heard of are really arguing that the effects of circumcision at are at the same scale of impact as the sex acts engaged in by individuals, their choice of whether to use safe sex practices, their choices with regard to sexual partners, and their medication choices, the only really physiologically relevant "behavioural factors" at play here, making this rather something of a strawman argument that doesn't do much to inform the reader of the actual dimensions of legitimate medical debate about this topic.

:Meanwhile, the shorter version still includes the less controversial an informative content: "Because the evidence that circumcision prevents HIV mainly comes from studies conducted in Africa, the Royal Dutch Medical Association (KNMG) in 2010 questioned the applicability of those studies to developed countries." Now this in itself is still a little wishy-washy in terms of the grounds on which it takes issue with the majority/consensus research position, because obviously there is no significant observed physiological difference between African and non-African peoples which would lead to statistically different outcomes for individuals exposed to HIV; that is to say, a circumscribed African and a circumcised non-African would (on average) get just as much benefit (or just as little, depending on your position) when exposed to HIV, so there are some problems with that statement as framed. But I presume the KNMG would explain this position more fully as "in non-African contexts, the benefits of circumcision on the larger epidemiological scale might render different statistical outcomes in terms of benefits to the larger population resulting from the practice." That's a questionable argument in itself, insofar as the KNMG doesn't point to countervailing research so much as casts doubt on the existing Africa-centric research, but it does get it farther past the smell test than some other aspects of their position. And then of course "Circumcision has not been included in their HIV prevention recommendations." is just simply perfectly factual.

:On the whole, I don't see a strong argument for the ] value of the elements included in the longer version, whereas I can see the benefit of the shorter version. I'd also like to note that (though I am sure it was a subconscious and unintentional choice, there seems to me to be some rhetorical bias built into how the two choices are presented here in terms of the nomenclature of the RfC: the "full version" of the "KNMG's recommendations" is just the summary of their position as advanced by one of our editors. The choice therefore is not between a "full" or "shortened" version, but rather between a longer and shorter version, and there's a suggestion in the language employed that we are somehow taking something naturally fulsome and cutting it down for convenience. That's not really appropriate framing any more than if the choices had been labelled a "punchy" version and "verbose" version, imo. Not a huge thing, but worth noting as something that could introduce bias into the discussion. '']]'' 20:31, 23 November 2022 (UTC)

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A slight change to the lead.

A slight change in the beginning of the article would be more direct.

In the context of high risk populations.... to

In high risk populations....

The second phrase says all that needs to be said. Michael Glass (talk) 03:16, 27 September 2021 (UTC)

It does sound better, tbh. Stix1776 (talk) 11:13, 5 October 2021 (UTC)
A third change to point out is that many, many studies don't show that circ prevents HIV. Tiggy The Terrible (talk) 09:03, 16 September 2022 (UTC)
A third change to point out is that many, many studies don't show that circ prevents HIV ← except that's a POV with no reliable source(s) backing it. Bon courage (talk) 09:06, 16 September 2022 (UTC)

MSM efficacy lead

The lead is too heteronormative. It should say something about efficacy among men who have sex with men. Thoughts? Prcc27 (talk) 03:10, 18 February 2022 (UTC)

What's problematic about the lead, @Prcc27:? Aren't all of these things already addressed? KlayCax (talk) 05:36, 10 September 2022 (UTC)
You are commenting on a section that is over 6 months old. The lead has since been updated by me to include information about MSM, after nobody voiced opposition in this thread. Prcc27 (talk) 04:11, 11 September 2022 (UTC)

