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Criticism of African Studies II

I attempted to add a couple brief references to dissenting scholarly works that are critical towards the African trials, which (as it says in the article) are a significant basis for the correlation between circumcision and HIV prevention. I've provided RS, as follows: (I recently changed the second link due to concerns raised by Alexbrn, but it leads to the same study). these RS should be more than adequate, especially a scholarly journal on medical ethics. it should even meet MEDRS requirements, since this consists of criticism of studies, rather than biomedical claims. it's important to include criticism & minority viewpoints to ensure an equitable, balanced article. despite all this, my edits have been reverted, which I believe is unjustified. Xcalibur (talk) 18:32, 31 October 2020 (UTC)

We do not publish fringe views. The view that circumcision does not reduce the risk of HIV is a fringe view per Misplaced Pages policy. The articles you linked (at least the first one) are the equivalent of “op Ed” pieces in journals - and are reliable enough for the claims you’re making per WP:MEDRS. Yes, criticism of studies also falls under that requirement - that would not make sense if it doesn’t. It is not important to include fringe viewpoints and we are actually prohibited from doing so by WP:FRINGE. -bɜ:ʳkənhɪmez (User/say hi!) 18:41, 31 October 2020 (UTC)
what you're saying is erroneous, no offense. it's not FRINGE, it's a minority view. more importantly, The view that circumcision does not reduce the risk of HIV is a fringe view per Misplaced Pages policy. nowhere did I assert this claim; fringe or not, this would be OR. all I said was that there's a minority of research that rejects the validity/integrity of the African studies, which are significant to the topic. that is true and on solid RS ground, I'm not connecting dots beyond that. my RS are not 'op ed', they're published articles in reputable secondary sources. MEDRS shouldn't be a problem here, the sources are certainly strong enough, and their age shouldn't be an issue given the context. MEDRS and FRINGE serve important purposes, but they should not be used as barricades to keep out unpopular information. Xcalibur (talk) 19:02, 31 October 2020 (UTC)
It is not WP:FRINGE to give due weight to minority viewpoints within the medical professional community. There is some legitimate criticism/conflicting results with regards to the African trials. For example, the Royal Australasian College of Physicians even mentions some of the issues with these studies: "A population survey conducted in South Africa however failed to show benefit of circumcision in prevention of acquisition of HIV. In addition there has been recent criticism of early cessation of clinical trials because of clear  therapeutic benefit because of the tendency for this practice to over-emphasise benefit". Prcc27 (talk) 19:45, 31 October 2020 (UTC)
It is the very definition of fringe to promote minority views within the medical community (e.g. that jade amulets prevent COVID-19). We really need good WP:MEDRS sourcing and I'm not sure why there's a push to spin editorial around weak sources. Alexbrn (talk) 21:16, 31 October 2020 (UTC)
  • That's a grossly inaccurate comparison. Are there any major medical organizations that actually take the jade amulet view seriously? The RACP is a major medical organization/WP:MEDRS compliant source, and if they take the criticism of the studies viewpoint seriously enough to at least give some recognization, then we should too. I'm not talking about adding something in the article that straight up says that the trials are flawed- just that we should mention that there is a significant non-fringe minority viewpoint that there are some flaws with the studies. Prcc27 (talk) 22:29, 31 October 2020 (UTC)
Your fringe views are totally unsupportad scientifically. These were landmark, valid studies and each study was stopped early by a different, independent ethics panel because the effect was strong enough to make it unethical to continue without offering circumcision to the control subjects. The earth is not flat, and circumcision does prevent transmission of HIV from women to men. Peter Millard, MD, PhD (epidemiology) Petersmillard (talk) 21:58, 31 October 2020 (UTC)
  • The RACP, a major medical organization, notes that stopping the trials short might mean that the benefits were over-emphasized. Why are you and Alexbrn making false equivalencies..? Are there any major scientific organizations that think the Earth is flat? These logical fallacies you two are making will get us nowhere. Prcc27 (talk) 22:29, 31 October 2020 (UTC)
I am making that equivalency because there is not the remotest possibility that circumcision does not prevent HIV transmission from women to men. If you believe in science, than you must accept scientific results. If you don't accept science, then you are a 'flat earther.' Tt is a closed case scientifically. Petersmillard (talk) 22:33, 31 October 2020 (UTC)
I never said that the RACP said that circumcision does not prevent HIV transmission. But they do note that the data that suggests that it prevents it is in conflict with a population survey conducted in the same country one of the RCTs was conducted in. And they suggest that even though circumcision does prevent HIV- ending the trials early means that the findings in favor of that view could have been overstated. So no, I am not proposing that we say "circumcision does not prevent HIV". I am suggesting that we mention that there is criticism with regards to the results and methodology of the trials. So even if "circumcision does not prevent HIV" was a fringe view- I am not even suggesting that we should write that in the article. P.S. could you please use ":" to indent your comments? Thank you. Prcc27 (talk) 22:48, 31 October 2020 (UTC)
If there were any validity to these criticisms, then, yes, I would agree with you. Unfortunately, there is not. A wealth of observational studies since the RCTs demonstrate that, on a population level, HIV prevalence is affected by male circumcision. If there is one study that says otherwise, it is a clear outlier. Petersmillard (talk) 22:54, 31 October 2020 (UTC)
  • So, to explain more fully. There is valid disagreement as to whether the studies can be generalized to all countries - and that's reflected in the current article. Per WP:CSECTION, a criticism section by itself is only merited if there is a large body of critical material, and if independent secondary sources comment, analyze or discuss the critical material. I don't feel that's the case here - there are a very small minority of medical professionals and scientists who actually are criticizing the studies themselves. I believe that the idea that the studies were fundamentally flawed as a whole, as opposed to just non-generalizable to developed countries, is a fringe viewpoint. The fringe guideline defines a fringe theory as an idea that departs significantly from the prevailing views or mainstream views in its particular field, and says that fringe theories often mainstream scientific theories and methodology while lacking a critical discourse or on weak evidence such as anecdotal evidence or weak statistical evidence. This first article is from the equivalent of an "op ed" section in the journal - not a peer reviewed section. The authors of PMID 22320006 have a conflict of interest with the subject, as one of the authors is a member of the board of Doctors Opposing Circumcision - which means he has a financial interest in creating controversy around this subject. I have yet to see a solidly peer-reviewed study, review, analysis, or guideline that actually calls into question the statistical methods and studies conducted in Africa - while some guidance and reviews question the studies' applicability, I haven't seen a solid questioning of their methodology or results itself. Thus, in my opinion, unless further better sources can be brought forth, this qualifies as WP:FRINGE.
    Even if it isn't a fringe theory, discussion of the results of medical studies falls under WP:MEDRS - which states that all biomedical information must be based on reliable, third-party published secondary sources, and must accurately reflect current knowledge (emphasis added). Discussion of whether the results of a medical study are valid or not is certainly a piece of "biomedical information" which falls under this policy - if the information from the studies would be considered biomedical (which it is), then criticism/discussion of those studies is also inherently biomedical. Per MEDRS, we must present prevailing medical or scientific consensus, which can be found in recent, authoritative review articles, in statements and practice guidelines issued by major professional medical or scientific societies and widely respected governmental and quasi-governmental health authorities, in textbooks (parenthetical examples removed for brevity). The prevailing consensus is that circumcision reduces the risk of a male becoming infected with HIV during heterosexual vaginal intercourse. The MEDRS policy then goes on to state that Although significant-minority views are welcome in Misplaced Pages, such views must be presented in the context of their acceptance by experts in the field - and that the views of tiny minorities need not be reported. Given that even governmental agencies who don't recommend circumcision for newborn males still concede that it has been shown to have a benefit, and that the number and quality of articles about this "criticism" are both low, I do not believe that even if it isn't fringe that it can be included.