Undue lead paragraph

“An association between circumcision and reduced heterosexual HIV infection rates was first suggested in 1986.”
Problematic wording. Who made the suggestion in 1986? If a random person made the suggestion in 1985, would that negate this sentence..?
“Experimental evidence was needed to establish a causal relationship, so three randomized controlled trials (RCT) were commissioned as a means to reduce the effect of any confounding factors. Trials took place in South Africa, Kenya and Uganda. All three trials were stopped early by their monitoring boards because those in the circumcised group had a substantially lower rate of HIV contraction than the control group, and hence that it would be unethical to withhold the treatment in light of overwhelming evidence of prophylactic efficacy”
Source seems too old. Possibly WP:POV for not mentioning concerns about the trials stopping too early.
”WHO assessed these as ‘gold standard’ studies and found ‘strong and consistent’ evidence from later studies that confirmed the results of the three RCT trials.”
Using two different sources to make a conclusion is a violation of WP:SYNTH. WP:UNDUE to talk about the trials that much in the lead compared to the other sentences.
”A scientific consensus subsequently developed that circumcision reduces heterosexual HIV infection rates in high-risk populations.”
Redundant; already covered by the first sentence in the lead. Prcc27 (talk) 03:04, 8 September 2022 (UTC)
"Source seems too old" What citation in particular is too old? The citation is recounting the historical background of the studies. It's not something that needs to be updated. The main sources in the lead are from 2017 and 2021 respectively. Both are extraordinarily recent. I'm uncertain what this is in reference to.
Possibly WP:POV for not mentioning concerns about the trials stopping too early It would be WP:POV to include it: as there is an overwhelming consensus among mainstream sources that circumcision is efficacious in the prevention of HIV in high risk populations. This has already been discussed a few months ago with @MrOllie: and @Alexbrn:. As Merson and Inrig (2017) states: "This led to a consensus that male circumcision should be a priority for HIV prevention in countries and regions with heterosexual epidemics and high HIV and low male circumcision prevalence" and Sharma et al. (2021) states: There is overwhelming immunological evidence in support of MC in preventing the heterosexual acquisition of HIV-1. WP: Due only applies when If a viewpoint is held by a majority ... significant minority... There isn't a significant minority that denies that it is efficacous in that context. The main debate over circumcision within the medical literature is predominately: 1.) The ethics of it being routinely performed without the individual's consent (instead of parents or other guardians) 2.) Whether these same benefits apply as significantly and/or counteracted by risks in developed nations. The mention of the debate in that context is preserved in the lead. This article is overwhelmingly about circumcision that is performed on heterosexual men in areas of high, endemic HIV transmission. KlayCax (talk) 05:32, 10 September 2022 (UTC)
The early cessation of the trials is not about history. I am sure you can find a newer source that analyzes the reason for why the trials should have/should not have been ended prematurely; your source was from 2009. Prcc27 (talk) 04:22, 11 September 2022 (UTC)
Siegfried, et al. (2009) is simply used in the reference for the statement: "Experimental evidence was needed to establish a causal relationship, so three randomized controlled trials (RCT) were commissioned as a means to reduce the effect of any confounding factors. Trials took place in South Africa, Kenya and Uganda" That's not a fact that's going to change over time. Outdated sources don't apply in that context, @Prcc27:. Siegfried, et al. (2009) is not being used to summarize current consensus.
Merson and Inrig (2017) states: "This led to a consensus that male circumcision should be a priority for HIV prevention in countries and regions with heterosexual epidemics and high HIV and low male circumcision prevalence". Sharma et al. (2021) states: There is overwhelming immunological evidence in support of MC in preventing the heterosexual acquisition of HIV-1.WP: Due only applies when If a viewpoint is held by a majority ... significant minority.... But every major medical association — including those in non-Anglophonic Europe — state that it is efficacious against the spread of HIV/AIDS in poor, high risk contexts. Both Merson and Inrig (2017) and Sharma et al. (2021) are under five years old.
We've had repeated discussions on the circumcision talk page with consensus on this matter: that it would only become undue if a major medical organization (or World Health Organization) denied that it was efficacious. As @MrOllie: stated on this very topic a few days ago: we going to undermine the well established consensus of mainstream medical science based on a few people publishing in questionable journals. WP: Undue doesn't mean the promotion of fringe theories denying a link in high risk populations. (Where heterosexually transmitted HIV/AIDS is common and the predominant form of transmission.) The disputed efficacy of it in developed nations is already covered. KlayCax (talk) 06:25, 11 September 2022 (UTC)
No, that is not the only sentence that the old source was used for. That source was also used for the “All three trials were stopped early by their monitoring boards because those in the circumcised group had a substantially lower rate of HIV contraction than the control group, and hence that it would be unethical to withhold the treatment in light of overwhelming evidence of prophylactic efficacy” sentence. This is WP:UNDUE. Also, please make sure you are careful about tagging users on talk pages– it can be seen as a violation of WP:CANVASS. Prcc27 (talk) 07:03, 11 September 2022 (UTC)
Once again, “This led to a consensus that male circumcision should be a priority for HIV prevention in countries and regions with heterosexual epidemics and high HIV and low male circumcision prevalence” is redundant. We do not need to say essentially the same thing twice in the lead.. Prcc27 (talk) 07:12, 11 September 2022 (UTC)
“No, that is not the only sentence that the old source was used for. That source was also used for the “All three trials were stopped early by their monitoring boards because those in the circumcised group had a substantially lower rate of HIV contraction than the control group, and hence that it would be unethical to withhold the treatment in light of overwhelming evidence of prophylactic efficacy” What's problematic with it? Were the three RCT's not stopped early by their monitoring boards? There's nothing problematic about citing it from there.
WP:UNDUE doesn't apply to fringe viewpoints: only those with a majority/significant minority following. Merson and Inrig (2017) states: "This led to a consensus that male circumcision should be a priority for HIV prevention in countries and regions with heterosexual epidemics and high HIV and low male circumcision prevalence". Sharma et al. (2021) states: There is overwhelming immunological evidence in support of MC in preventing the heterosexual acquisition of HIV-1.WP: Due only applies when If a viewpoint is held by a majority ... significant minority.... But every major medical association — including those in non-Anglophonic Europe — state that it is efficacious against the spread of HIV/AIDS in poor, high risk contexts. Both Merson and Inrig (2017) and Sharma et al. (2021) citations are under five years old. It's a violation of WP: Undue to include fringe viewpoints.
Also, please make sure you are careful about tagging users on talk pages– it can be seen as a violation of WP:CANVASS. Both @MrOllie: and @Alexbrn: have been directly involved in conversations with you surrounding this topic on this article's talk page and on circumcision's. WP:CANVASS doesn't apply here. I tagged others previously involved with this discussion because there's not going to be an established resolution to this otherwise. (Outside of the RfC's already performed on the issue and how consensus should be characterized) There's already been a RfC on the circumcision talk page establishing a consensus on the matter among heterosexuals in high-risk, undeveloped contexts. But I'll tag @TiggyTheTerrible: as well. A discussion on this matter has already taken place. If a major medical organization (such as the British Medical Association, American Academy of Pediatrics, World Health Organization, et al.) denies a link between HIV and circumcision in high risk contexts, feel free to start another RfC on it. (And in that circumstance I think a dissenting view on the matter should be included.) Merson and Inrig (2017)'s quote is only five years old. Sharma et al. (2021)s quote stating a consensus is only a year old.
We do not need to say essentially the same thing twice in the lead A consensus didn't emerge until after the three RCT's (and subsequent history.) Before then, there was widespread open debate among the scientific community over whether it was efficacious. That's why the sentence is there. It establishes what the consensus is based upon. However, I don't have a really significant opinion on the matter either way. We can keep it removed from the lead if preference. KlayCax (talk) 04:29, 13 September 2022 (UTC)
Tagging @Prcc27: KlayCax (talk) 04:30, 13 September 2022 (UTC)
  • You are trying to state an ethical view as factual: “hence that it would be unethical to withhold the treatment”. Not to mention, non-therapeutic circumcision isn’t “treatment”, it is often seen as “prevention” though. It is definitely WP:UNDUE/WP:POV to use an old source to say there is “overwhelming evidence of prophylactic efficacy.” Prcc27 (talk) 05:00, 13 September 2022 (UTC)
You are trying to state an ethical view as factual: “hence that it would be unethical to withhold the treatment”. It's widespread in medical ethics to end studies early in those types of situations. Within context, it's clearly referring to the study's author's and monitor boards concluding it. Something such as Hence that it would be unethical to withhold the treatment by the monitoring board(s) could easily be added unto it. KlayCax (talk) 06:12, 13 September 2022 (UTC)
Non-therapeutic circumcision isn’t “treatment”, it is often seen as “prevention” though. "Treatment" is widely used in the context of clinical trials and is a verbatim wording of what the sources state. It meets the criteria for the word.
It is definitely WP:UNDUE/WP:POV to use an old source to say there is “overwhelming evidence of prophylactic efficacy.” Recent sources such as Merson and Inrig (2017) and Sharma et al. (2021) (as mentioned above) as well as major medical organizations universally state the same. WP:UNDUE/WP:POV doesn't apply.
Tag, @Prcc27:. KlayCax (talk)
  • ”Consensus” and “overwhelming evidence” are two very different things. Also, it is not a universal consensus among major medical organizations, if you recognize the Royal Dutch Medical Association as a major medical organization. Prcc27 (talk) 14:59, 13 September 2022 (UTC)
FFS, we're not going to do this *again* are we. I return to this page after a long hiatus and see the same POV pushing. As has previously been stated by others, the view that circumcision does not reduce the risk of HIV is a fringe view per Misplaced Pages policy. We are not going to indulge fringe views. That circumcision reduces HIV risk in certain circumstances is established medical fact. Bon courage (talk) 15:46, 13 September 2022 (UTC)
As stated in a previous discussion, there is a difference between a “fringe viewpoint” and a significant minority viewpoint. Just because a view is in the minority, does not automatically make it fringe. Prcc27 (talk) 17:34, 13 September 2022 (UTC)
@Prcc27 I don't know if you've seen one, but this goes into why the African trials were suspect - if not outright fraudulent. https://www.researchgate.net/publication/272498905_Sub-Saharan_African_randomised_clinical_trials_into_male_circumcision_and_HIV_transmission_Methodological_ethical_and_legal_concerns Tiggy The Terrible (talk) 07:12, 13 September 2022 (UTC)
Also, worth mentioning that since most doctors outside the USA/Africa think circ should NOT be routine, the APA guidelines on this would qualify as fringe in a lot of places. So I think we should be careful about that word. Tiggy The Terrible (talk) 17:47, 13 September 2022 (UTC)
1) Any paper from 'Doctors Opposing Circumcision' is suspect itself. The authors have no relevant expertise. 2) The question here is not whether circumcision should be routine, it is whether it reduces HIV infection rates. The position that it doesn't is clearly fringe. MrOllie (talk) 16:14, 14 September 2022 (UTC)