    So, where does that leave this discussion? There's obviously disagreement on this issue - and I don't know that my explanation here will resolve it even though I'm trying. For this reason, I feel that the next step may be to hold a request for comment to get some uninvolved eyes and opinions on this issue. If that's desired, I propose the following options be given for editors to choose to agree with or not, with the introduction of: Regarding criticism of the African studies conducted prior to 2000, which of the following options best describes their place in this article? The options could be followed by a list of sources presented which could be utilized to construct this section, as well as sources which may suggest it is a fringe theory, or that it is against the current scientific consensus. The sources could be accompanied by a short explanation such as "This source is a letter to the journal which expresses concern about the studies" or "This systematic review article discounts the criticism as invalid" or similar if people desire to put a comment with their sources.
    • Option 1: The criticism should be included in the article in a section devoted to this criticism.
    • Option 2: The criticism should be included in the article in a section which currently exists, but should not have a section devoted to it. Please specify the section you believe it should be discussed in.
    • Option 3: The criticism is a fringe view which should not be included in the article.
    • Option 4: The criticism is not a fringe view, but cannot be included unless reliable medical sources are found which discuss the criticism.
    • Option 5: The criticism is not a fringe view but should not be included as it is not due weight.
  • I feel that this is a neutral way to pose this question such that other editors can express a) whether it should be included, b) if it shouldn't be included, why not, and c) if it should be included, where and how to include it. I figured I'd post this before just going off and starting an RFC here - if everyone is okay with getting uninvolved people to opine on this topic. If nobody objects in a day or so, I plan to go ahead and start the RfC so others can be invited to opine on the issue. Regards -bɜ:ʳkənhɪmez (User/say hi!) 01:34, 1 November 2020 (UTC)
I think an RFC would probably be best. Prcc27 (talk) 02:04, 1 November 2020 (UTC)
I think Berchanhimez and Petersmillard have it exactly right. We're not going to be promoting some fringe unreliable source here to say the African studies were "fatally flawed" when we have a settled view from pretty much every other type of WP:MEDRS source to the contrary. In my view, a RfC would verge on being disruptive seeing as the consensus must be against inclusion - it would improper to press for including fringe/unreliable content. Alexbrn (talk) 08:22, 1 November 2020 (UTC)
Even if the "fatally flawed" claim itself is fringe, not all criticism of the studies should automatically be seen as "fringe". One can argue that there were some flaws in the studies, yet still agree holistically with their findings. By the way, here is what the Royal Dutch Medical Association's background study said about the trials: "in recent decades, evidence has been published which apparently shows that circumcision reduces the risk of HIV/AIDS, but this evidence is contradicted by other studies". Even if the RACP and KNMG agree overall that the RCTs prove that circumcision prevents HIV- they seem to also think that the contradicting evidence against it is at least somewhat noteworthy. I do think we need resolution to this discussion, since it keeps being brought up, and IMHO, an RFC seems like the best way to do that. I genuinely think we could benefit from hearing what other Misplaced Pages users have to say. Then, if the issue ever comes up again in the future, we would have the RFC to fall back on with regards to how we should move forward. Prcc27 (talk) 08:47, 1 November 2020 (UTC)
There is a new position paper from WHO which summarizes all the evidence. https://www.malecircumcision.org/resource-bundle/preventing-hiv-through-safe-voluntary-medical-male-circumcision-adolescent-boys-and Petersmillard (talk) 11:46, 1 November 2020 (UTC)
First of all, there are major false equivalencies above. ideas such as flat earth, or preventing disease through amulets, are not only unscientific but prescientific. there is no comparison between a reputable minority view that goes against the grain, vs. completely disregarding the scientific method. secondly, I am making that equivalency because there is not the remotest possibility that circumcision does not prevent HIV transmission from women to men. If you believe in science, than you must accept scientific results. If you don't accept science, then you are a 'flat earther.' Tt is a closed case scientifically. as I've warned you previously, science is a method, not a dogma. it provides us with very useful tools, but these must be used correctly (i.e. proper methodology). if science is not done properly, the results become skewed and incorrect; therefore, it is reasonable to critique and question scientific results on those grounds. your claim seems to be that we must blindly accept any result labeled as scientific, or reject science as a method entirely, which is a false dichotomy.
op-ed/CoI: it's not an op-ed or letter to the editor, it's a published article. as for CoI, I understand your concerns, but it's up to peer-reviewed journals to make those judgment calls. if it's good enough for scholarly literature, it should be good enough for Misplaced Pages, simple as that.
FRINGE: just because it's a minority viewpoint doesn't mean it's fringe. I have in fact provided scholarly critiques of the relevant methodology and findings, so this doesn't apply. really, the Fringe policy is designed to keep out nonsense like homeopathy, flat earth, conspiracy theories, planet Nebiru, and Barry Fells version of history & archaeology. it's not intended as a means of gatekeeping dissenting minority views that are published in peer-reviewed literature. keep in mind, we must use a bit of flexibility and judgment in interpreting these policies, since they're not written with one particular article in mind. since the RS are on solid ground, Fringe shouldn't apply here.
MEDRS: the number may be relatively low, but the quality is fine. I'd argue that my RS should pass muster under MedRS, since the work is scholarly and peer-reviewed. it doesn't get much more reliable and relevant than a scholarly journal on medical ethics. the only complaint here is that it's not recent, but the African studies themselves are from the 2000s, so this shouldn't factor in. again, we must use our judgment when interpreting 'one-size-fits-all' policies. MedRS is intended to ensure high quality medical information, and to guard against misinformation and outdated results. for example, if you publish a claim about COVID-19 treatments on the relevant article, you must have very strong & recent support for this, otherwise you could end up causing harm. that's a different situation than including critiques of the African studies, which is indirectly biomedical in nature. In other words, a statement like 'x treatment cures y disease' should be considered differently than 'z study on the efficacy of x treatment may be methodologically flawed'.
I'm willing to abide by DUE WEIGHT, briefly citing criticism within the text, while allowing majority views to dominate the article. keep in mind, even if circumcision reduces HIV transmission, it doesn't *prevent* transmission, indeed, sources I've looked up warn against 'false confidence' created by circumcision, since it is no replacement for condom use. to quote other sources I've referred to: until we know why and how circumcision is protective, exactly what the relationship is between circumcision and other STIs, and whether the effect seen in high-risk populations is generalisable to other groups, the wisest course is to recommend risk reduction strategies of proven efficacy, such as condom use. additionally, I've come across a new source recently which casts more doubt on this topic:
I agree that a RfC, properly executed, would be a productive solution. Xcalibur (talk) 15:33, 2 November 2020 (UTC)
new sources: Xcalibur (talk) 14:35, 3 November 2020 (UTC)