This discussion is partly about whether the evidence is “overwhelming”. I think that is a problematic and POV word to use. “Strong” would probably be a better alternative. Although I still am not sure the information about the trials belongs in the lead.. Prcc27 (talk) 17:35, 14 September 2022 (UTC)

I think that is a problematic and POV word to use. It's not a violation of NPOV to reproduce what major medical organizations and multiple metastudies have uniformly concluded (including those referenced above): as @MrOllie: and @Alexbrn: have also mentioned. The wording would only be problematic if a majority or significant minority denied that viewpoint. They don't.
If their positions are modified or new evidence emerges: of course that the lead could be altered.
Not sure about the trials belongs in the lead There was no scientific consensus that circumcision prevented HIV/AIDS before those three RCT's. KlayCax (talk) 22:44, 15 September 2022 (UTC)
Which sources use the term “overwhelming”? How old are those sources? Prcc27 (talk) 20:40, 16 September 2022 (UTC)
Sharma, et al. (2021) uses it : "There is overwhelming immunological evidence in support of MC in preventing the heterosexual acquisition of HIV-1." There's other numerous verbatim examples — all within the past five years — from medical journals, major medical organizations, et cetera on the issue, dating back to at least 2008. Any objections to restoration, per this conversation and previous (and repeated) RfC consensus, @MrOllie: or @Alexbrn:? KlayCax (talk) 03:28, 18 September 2022 (UTC)
  • Your proposed wording for the lead talks specifically about the African trials. That quote you just cited says nothing about the trials. Using that source for what you’re proposing would be a violation of WP:OR. You do not need to tag those users, I am sure they are already following along and reading this discussion. Plus, I still feel like it comes off as canvassing. Prcc27 (talk) 04:45, 18 September 2022 (UTC)
That quote you just cited says nothing about the trials Sharma, et al. (2021) states: MC is... strongly supported by the data from three large RCTs conducted in Africa right before that. It directly mentions the three RCT trials as part of the "overwhelming evidence" for circumcision in high risk contexts.
Scientific American (2008) states: all three trials were stopped early due to the overwhelming evidence of circumcision's protective effect.
Thomas, et al. (2011) states: Overwhelming evidence, including three clinical trials, shows that male circumcision (MC) reduces the risk of HIV infection among men.
Lie and Miller (2011) states: Only after the results of three RCTs were available was the public health community convinced that there was sufficient evidence to initiate provision of circumcision services in high prevalence areas
Holmes, Bertozzi, & Bloom (2017) states: Circumcision of adult males is 70 percent effective in reducing transmission from females to males based on three RCTs... (very strong evidence).
Piontek and Albani, (2019) states: Randomized controlled trials have demonstrated circumcision results in a 50–60% reduction in risk of acquiring HIV infection in heterosexual males. In three clinical trials performed in sub-Saharan Africa, uncircumcised men were randomly assigned to one of two groups. One group was offered immediate circumcision (treatment group) and those in the other group (control group) were offered circumcision at the end of the trial. All participants received HIV testing and counseling, condoms, and safe sex counseling. All three trials were stopped early due to the overwhelming evidence that circumcision offered a protective effect against HIV, and it was felt to be unethical to ask the control group to wait to be circumcised.
World Health Organization (2020) states: The evidence that circumcision reduces the risk of HIV infection in men is strong. Results come from diverse settings, span 32 years (1986 to 2017), and are very consistent... Data from three RCTs.
And so on and so forth. There's numerous other metastudies and/or major medical organizations — easily findable online — that call the three RCTs provide "overwhelming", "very strong", or "strong" evidence. In the context of high-risk populations, anything to the contrary is a fringe perspective at this point. KlayCax (talk) 06:06, 18 September 2022 (UTC)
  • Exactly. “Strong” is one of the words used to describe the RCTs. There is no reason to use “overwhelming”, in light of more accurate terms. Significant minority viewpoints are not “fringe”. We’ve all made ourselves clear whether we think it is fringe or not; I see no point in continuing to argue about this, especially since it has little to do with the “strong” vs. “overwhelming” issue. Prcc27 (talk) 12:53, 18 September 2022 (UTC)
"Strong" and "overwhelming" isn't a contradiction.
Significant minority viewpoints Which, as established, doesn't apply here.
We’ve all made ourselves clear whether we think it is fringe or not Multiple RfC's have as well. KlayCax (talk) 22:00, 18 September 2022 (UTC)
We've had numerous, multiple RFC's on circumcision and this article's talk page about it: all with a similar consensus. Saying that a significant minority of researchers deny a link between HIV/AIDS transmission in circumcision in high-risk contexts (heterosexual transmission) is obviously wrong: as major medical organizations such as the WHO/UNAIDS and all the above sources state. If you're not going to going to participate in discussion: I'm going to add it back unless a new RfC about the matter concludes otherwise. (Since multiple RFC's on the matter have all concluded uniformly the same.)
Given the multitude of sources listed above, it shouldn't be an article of dispute. KlayCax (talk) 22:12, 18 September 2022 (UTC)
  • If you actually read the RFCs on this talk page, you would see that there actually was no consensus on whether that view qualifies as “fringe” or a “significant minority viewpoint”. I did not say I would not participate in discussion..? I pretty much said you are wasting our time by focusing on something that is not relevant to the merits of the issue, but in a more civil way. A lot of your information is already in the body paragraphs of this article, but there seems to be no consensus to make the lead disproportionately about the African trials. Consensus that the African trials have “strong” (or even “overwhelming”) evidence ≠ consensus to add that information into the lead. Prcc27 (talk) 22:55, 18 September 2022 (UTC)

Outdated/fringe POV

Prcc27 evidently wants to re-insert this 2010 "viewpoint" material. It's WP:UNDUE and a bit fringey so this would harm the article I think. Bon courage (talk) 05:09, 6 October 2022 (UTC)

I am okay with cleaning up older content, but I feel this would be problematic to the section if newer recommendations are lacking or not as thorough as older recommendations. Keep in mind, we actually have older content than the KNMG viewpoint in that paragraph right now (from 2007). We have had the fringe argument many times on this talk page before, and there was never a consensus to treat KNMG as “fringe”. There was a split view about whether their viewpoint is “fringe” or a “significant minority viewpoint”. Regardless, the original consensus has not changed thus far. Prcc27 (talk) 05:18, 6 October 2022 (UTC)
I'm not see any justification, or even argument, for inserting this content (and yes, there is yet more old cruft that needs removing too). It's just an outdated unimportant fringey view. Is there anything at all in its favour? Bon courage (talk) 05:34, 6 October 2022 (UTC)
As stated in prior discussions, it is important to include recommendations from around the world, and to include significant minority viewpoints. The debate around the timing of circumcision and comparing and contrasting circumcision vs. other prevention methods is something the KNMG touches on, as well as something the other recommendations touch on. It is okay to use older sources when newer sourcing is lacking, as evident by the AAP (2012) and WHO (2007) sources being included currently. Prcc27 (talk) 05:51, 6 October 2022 (UTC)
I don't think we can undercut established science with fringe views. Those prior discussions never got anywhere anyway. We've already got some KNMG/Dutch stuff now. That's enough (maybe too much and should go too?). Bon courage (talk) 05:56, 6 October 2022 (UTC)
  • The consensus was/is for KNMG to be included. The raw science belongs in the other sections. The recommendations section should show readers different perspectives on how the science should be applied. Prcc27 (talk) 06:21, 6 October 2022 (UTC)
    The consensus was/is for KNMG to be included ← don't think so. Where was this "consensus" assessed and recorded? If you want something like that maybe start an RfC if this thread doesn't result in something clear-cut. Bon courage (talk) 06:26, 6 October 2022 (UTC)
    View the archives. Start with the “2013 position paper of small Dutch medical organization - WP:MEDDATE and WP:REDFLAG” and “Recommendations section”. MEDDATE & MEDRS concerns were addressed there. Prcc27 (talk) 22:08, 6 October 2022 (UTC)
    I don't think there was ever a consensus to include KNMG. Prcc27 has just spoken more loudly than anyone else and threatened others who disagreed with his viewpoint. The fact remains that KNMG is an outlier and encyclopedias do not exist to give equal space to outliers. The AAP, ACOG, and CDC recommendations are mainstream, consistent with WHO recommendations, and that should be the end of it. Petersmillard (talk) 19:50, 6 October 2022 (UTC)
    You’re welcome to view the archives, there were others on board with KNMG. Also, I never threatened anyone. Please quit spreading lies! Prcc27 (talk) 22:03, 6 October 2022 (UTC)
@Prcc27 WHO sources were updated to 2020 and CDC/AAP/ACOG reconditions haven't changed 74.75.197.221 (talk) 21:05, 6 October 2022 (UTC)
There is a 2007 WHO quote in the article, and the expired AAP viewpoint is from 2012. Prcc27 (talk) 22:02, 6 October 2022 (UTC)
IP is Petersmillard just in case anyone is confused. Prcc27 (talk) 22:12, 6 October 2022 (UTC)

RfC: Is there a consensus surrounding circumcision and HIV + should it be in lead?

FAILED PROPOSAL Procedural self-close due to improper formatting of the RfC. Will reopen as another RFC per recommendation by User:Snow Rise. Please check back in a few days after the formatting is fixed. Thanks! KlayCax (talk) 04:35, 12 October 2022 (UTC)

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


The two questions asked are:

  • Is there a general consensus in the scientific community that circumcision reduces HIV/AIDS transmission in high-risk contexts: particularly sub-Saharan Africa?
  • Is the strikethroughed material WP: DUE for the the lead? (e.g. version #1) In particular, the wording that has been struckthrough by Prcc27: who argues there is a substantive debate in the scientific community over the issue of circumcision's prophylactic effects against HIV/AIDS in the context of high risk populations?

Leading to the question:

  • Which version is the best? Version #1, #2, or #3?

KlayCax (talk) 16:25, 7 October 2022 (UTC)

There has been a dispute among editors on whether the article should portray (medically performed) circumcision's prophylactic effect on HIV/AIDS transmission in high-risk contexts — in particular, sub-Saharan Africa — as a general consensus among scientists and how the lead should cover it. The full details of which can be seen in the edit history of the article and in the talk page above.

Per usual formatting: Text that has been deleted in each version of the lead is strikethroughed like this. Text that is added is bolded like this.

Version #1 (before reversion; note that this was added by me from statements already existant in the body):

Male circumcision reduces the risk of human immunodeficiency virus (HIV) transmission from HIV positive women to men in high risk populations.

The first academic paper suggesting a protective association between circumcision and reduced heterosexual HIV infection rates was published in 1986. Experimental evidence was needed to establish a causal relationship, so three randomized controlled trials (RCT) were commissioned as a means to reduce the effect of any confounding factors. Trials took place in South Africa, Kenya and Uganda. All three trials were stopped early by their monitoring boards because those in the circumcised group had a substantially lower rate of HIV contraction than the control group, and hence it was concluded that it would be unethical to withhold the treatment in light of overwhelming evidence of prophylactic efficacy. WHO assessed the trials as "gold standard" studies and found "strong and consistent" evidence from later studies that confirmed the results of the three RCT trials. A scientific consensus since subsequently developed that circumcision reduces heterosexual HIV infection rates in high-risk populations.

In 2020, the World Health Organization (WHO) reiterated that male circumcision is an efficacious intervention for HIV prevention if carried out by medical professionals under safe conditions. Circumcision reduces the risk that a man will acquire HIV and other sexually transmitted infections (STIs) from an infected female partner through vaginal sex. The evidence regarding whether circumcision helps prevent HIV is not as clear among men who have sex with men (MSM). The effectiveness of using circumcision to prevent HIV in the developed world is not determined.

Version #2 (original Prcc27's edit; deleting the lead paragraph, portraying the scientific community as divided on the issue): (See here for edit summary/justification.)

There is evidence that male circumcision reduces the risk of human immunodeficiency virus (HIV) transmission from HIV positive women to men in high risk populations.

The first academic paper suggesting a protective association between circumcision and reduced heterosexual HIV infection rates was published in 1986. Experimental evidence was needed to establish a causal relationship, so three randomized controlled trials (RCT) were commissioned as a means to reduce the effect of any confounding factors. Trials took place in South Africa, Kenya and Uganda. All three trials were stopped early by their monitoring boards because those in the circumcised group had a substantially lower rate of HIV contraction than the control group, and hence it was concluded that it would be unethical to withhold the treatment in light of overwhelming evidence of prophylactic efficacy. WHO assessed the trials as "gold standard" studies and found "strong and consistent" evidence from later studies that confirmed the results of the three RCT trials. A scientific consensus since subsequently developed that circumcision reduces heterosexual HIV infection rates in high-risk populations.