Sources

Placeholder for others to add in sources which may support inclusion of criticism, or argue against inclusion for reasons of due weight or fringe policy. Beyond a quick explanation of the source (ex: authors, title, journal, what it discusses in brief) discussion should take place in the RfC section below. -bɜ:ʳkənhɪmez (User/say hi!) 15:48, 2 November 2020 (UTC)

References

  1. Svoboda, Steven; Van Howe, Robert (July 2013). "Out of Step: Fatal Flaws in the Latest AAP Policy Report on Neonatal Circumcision". Journal of Medical Ethics. 39 (7). BMJ: 434–441. doi:10.1136/medethics-2013-101346. JSTOR 43282781. PMID 23508208. S2CID 39693618.
  2. https://pubmed.ncbi.nlm.nih.gov/22320006/
  3. Dowsett GW, Couch M (May 2007). "Male circumcision and HIV prevention: is there really enough of the right kind of evidence?". Reproductive Health Matters. 15 (29): 33–44. doi:10.1016/S0968-8080(07)29302-4. PMID 17512372.
  4. Darby R, Van Howe R (2011). "Not a surgical vaccine: there is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia". Australian and New Zealand Journal of Public Health. 35 (5): 459–465. doi:10.1111/j.1753-6405.2011.00761.x. PMID 21973253.
  5. Frisch M; et al. (2013). "Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on Male Circumcision". Pediatrics. 131 (4): 796–800. doi:10.1542/peds.2012-2896. PMID 23509170.
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RFC on criticism of studies

Regarding criticism of the African studies conducted prior to 2000 which showed a reduction in HIV infection risk from heterosexual intercourse in circumcised males compared to uncircumcised, which of the following options best describes this information's place in this article? -bɜ:ʳkənhɪmez (User/say hi!) 15:48, 2 November 2020 (UTC)

  • Option 1: The criticism should be included in the article in a section devoted to this criticism (or in a reception section which includes both criticism and acceptance).
  • Option 2: The criticism should be included in the article in a section which currently exists, but should not have a section devoted to it. Please specify the section you believe it should be discussed in.
  • Option 3: The criticism is a fringe view unsupported by any significant minority of professionals which should not be included in the article.
  • Option 4: The criticism is not a fringe view, but cannot be included at all unless reliable medical sources are found which discuss the criticism.
  • Option 5: The criticism is not a fringe view but should not be included at all as it is not due weight.

Additional note: Please see section(s) above for prior discussion and list of sources that may be useful to considering this question. -bɜ:ʳkənhɪmez (User/say hi!) 17:50, 2 November 2020 (UTC)