In 2020, the World Health Organization (WHO) reiterated that male circumcision is an efficacious intervention for HIV prevention if carried out by medical professionals under safe conditions. Circumcision reduces the risk that a man will acquire HIV and other sexually transmitted infections (STIs) from an infected female partner through vaginal sex. The evidence regarding whether circumcision helps prevent HIV is not as clear among men who have sex with men (MSM). The effectiveness of using circumcision to prevent HIV in the developed world is not determined.

Version #3 (new Prcc27's suggested edit; preserving the original wording of the first sentence and deleting the overview of the subject in the lead, arguing it's not a consensus that it prevents HIV/AIDS in high-risk populations):

Male circumcision reduces the risk of human immunodeficiency virus (HIV) transmission from HIV positive women to men in high risk populations.

The first academic paper suggesting a protective association between circumcision and reduced heterosexual HIV infection rates was published in 1986. Experimental evidence was needed to establish a causal relationship, so three randomized controlled trials (RCT) were commissioned as a means to reduce the effect of any confounding factors. Trials took place in South Africa, Kenya and Uganda. All three trials were stopped early by their monitoring boards because those in the circumcised group had a substantially lower rate of HIV contraction than the control group, and hence it was concluded that it would be unethical to withhold the treatment in light of overwhelming evidence of prophylactic efficacy. WHO assessed the trials as "gold standard" studies and found "strong and consistent" evidence from later studies that confirmed the results of the three RCT trials. A scientific consensus since subsequently developed that circumcision reduces heterosexual HIV infection rates in high-risk populations.

In 2020, the World Health Organization (WHO) reiterated that male circumcision is an efficacious intervention for HIV prevention if carried out by medical professionals under safe conditions. Circumcision reduces the risk that a man will acquire HIV and other sexually transmitted infections (STIs) from an infected female partner through vaginal sex. The evidence regarding whether circumcision helps prevent HIV is not as clear among men who have sex with men (MSM). The effectiveness of using circumcision to prevent HIV in the developed world is not determined.

Thanks! KlayCax (talk) 16:25, 7 October 2022 (UTC)

Survey

  • Yes, there is consensus that circumcision lowers risk of HIV; no, do not explain much in the lead The problem with explaining is that doing so communicates that the issue is debatable. It is not. There is an established scientific consensus. Any arguments to the contrary start from either exceptions not worth mentioning, or from fringe views. The highest medical authoritative sources are unambiguous and it would be WP:UNDUE to present dissenting, fringe views in the lead. Bluerasberry (talk) 17:17, 7 October 2022 (UTC)
  • Version #1: (Note to other editors: That I started this RfC + have been directly involved in this discussion/dispute. See above on the talk page.) Both a brief summarization of the topic and the statement that there is a consensus is WP: Due and in line with other article related to scientific topics. Sources that state alternatively are WP: Fringe and shouldn't be included in the article.

Some relevant sources addressing the topic include:

Scientific American (2008) states: all three trials were stopped early due to the overwhelming evidence of circumcision's protective effect.
Thomas, et al. (2011) states: Overwhelming evidence, including three clinical trials, shows that male circumcision (MC) reduces the risk of HIV infection among men.
Lie and Miller (2011) states: Only after the results of three RCTs were available was the public health community convinced that there was sufficient evidence to initiate provision of circumcision services in high prevalence areas
Holmes, Bertozzi, & Bloom (2017) states: Circumcision of adult males is 70 percent effective in reducing transmission from females to males based on three RCTs... (very strong evidence).
Piontek and Albani, (2019) states: Randomized controlled trials have demonstrated circumcision results in a 50–60% reduction in risk of acquiring HIV infection in heterosexual males. In three clinical trials performed in sub-Saharan Africa, uncircumcised men were randomly assigned to one of two groups. One group was offered immediate circumcision (treatment group) and those in the other group (control group) were offered circumcision at the end of the trial. All participants received HIV testing and counseling, condoms, and safe sex counseling. All three trials were stopped early due to the overwhelming evidence that circumcision offered a protective effect against HIV, and it was felt to be unethical to ask the control group to wait to be circumcised.
World Health Organization (2020) states: The evidence that circumcision reduces the risk of HIV infection in men is strong. Results come from diverse settings, span 32 years (1986 to 2017), and are very consistent... Data from three RCTs.
Sharma, et al. (2021) states: There is overwhelming immunological evidence in support of MC in preventing the heterosexual acquisition of HIV-1. KlayCax (talk) 18:52, 7 October 2022 (UTC)
  • Version 1, the consensus seems to agree that circumcision lowers risk of HIV.--Ortizesp (talk) 21:54, 7 October 2022 (UTC)
  • Version 2 (maybe even version 3). Is there a “general consensus”? Perhaps. But there are significant minority viewpoints that question the efficacy of circumcision for HIV prevention (i.e. the Royal Dutch Medical Association). That view should be given at least some coverage in the article (not necessarily in the lead), per WP:DUE. There is not a “universal consensus” that circumcision prevents HIV (especially when we are talking about the developed world). The lead proposal is UNDUE per reasoning I gave in previous sections on this talk page. Prcc27 (talk) 22:42, 7 October 2022 (UTC)
  • Version 2. WP doesn't deal in absolutes, there's a significant minority viewpoint counter to the absolute claim, and the lead is no place for a paragraph of source detailia that dense.  — SMcCandlish ☏ ¢ 😼  21:58, 9 October 2022 (UTC)
    WP doesn't deal in absolutes Who knows? Perhaps we are The Sith? -- Emir of Misplaced Pages (talk) 20:56, 11 October 2022 (UTC)
  • First choice: version 3, Second choice: version 2 (and this RfC is highly problematic in it's format). Two different changes should not be the subject of the same !vote as has been done here: as it stands, the way this RfC is formatted, it almost gives the impression that it was purposefully designed to the "split the !vote" between those wishing to support a strong the position that there is strong consensus in the sources for the prophylactic value of the procedures in question, dividing such !votes among options 2 and 3, whereas all !votes supporting a different read on the sources will be aggregated into a single choice, making it easier for that option to reach a higher threshold in responses. I'm going to AGF that this was not intentional--the OP seems to think that version 1 actually advances the argument for strong consensus, afterall; I am not sure I agree with that assessment, but regardless this is specifically why RfCs are not meant to be formatted in such a fashion where two different additions/deletions are contemplated at once. For that matter, there easily could have been a forth option here that dismissed both the proposed added and deleted content.
All that said, and assuming the RfC doesn't get a procedural close and a re-start, I think the corpus of sources as presented is pretty straightforward here: there is a clear scientific consensus on the existence of a statistically significant prophylactic effect of the medical procedures in question with regard to HIV infection rates (whatever the rest of the cultural conflict surrounding customs regarding circumcision). Version 3 most clearly aligns with the balance of the sources, but version 2 is marginally better than version 1. While version 1 does include reference to some of the more robust studies in question, I don't think the lead is the right place for this level of granularity, and I agree with others who have already noted that it actually undermines an accurate portrayal of the overall strength of the broader consensus. And if steps are not taken to reform the RfC, I certainly hope the closer takes the possible bias inherent in the way the !vote has been constructed into question. SnowRise 06:58, 10 October 2022 (UTC)
You're probably right. (And from the comments: there's not going to be a current consensus from the RfC.) I'm procedurally self-closing and restarting in a few days. KlayCax (talk) 04:35, 12 October 2022 (UTC)
  • Version 2 is my first choice. Instead of striking the paragraph, though, I would change it to something representative of the past three decades of research and not just the beginning. I remember reading that circumcision increased the transmission rate in one study, but it was because the men were resuming sexual activity before they were fully healed. Darkfrog24 (talk) 01:14, 12 October 2022 (UTC)