Comments

  • Barring further development of reliable sources which do not have a conflict of interest and are accepted in the mainstream community as valid, I believe that any of option 3-5 are acceptable. I think an entire section is more than undue and would suffer from the issues regarding any section devoted entirely to criticism, thus I would recommend that option 1 only be considered if a reception section which includes criticism and acceptance can be fleshed out. I will reserve my final opinion pending the discussion of editors here and any sources that may arise. -bɜ:ʳkənhɪmez (User/say hi!) 15:48, 2 November 2020 (UTC)
  • It is an irrelevant question. The studies done prior to 2000 were all observational studies. It is easy to critique observational studies because of uncontrolled confounding. Observational studies are often done as a prerequisite to RCTs, which are expensive but provide scientific proof of hypoetheses initially tested through observational studies. The 2 large RCTs conducted in Africa after 2000 put the question to rest. Adult male cirucumcision reduces HIV transmission from female partners by about 50%. — Preceding unsigned comment added by 74.75.197.221 (talk) 16:20, 2 November 2020 (UTC)
  • The only source on offer seems to be a twenty year old primary one with a polemical stance, thereby failing WP:MEDRS, and at odds with what has subsequently become settled medical knowledge. Basically, this looks like yet another push to get any possible "criticism" of circumcision into Misplaced Pages, and going by the balance of sources it would be completely WP:UNDUE (and also a bad idea for the reasons set out in WP:CRITS). Alexbrn (talk) 17:47, 2 November 2020 (UTC)
  • Option 2 (but open to option 1). We should expand on the criticism that major medical organizations have made with regards to the RCTs in the recommendations section. The Royal Dutch Medical Association notes that there are studies that contradict the RCTs, and the Royal Australiasian College of Physicians notes that the studies might overemphasize the benefits due to the studies being terminated early. That being said, we would still have to put their views into context to make clear that they still believe that in general, there is enough evidence that circumcision prevents HIV (especially the RACP). Prcc27 (talk) 19:00, 2 November 2020 (UTC)
  • Option 5 per WP:UNDUE Idealigic (talk) 20:19, 9 November 2020 (UTC)
  • Option 2 (Option 1 would also be acceptable). the claim that circumcision reduces HIV transmission is largely based on the African studies, which makes them significant to the article; this also means that criticism of their scientific validity is also significant. the information I propose to add is from scholarly sources, including a scholarly journal on medical ethics, which should satisfy reliability. the FRINGE policy is for keeping out pseudoscience, not for gate-keeping well-founded minority views, so it's being misused in this case. also, if the African trials were unscientific, that doesn't necessarily refute the correlation between circumcision and reduced risk of HIV; they may have been fatally flawed, and the correlation may be valid, both of these conditions can be true. flawed methodology doesn't explicitly disprove findings, it just makes them less probable and reliable. in other words, criticizing the studies is not necessarily rejecting their conclusion, it's just criticizing and casting doubt on the matter. personally I think it's likely that, while the correlation is there, it may have been significantly exaggerated by the studies, but this is just my own conjecture. Xcalibur (talk) 07:24, 11 November 2020 (UTC)
  • Option 5 (or 3 or 4, but certainly not 1 or 2) per my and others' comments above. We have up-to-date top quality WP:MEDRS giving an overview of the topic, so should not be scraping around among weak sources to try and confect a counter-view. There is a fundamental question of WP:NPOV here. Alexbrn (talk) 07:42, 11 November 2020 (UTC)
  • Options 3, 4, or 5. It's sort of borderline fringe, in the sense that some of the scientific criticisms are not exactly wrong, but they are overstated, do not align with mainstream views, and critics frequently misrepresent mainstream views. In terms of finding sources, if it's going to be mentioned at all, then I suggest excluding as patently unreliable any source that says risk reduction doesn't save lives – "only 10%" would be a lot of lives saved – or that is focused on involuntary circumcision or opposes men's rights to voluntarily choose circumcision. Other points:
    • The amount of value that any risk-reduction program provides an individual depends upon factors outside that individual's control. I don't know how many of you are familiar with HIV testing, but the typical rapid HIV testing has a significant false-positive and false-negative rate. So imagine that you get a quick test, and it comes back positive. This test produces what we consider to be a preliminary result. You want to know whether you actually have HIV. I don't know. If you're in the US, the first question that I'm going to ask you is whether you're gay. What's your sexual orientation have to do with the test results? Because the risk of infection is so much higher in men who have sex with men that it actually makes a noticeable difference. If you are a US white female, then your "positive" test is probably a mistake. If you are a US gay man, then your positive test is probably real (and I'm sorry). Why this tangent is relevant: Some of the opposition to this subject is due to misunderstanding the applicability of these results to other situations. As a public health measure, the practical benefit will be highest when men have multiple high-risk female partners (e.g., in a place where prostitution is common), other forms of risk reduction (e.g., condoms, PrEP) are frequently not used, other STIs are not easily treated, and HIV rates are high. The practical benefit will be lowest in countries/groups with good healthcare, higher rates of monogamous sexual relationships, and low HIV rates. So even if you utterly ignore people's personal views about circumcision/intactivism, this intervention would be expected to work better in Cambodia than in the Netherlands. That's just how the math works, and that's why I'm unimpressed by the argument that has appeared on this page that if that one website from the Netherlands doesn't recommend it, then it's not mainstream science. That's not what that means. What that means is that people in the Netherlands have a lower risk to begin with, and they therefore get less absolute benefit from this intervention. It's still mainstream science.
    • I oppose option 1 specifically per Misplaced Pages:Neutral point of view#cite note-1 and Misplaced Pages:Criticism#Integrated throughout the article. It think it is the worst option. WhatamIdoing (talk) 22:41, 16 November 2020 (UTC)
      • I don't think the Royal Dutch Medical Association's view on HIV and circumcision is "the Netherlands has lower HIV rates, so that's the only reason why circumcision isn't (as) effective in the Netherlands". They argue that there is conflicting evidence with regards to whether or not circumcision prevents HIV in general, and some of that "conflicting evidence" is regarding circumcision's efficacy at preventing HIV in Africa.. Here are some of the sources with regards to Africa that they cite: . The first source says "the apparent lack of a protective effect of male circumcision contrasts with other studies in Africa." The second sources says "women... whose partners were circumcised ... were also at higher risk of being infected." I'm not saying that the Royal Dutch Medical Association's overall view is that circumcision doesn't prevent HIV in Africa. But they at least seem to give some sort of recognition to the idea that maybe circumcision isn't an effective HIV prevention measure, even in Africa.
      • Side tangent: I take issue with you insinuating that sexual orientation has anything to do with HIV risk. Sexual behavior, not sexual orientation, is a risk factor. I think it is way more respectful for you to say that MSM are at higher risk of HIV, than to say gay people in general are. I'm a Queer male, but am at low risk of HIV because I am not a MSM. I assume you didn't mean for your remarks to come off as offensive, but they offended me personally. There's a reason why Misplaced Pages uses "MSM" (including in this article), not "gay". Prcc27 (talk) 09:22, 17 November 2020 (UTC)
        I'm sorry that you were offended by the common, casual assumption that sexual orientation correlates strongly enough with sexual behavior to be a practical question. The MSM language has been criticized as a form of queer erasure, and in my experience, more gay men are offended or disconcerted by being asked if they have sex with men than being asked if they're gay.
        As for the 1994 and 1995 papers you linked, they're both observational studies (not randomized experiments), so their scientific value is limited. It's possible that some other factor was involved (e.g., circumcision happened to be more common among men with an additional risk factor) or that it was just random chance. Other studies, including some in the same areas (such as the communities around Lake Victoria, which is notorious for its Sex for fish problem), have shown the opposite. The fact that studies sometimes conflict is one of the reasons that WP:MEDRS prefers a good Meta-analysis or review article instead of a cherry-picked study. WhatamIdoing (talk) 06:27, 30 November 2020 (UTC)
        • If we were citing those papers directly, then yes, I would understand why we would be hesitant to include it. However, I was talking about attributing the view that there are conflicting studies to the Royal Dutch Medical Association. The conflicting studies don't negate the accuracy or lack thereof of the RCTs. I wasn't suggesting that we say it does. Perhaps my proposed Royal Dutch Medical Association sentence could be left out though. Regardless, that still leaves my other proposed sentence along the lines of "the Royal Australiasian College of Physicians notes that the RCTs might overemphasize the benefits due to the studies being terminated early." FWIW, they're not even saying that the RCTs' conclusions are false, just that they might be overstated. Why shouldn't we include the proposed Royal Australiasian sentence? Prcc27 (talk) 06:59, 30 November 2020 (UTC)
          • Because we don't use weak sources to undercut strong ones. We have über-strength WP:MEDRS giving us the settled consensus of medical science on this topic. BTW, "notes" is another hallmark of POV-pushing. Alexbrn (talk) 07:47, 30 November 2020 (UTC)
            • I wouldn't consider the Royal Australiasian College of Physicians a "weak source". We considered adding them as a source before, and nobody argued that the source was too "weak" to be added. My proposed sentence does not undercut the holistic view of the RCTs being seen as accurate and coming to the conclusion that circumcision helps prevent HIV. I don't think it was the RACP's intent to undercut the trials. Even the highest quality studies can have setbacks. The RACP didn't necessarily bring up the setbacks to try to discredit the studies in its entirety. As for the wording.. it was a rough suggestion that would obviously be tweaked. I never said it couldn't be improved. Prcc27 (talk) 16:15, 30 November 2020 (UTC)
              • Why would we use a low-grade 10 year-old source when the settled science, as represented by top-quality recent WP:MEDRS, has moved on, unless we wanted to push a POV? If you want to criticise circumcision via any means possible, maybe start a blog or something? Doing it here is getting increasingly disruptive. Alexbrn (talk) 16:20, 30 November 2020 (UTC)
                • I'm not really sure what qualifies as "low-grade". In another section, you seemed to be okay with adding 1 sentence based on the RACP's views, which would imply that the RACP isn't necessarily low-grade enough to prevent it from being added altogether. So it's not just the source that is the problem, the issue seems to be that you think the RACP's comments on overstating the results contradict the other sources we use. Perhaps they, but only to a degree. In general, the RACP seems to view the RCTs as being accurate. Criticizing RCTs with regards to circumcision ≠ criticizing circumcision. In a previous section, you falsely accused me of POV-pushing when A) implementing a proposal that another user (not I) suggested and b) falsely assumed that I knew the KNMG's study was separate from their overall viewpoint, even though I did not know they were not part of the viewpoint. If you would have pointed out potential POV issues in good faith, without jumping to conclusions, maybe I could entertain your POV accusations now. It's just hard to take you seriously when I know you've falsely accused me of POV-PUSHING in the past. If other users here think there are POV issues with what I'm proposing, I'd be much more likely to yield to their concerns. Also, the reason this RfC was started was to settle this issue once and for all. While consensus can change, I will ultimately respect the outcome of this RfC. The RfC was created to settle this dispute, not to stonewall. I don't have any intention of re-proposing something if it is rejected in an RfC. Prcc27 (talk) 16:57, 30 November 2020 (UTC)
                  • It's ten years old, from one (of several) of the colleges of health workers in Australia. Their official position on circumcision currently returns a 404 on their web site. This looks very much like a "I've got a POV, now let's find a source - any source - to back it". If we want to represent what "Australia" thinks about "circumcision and HIV" (if anything), then at least go up the chain to the Australian DoH or something. Alexbrn (talk) 17:11, 30 November 2020 (UTC)
                    • The RACP covers New Zealand too though.. Also, I'm not opposed to using other sources for the "national" representation of the issue, instead of the RACP, if better sources exist from those countries. But I don't think any other Australian/New Zealander sources were proposed until just now.. FWIW, I originally proposed adding the American Academy of Family Physicians, which seemed to be more critical than the AAP, but we ended up settling for the AAP viewpoint once we learned that it included a large taskforce (which also consisted of the AAFP). Then we added the CDC, since it was newer than the AAP source, and basically reinforced the AAP view. Prcc27 (talk) 17:24, 30 November 2020 (UTC)
                      On the question of whether we should repeat RACP's warning about stopping trials early: The fact that stopping a trial early will, on average, overstate the benefits has been known for about 30 years. It is not unique to these trials; it is merely a consequence of random chance and happens in absolutely every study that collects data at more than one point in time. (This happens because you're more likely to reach your 'stop early' numbers if the benefits happened to randomly go up just before your interim analysis point than if they randomly went down then. This phenomenon is also why you don't plant spring flowers just because you happened to get one warm day in the winter, or even several in a row: a random uptick doesn't mean that the overall average has moved that far.)
                      Since this has been known for three decades, I therefore assume that the scientists working in this subject are also aware of it, and have already factored that into their estimates and recommendations. I do not see any need for Misplaced Pages editors to push forward our own peer-review efforts. WhatamIdoing (talk) 04:41, 1 December 2020 (UTC)
On the question of whether we should repeat RACP's warning about stopping trials early: The fact that stopping a trial early will, on average, overstate the benefits has been known for about 30 years. ... I therefore assume that the scientists working in this subject are also aware of it, and have already factored that into their estimates and recommendations. that's a fairly significant assumption, and all the more reason to include relevant criticism. It's ten years old, from one (of several) of the colleges of health workers in Australia. 10 year old criticism of studies conducted more than 10 years ago should still be just as applicable. in this case, age shouldn't detract from credibility; it's not a dynamic situation like covid-19 where we need to the most up-to-date information possible. Xcalibur (talk) 11:08, 8 December 2020 (UTC)
  • Option 2, per Xcalibur. ImTheIP (talk) 15:08, 2 December 2020 (UTC)
  • Option 2 (or Option 1 as 2nd choice). I think its important we talk about the problems with the studies, because this is far from being a proven phenomenon. These results should be treated as skeptically as any other subject. Off topic, but I'm also internally wondering if the WHO authors had conflicts of interest, bc I read something about that years ago (maybe it was fake news) --Pythagimedes (talk) 01:22, 13 January 2021 (UTC)