Discussion

  • It's not a debatable point which needs consensus (an odd circumstance which requires WP:RS/AC sourcing); it's just settled science. Any "debate" seemingly died years ago (except in fringe circles and on this Talk page). Bon courage (talk) 16:36, 7 October 2022 (UTC)
I obviously agree with you. But there were dissenting voices (including other IP editors) who kept reverting the paragraph + wording that stated there was a consensus. (As I'm sure you're aware.) I felt like the start of a RfC was the only way to definitely establish a consensus on the matter + the wording within the lead. Or else we would be going back and forth upon this topic for monthsc: without anything productive occuring + and more reversions/edit wars. KlayCax (talk) 18:37, 7 October 2022 (UTC)
  • Relevant links from discussions above:
Scientific American (2008) states: all three trials were stopped early due to the overwhelming evidence of circumcision's protective effect.
Thomas, et al. (2011) states: Overwhelming evidence, including three clinical trials, shows that male circumcision (MC) reduces the risk of HIV infection among men.
Lie and Miller (2011) states: Only after the results of three RCTs were available was the public health community convinced that there was sufficient evidence to initiate provision of circumcision services in high prevalence areas
Holmes, Bertozzi, & Bloom (2017) states: Circumcision of adult males is 70 percent effective in reducing transmission from females to males based on three RCTs... (very strong evidence).
Piontek and Albani, (2019) states: Randomized controlled trials have demonstrated circumcision results in a 50–60% reduction in risk of acquiring HIV infection in heterosexual males. In three clinical trials performed in sub-Saharan Africa, uncircumcised men were randomly assigned to one of two groups. One group was offered immediate circumcision (treatment group) and those in the other group (control group) were offered circumcision at the end of the trial. All participants received HIV testing and counseling, condoms, and safe sex counseling. All three trials were stopped early due to the overwhelming evidence that circumcision offered a protective effect against HIV, and it was felt to be unethical to ask the control group to wait to be circumcised.
World Health Organization (2020) states: The evidence that circumcision reduces the risk of HIV infection in men is strong. Results come from diverse settings, span 32 years (1986 to 2017), and are very consistent... Data from three RCTs.
Sharma, et al. (2021) states: "There is overwhelming immunological evidence in support of MC in preventing the heterosexual acquisition of HIV-1.""
Version #1 is the best. (Per these sources, discussion above, and various other reasons.) More about it is stated in survey subsection. KlayCax (talk) 18:46, 7 October 2022 (UTC)

All are written bad even if the science is right. What makes a 2020 reiteration of settled science so notable? Emir of Misplaced Pages (talk) 13:10, 9 October 2022 (UTC)

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

The evidence on HIV prevention is very unclear

There are a great number of studies that show it has not effect, r even increases infection rates. So why is the lede so adimant that its only a good thing? Tiggy The Terrible (talk) 13:51, 6 November 2022 (UTC)

RFC on the Royal Dutch Medical Association

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Which version of the Royal Dutch Medical Association's recommendations should be included in the article, the full version or the shortened version?

  • Full version: "Because the evidence that circumcision prevents HIV mainly comes from studies conducted in Africa, the Royal Dutch Medical Association (KNMG) in 2010 questioned the applicability of those studies to developed countries. Circumcision has not been included in their HIV prevention recommendations. The KNMG viewpoint document said that the relationship between HIV transmission and circumcision was unclear, and that behavioral factors seemed to have more of an effect on HIV prevention than circumcision. The KNMG also said that the choice of circumcision should be put off until an age when a possible HIV risk reduction would be relevant, so that boys could decide for themselves whether to undergo the procedure or choose other prevention alternatives. This KNMG circumcision policy statement was endorsed by several Dutch medical associations."
  • Shortened version: "Because the evidence that circumcision prevents HIV mainly comes from studies conducted in Africa, the Royal Dutch Medical Association (KNMG) in 2010 questioned the applicability of those studies to developed countries. Circumcision has not been included in their HIV prevention recommendations."

Some users have argued that the Royal Dutch Medical Association (KNMG) viewpoint is WP:FRINGE and out-of-date, while others have argued that the KNMG recommendations qualify as a "significant minority viewpoint" per WP:DUE and that it is important to include recommendations on circumcision & HIV from different regions of the world. Prcc27 (talk) 00:20, 20 November 2022 (UTC)

  • Full version: The Royal Dutch Medical Association is a large medical organization with over 65,000 doctors and medical students as members. The recommendations section of the article, is where "significant minority viewpoints" belong. Of course, if we get more up-to-date and higher quality recommendations, we should replace the older recommendations with the newer ones. But it is worth noting, that the AAP's viewpoint is technically expired, and that there is a quote from The WHO's 2007 viewpoint which is currently in the article, that is actually older than the KNMG viewpoint. Prcc27 (talk) 00:28, 20 November 2022 (UTC)
  • Full version. I tend to agree with Prcc27's points, and in reading the two versions, I find the longer one is considerably more informative about KNMG's position (the additional material is not fluff or blather).  — SMcCandlish ☏ ¢ 😼  06:34, 20 November 2022 (UTC)
  • Full. The Dutch Royal Medical Association is a major institution with a minority viewpoint. Also, the full version gives more details and isn't fluff. — Franklin! 21:14, 20 November 2022 (UTC)
Shortened version: I'm not sure if it's fringe or not but it is certainly a bit out of date and not needing every detail. Other out of date viewpoints in the article can also be appropriately um trimmed or replaced with newer ones if available. BogLogs (talk) 23:49, 22 November 2022 (UTC)
Shorter summary of the KNMG position. Let me preface this by saying I think the KNMG stance is, at most, FRINGE-adjacent, not truly fringe: yes, it is a significant minority opinion in some respects

as compared against consensus medical science on the topic, but let's remember that we are talking about legitimate national-scale body representing tens of thousands of physicians, and at least some of what it has to say on the topic is not altogether controversial. The timeliness issues does raise some concerns in terms of WP:DUE, but sources in Misplaced Pages articles covering this topic are kind of all over the place on the timeline of research as is.

All of that said, the portions that come in under the extended version are definetly those which are either a) closest to fringe statements, relative to the broad corpus of research, such as the claim that "the relationship between HIV transmission and circumcision was unclear" (the particulars may be up for debate but consensus research is pretty clear about the existences of a statistically significant observable relationship), or b) so non-controversial I'm not sure it bears lengthening the article and muddying the waters to include it, as with "behavioral factors seemed to have more of an effect on HIV prevention than circumcision" (no researchers that I have ever heard of are really arguing that the effects of circumcision at are at the same scale of impact as the sex acts engaged in by individuals, their choice of whether to use safe sex practices, their choices with regard to sexual partners, and their medication choices, the only really physiologically relevant "behavioural factors" at play here, making this rather something of a strawman argument that doesn't do much to inform the reader of the actual dimensions of legitimate medical debate about this topic.
Meanwhile, the shorter version still includes the less controversial an informative content: "Because the evidence that circumcision prevents HIV mainly comes from studies conducted in Africa, the Royal Dutch Medical Association (KNMG) in 2010 questioned the applicability of those studies to developed countries." Now this in itself is still a little wishy-washy in terms of the grounds on which it takes issue with the majority/consensus research position, because obviously there is no significant observed physiological difference between African and non-African peoples which would lead to statistically different outcomes for individuals exposed to HIV; that is to say, a circumscribed African and a circumcised non-African would (on average) get just as much benefit (or just as little, depending on your position) when exposed to HIV, so there are some problems with that statement as framed. But I presume the KNMG would explain this position more fully as "in non-African contexts, the benefits of circumcision on the larger epidemiological scale might render different statistical outcomes in terms of benefits to the larger population resulting from the practice." That's a questionable argument in itself, insofar as the KNMG doesn't point to countervailing research so much as casts doubt on the existing Africa-centric research, but it does get it farther past the smell test than some other aspects of their position. And then of course "Circumcision has not been included in their HIV prevention recommendations." is just simply perfectly factual.
On the whole, I don't see a strong argument for the WP:WEIGHT value of the elements included in the longer version, whereas I can see the benefit of the shorter version. I'd also like to note that (though I am sure it was a subconscious and unintentional choice, there seems to me to be some rhetorical bias built into how the two choices are presented here in terms of the nomenclature of the RfC: the "full version" of the "KNMG's recommendations" is just the summary of their position as advanced by one of our editors. The choice therefore is not between a "full" or "shortened" version, but rather between a longer and shorter version, and there's a suggestion in the language employed that we are somehow taking something naturally fulsome and cutting it down for convenience. That's not really appropriate framing any more than if the choices had been labelled a "punchy" version and "verbose" version, imo. Not a huge thing, but worth noting as something that could introduce bias into the discussion. SnowRise 20:31, 23 November 2022 (UTC)
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