Voluntary Medical Male Circumcision

The source in the lead refers to "Voluntary Medical Male Circumcison". And throughout in the article, we use the term "Voluntary Medical Male Circumcison". So why is the term "Voluntary Male Circumcison" being used in the lead? I've never heard that term, I'm not sure that term even exists, and I'm not sure it's backed by the sources. Prcc27 (talk) 09:43, 16 January 2021 (UTC)

There are two sources in the lede. Harrison's just says "male circumcision" and the conclusion of the other source begins "The evidence that circumcision reduces the risk of HIV infection in heterosexual men is strong and consistent from a wide diversity of study designs and settings". Furthermore it makes the point "Promoting male circumcision to reduce the risk of heterosexual transmission in epidemics where circumcision is already commonly practiced for cultural reasons (e.g. religion and/or social norms) would have limited impact on the HIV epidemic." The body is the place to go into finer-grained categorisations, but in the lede we must be necessarily more approximate to avoid error. I'd be fine to drop the word "voluntary". Alexbrn (talk) 09:59, 16 January 2021 (UTC)
I'm also okay with dropping "voluntary", so that we can use a term backed by the sources. Prcc27 (talk) 10:04, 16 January 2021 (UTC)

Criticism of African Studies III / Risk Section

The RfC was inconclusive, in my estimation. I've tried to add the critical content back, only to encounter resistance again. I see nothing wrong with adding relevant criticism from scholarly sources; if the African studies are to be mentioned at all, then critiques of them should be included, even if it's a minority view. The points made in the edit summaries (NPOV, MEDRS) don't hold weight imo. I'm not denying the consensus view (that circumcision reduces transmission), I'm adding relevant criticism. If the studies have flawed methodology, that doesn't necessarily disprove the results, it just makes them unreliable; it's possible for a flawed study to be accidentally correct. As for Reliability, I've cited articles from relevant scholarly journals, which should be more than adequate. Some of the particular demands of MEDRS, such as recent information, don't apply to this particular case. Criticism of studies conducted in the 2000s do not become obsolete over time -- HIV and circumcision have not substantially changed in the past 15 years, and since the studies and their findings are still relevant, then criticism should also still be relevant. Otherwise, we could reject any mention of the studies on the grounds of MEDRS because they were too long ago, which would be absurd. If you want me to reduce the text, I'm willing to negotiate. But there's no need to gatekeep the article against relevant, well-sourced information. Xcalibur (talk) 13:06, 20 January 2021 (UTC)

The point is we can't source biomedical stuff to unreliable sources. What do reliable sources say on this matter? Alexbrn (talk) 13:10, 20 January 2021 (UTC)
here are my sources: scholarly journals on medicine should be more than sufficient for inclusion. Xcalibur (talk) 13:48, 20 January 2021 (UTC)
  1. ^ Svoboda, Steven; Van Howe, Robert (July 2013). "Out of Step: Fatal Flaws in the Latest AAP Policy Report on Neonatal Circumcision". Journal of Medical Ethics. 39 (7). BMJ: 434–441. doi:10.1136/medethics-2013-101346. JSTOR 43282781. PMID 23508208. S2CID 39693618.
  2. Boyle, G. J.; Hill, G. (2011). "Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns". Journal of Law and Medicine. 19 (2): 316–34. PMID 22320006.
Such sources are not reliable for "criticism" of the biomedical aspects of research. They may be reliable for their own views of ethics questions (a separate topic), but then the question of WP:WEIGHT comes up. Are then any secondary/MEDRS sources on this topic that would be suitable? BTW, your signature seems to disagree with your username, which is a problem I think. Alexbrn (talk) 14:01, 20 January 2021 (UTC)
WEIGHT shouldn't be an issue, since I'm only inserting a brief blurb into a relevant section of the article, not shifting the overall focus. I could search for more RS, but the ones I linked should already be enough. I don't see how they aren't reliable, reputable scholarly journals are about as reliable as it gets for a given topic. I've already addressed why time shouldn't be an issue here, especially since my blurb was added to the 'History' section, with citations from 2000, 2005, 2009, 2011, even one from 1986. in fact, I see references from 2007 and 2011 elsewhere in the article. Xcalibur (talk) 14:29, 20 January 2021 (UTC)
Please see WP:MEDRS, for biomedical claims we really want secondary sources (reviews, etc.). Weight is an issue because if a person's dated view has received no traction in better sources, why should Misplaced Pages be mentioning it? We could end up doing the problematic thing of promoting old, wrong, obscure material in a way which undercuts up-to-date knowledge. Alexbrn (talk) 14:33, 20 January 2021 (UTC)
actually, issues with experimental methodology fall under ethics, which makes the journals relevant. I agree that we shouldn't undercut current biomedical knowledge with dated info, but that doesn't apply here. the content I'm adding is largely not biomedical, it's about experimental methodology. it also covers epidemiological factors, which may be biomedical, but are on solid ground. if I made a claim about the relationship between circumcision and HIV, that would be biomedical, but I'm not doing so. Xcalibur (talk) 04:15, 21 January 2021 (UTC)
There may be ethical aspects to methodology, but that's not what you added. Discussions of bias and statistical approach are not "ethics". Misplaced Pages articles must be based on secondary sources, and while in the RfC above there was no consensus even about the existing (problematic) "criticism" in the article, there was certainly to consensus to trawl around for more. I think before we can ever consider this question further, far better sources are needed, if indeed any such exist; the best sources seem to have accepted this research, rather than "critiqued" it. Alexbrn (talk) 07:36, 21 January 2021 (UTC)
there are ethical implications, so it's within scope. this is just hair-splitting. the point is, I have quality sources, ie scholarly journals, which represent a minority view on the African Studies. it is proportionate and proper to add a blurb about this to the article text, while letting the majority view dominate the rest of the article. I'm not drawing any biomedical conclusions from the fact that there's RS criticism of the studies and their methodology, I'm simply stating that it exists and describing it. I don't see any grounds for reverting. Xcalibur (talk) 09:17, 21 January 2021 (UTC)
Show me proper secondary sourcing. For every topic there is a huge load of primary sourcing which we properly ignore. If there was a texbook examining the issue in overview, for example, that would be good. If there's a genuinely ethical angle, that might be due. I suggest if you want to widen consensus, checking at WT:MED. (Also, your signature keeps changing & it's hard to reconcile with the username I see on my watchlist, which would appear to be a problem per WP:CUSTOMSIG/P.) Alexbrn (talk) 09:31, 21 January 2021 (UTC)

If an RfC is inconclusive, for the most part, that means that you should not implement an edit that lacks consensus. I don't think we should be starting new discussions on the matter. If there's more to discuss, it should be done at the RfC. But the discussion there seems to be coming to a close. We could have the RfC formally closed, once we feel like the discussion there is finished. But like you said, the consensus is "inconclusive", so we probably wouldn't even need a formal closure to ascertain what the RfC consensus is. Prcc27 (talk) 10:42, 21 January 2021 (UTC)

@Prcc27 - I wanted to give it another try. the RfC discussion has a fairly recent comment, but otherwise it seems gridlocked. I thought starting up discussion again from another angle might achieve a breakthrough.
@Alexbrn - there seems to be a misunderstanding. the initial publication of the African studies would be a primary source. journals commenting on them are secondary RS. a textbook is typically a tertiary source. thus, I've already supplied secondary RS. the hang-up on ethics is not an issue, especially since I'm using both Journal of Medical Ethics and Journal of Law and Medicine. with all due respect, did you bother to review the refs I provided? also, I only changed my signature once. Xcalibur (talk) 12:05, 21 January 2021 (UTC)
MEDRS is clear what it wants: review article or better. While it's true primary sources have secondary aspects to them, these are generally not used because the secondary element is nearly always (cherry) picked to support the primary argument. As I say, check at WT:MED to widen the consensus. But while an RfC on an existing tranche of (MEDRS) "criticism" is ongoing I don't think it's wise to start trying to push for an extra load of it, from iffy sources. Alexbrn (talk) 12:28, 21 January 2021 (UTC)
I've offered relevant articles from reputable scholarly journals as secondary RS. that should be plenty enough to support inclusion of a brief passage in the text, assuming you're being fair and impartial. but that's all I'll say for now. Xcalibur (talk) 12:41, 21 January 2021 (UTC)

Risk Section

having noticed that an entire section was deleted on flimsy grounds, I took the liberty of restoring it, only for much of the content to be removed. for reference, here's the whole section: which was reduced to just the last paragraph acknowledging the criticism, I restored 2 of the paragraphs with an additional scholarly source that directly supports the material in question: the literature does in fact confirm the following points: 1. circumcision can lead to 'risk compensation', in which subjects behave as if circumcision provides immunity against HIV (ie a 'natural condom') instead of just reducing risk, which can offset benefits, and 2. engaging in sexual activity before the circumcision wound is fully healed significantly increases risk. the sourcing is reliable, with the addition of a medical RS, and I could add even more if needed (also, it's not really edit-warring when I left out the first contested paragraph and improved sourcing). in light of all this, the material should stay up. Xcalibur (talk) 13:34, 24 January 2021 (UTC)

  1. ^ Fox, Marie; Thomson, Michael (December 2010). "HIV/AIDS and circumcision: lost in translation". Journal of Medical Ethics. 36 (12). BMJ: 798–801. JSTOR 25764321. S2CID 39693618.
It was removed on good grounds. I still cannot tell who you are from your signature - this lack of basic courtesy despite a request disinclines me to engage further. Alexbrn (talk) 13:37, 24 January 2021 (UTC)
my account is Bigdan201, and Xcalibur is my signature. I changed my sig only once, there's no obfuscation involved. it seems like you're focusing on a detail to distract from the main issues at hand: MedRS does in fact describe risks involved with circumcision, which relate to HIV, and this should be documented in the article. even if you believe stronger sourcing is needed, that doesn't justify deleting content wholesale, and I've added a new scholarly source to back it up. in a larger sense, this article reads like a promotional piece for circumcision as a policy for HIV containment, ignoring risks, confounding factors, and the fact that it only reduces risk & is not nearly as effective as condom use; all of which is documented in scholarly journals. I'm not the only user to see a problem with POV/BIAS here. Xcalibur (talk) 13:51, 24 January 2021 (UTC)
Please see WP:CUSTOMSIG/P. We need MEDRS sources, "scholarly" is generally not enough. Alexbrn (talk) 13:56, 24 January 2021 (UTC)
I still don't see it as a big deal. and medical journals should be good enough for discussing related factors, especially when I'm not making a policy recommendation. however, since you insist on top-quality sources, I can provide them in this case. MEDRS for risk compensation: MEDRS for higher risk of transmission from sexual activity in the time window before the circumcision wound has healed: now that there's MEDRS, I trust that you'll assent to restoration of the relevant content. Xcalibur (talk) 14:14, 24 January 2021 (UTC)
I clicked on the first one. It was a comment from 2007. Have you even read WP:MEDRS? Your signature is still misleading too. Alexbrn (talk) 14:18, 24 January 2021 (UTC)
of course I've read it. that was a journal article, not a "comment", and from a rock-solid source already used in this article. as for it being published in 2007, this information is not particularly time-sensitive (unlike a topic like covid-19, which demands up-to-date sourcing). but if that's the hangup, here's another MEDRS for risk compensation from 2015 (like the 2nd one): I hope that resolves the matter. Xcalibur (talk) 14:39, 24 January 2021 (UTC)
Primary research, not WP:MEDRS. If you don't understand WP:MEDRS maybe try WP:WHYMEDRS and WP:MEDFAQ for background which may be enlightening. Alexbrn (talk) 14:44, 24 January 2021 (UTC)
I do understand, and we're allowed to use primary sources, especially to briefly underline the concluding point. but here's another, and another both of which are recent. Xcalibur (talk) 14:57, 24 January 2021 (UTC)
No use. Alexbrn (talk) 15:00, 24 January 2021 (UTC)
of course it's no use, because you're abusing the WP:MEDRS policy to gatekeep the article on the basis of WP:IDONTLIKEIT. the point of the policy is to ensure that WP has sound medical advice. it's not supposed to be a bar that you keep raising ever higher to exclude wrongthink, ie any information that is less than glowing praise for circumcision. also, in light of the condescending remark on enlightenment, and the "is this trolling?" edit summary, I must remind you to be WP:CIVIL. at this point, I have to ask: is there any existing source that would qualify, in your view? Xcalibur (talk) 15:08, 24 January 2021 (UTC)
First of all, your misleading signature is a problem: it is bad to expect other editors to memorize and connect two different names in dealing with you, the one they see on their watchlist, and the one they see in signatures. Second, Misplaced Pages is absolutely prohibited from giving "medical advice". The bar does not change; MEDRS is consistent. I don't know if I "like" the content of non-MEDRS articles because once I see it a non-viable type, I ignore it. Whether an editor "likes" content or not does not feature in a decision on its viability - you seem to be projecting in that. If you understand MEDRS, why do you keep producing non-MEDRS sources and calling them MEDRS? The meta-analysis cited in the risks section is a viable, MEDRS, source.
Looking on PUBMED, PMID 32558344 appears to be a good MEDRS on the topic of HIV/circumcision/risk. I haven't read it though. Alexbrn (talk) 15:17, 24 January 2021 (UTC)
I'm not giving medical advice, I'm pointing out possible complicating factors, without drawing any conclusions or making any recommendations. there's no projection, simply the observation that any information even slightly critical of circumcision is removed from the article, no matter the quality of sources. based on your input, you barely read the sources and find various nitpicks. I notice that the meta-analysis is from 2008, yet you don't complain about it being 'too old' (leaving aside the point that not all information is time-sensitive anyway). if you'd prefer Springer Link for MEDRS, then how about this? Xcalibur (talk) 15:43, 24 January 2021 (UTC)
and of course PMID 32558344 gets your acceptance, because its findings go against risk compensation. the sources are not unanimous on the topic, so you could add a line to the section stating that, instead of deleting. Xcalibur (talk) 15:48, 24 January 2021 (UTC)
If I say something is removed because it's unreliable, I'll stand by that. Your accusation of "no matter the quality of source" is shabby and untrue. You yet again post primary research (it even says in big letters at the top "Research article"). In any case I have now added the Farley et al article as an update. I had forgotten we were already citing it - it's hard to image a stronger source. Your whole approach seems to be think of sources as things which are found to support a POV. That is 100% wrong - simply find the WP:BESTSOURCES and then summarize them - that's the way we make the encyclopedia good. I have sent you all think links that explain how to do this. Alexbrn (talk) 15:53, 24 January 2021 (UTC)
Xcalibur, you are not allowed to use primary sources to contradict or undermine the conclusions of secondary sources. If you want to criticize a secondary source, then you must use an equivalent or better secondary source. WhatamIdoing (talk) 03:00, 25 January 2021 (UTC)

and here's another, for the other topic: as I said, we're allowed to use primary research for particular points, as long as the article doesn't rely on it too heavily. Your whole approach seems to be think of sources as things which are found to support a POV. what POV am I supporting? I'm simply adding info that's left out of the article. on the contrary, it's hard to image a stronger source. I'm pretty sure if that source were critical of circumcision, you'd dismiss it as unreliable as well. this article is dominated by a POV, that circumcision is the best response to HIV. I'm not refuting that, I'm trying to put up information that doesn't strictly conform to that POV, that's all. I don't think there's a source anywhere in the world that you'd accept if it were critical of circumcision in any way. Xcalibur (talk) 16:07, 24 January 2021 (UTC)

Another primary source, a misrepresentation of the WP:PAGs (*please* actually read the links I've posted) and a bad faith accusation. Excuse me if I disengage. Alexbrn (talk) 16:14, 24 January 2021 (UTC)
on the contrary, the strategy here seems to be misusing the policies and guidelines in order to gatekeep a one-sided article. I quote from the MEDRS policy page, Text that relies on primary sources should usually have minimal weight, only be used to describe conclusions made by the source, and must describe these findings clearly so that all editors even those without specialist knowledge can check sources. Primary sources should never be cited in support of a conclusion that is not clearly made by the authors (see WP:Synthesis). as I said, we're allowed to use them, especially in conjunction with secondary RS (which I've already provided). simply put, describing how risky behaviors can offset the stated benefits of circumcision should not have the same requirements as describing how a drug affects the nervous system, for example. arguably, the content I'm adding is more in line with general information than biomedical, which would exempt it from the MEDRS standard. at the very least, it's ambiguous. Xcalibur (talk) 16:29, 24 January 2021 (UTC)
The article seems one-sided because the science is: your problem is with the science, not the article. Your attempt to cherry pick MEDRS is familiar. It also says "For biomedical content, primary sources should generally not be used" and also "Primary sources should not be cited with intent of 'debunking', contradicting, or countering any conclusions made by secondary sources". We have excellent secondary sources on this topic, so let's stick with them. If you could find something of similar weight to Farley et al, that would be useful. Alexbrn (talk) 16:41, 24 January 2021 (UTC)
expanding the scope is not cherry-picking. the consensus view is well-supported, so I'm focusing on points that are not given coverage. and yes, it says 'generally not' rather than 'never'. as for 'debunking', contradicting, or countering, I'm not doing this either. I'm not arguing against the consensus opinion at all, rather I'm providing information that's relevant, but may show another side to the topic; that is, I'm documenting possible issues and downsides. there's also confounding factors, which I haven't even gotten into yet. one of my sources described how some African societies perceive circumcision as a rite of passage and cultural event that must be done with traditional methods, and those who get the modern procedure done may lose their standing with the tribe. there's a number of issues that aren't discussed at all.
more to the point, having thought about it a bit more, it seems to me that the issues I've discussed on this talk page (associated risks, a minority view criticizing the African studies on methodological grounds, etc) should be categorized as general information, not biomedical. this would exempt it from MEDRS requirements, making that whole objection a moot point. the only biomedical aspects to the Risk section are the statements that risky sexual behavior, and sexual behavior with a wound on one's genitals, increase transmission risk, but this is thoroughly documented. as MEDRS says, general information doesn't have the same requirements. Xcalibur (talk) 17:15, 24 January 2021 (UTC)
The attempt to argue that WP:Biomedical information somehow isn't, is also a familiar tactic. I suggest if you want wider consensus, raise a query at WT:MED. Alexbrn (talk) 17:23, 24 January 2021 (UTC)
some of the issues I've raised seemingly fall under Biomedical Research, but let's take a closer look: Information about clinical trials or other types of biomedical research that address the above entries or allow conclusions to be made about them. meaning, research that has direct implications for biomedical information. that's a key point, and if the information doesn't tie in directly, or if a biomedical conclusion is not stated, then it should fall under general info. in particular, the belief among Africans that circumcision prevents HIV (leading to risky behavior), falls under Beliefs, categorized under What Is Not Biomedical. it seems to me that, if my information is biomedical, it is to a much lesser degree. on top of this, 'risk compensation' is already mentioned and cited in the article, so that should not be an issue.
I just offered a new compromise text, let me know if that's acceptable. Xcalibur (talk) 17:46, 24 January 2021 (UTC)
Sorry I've been AWOL here - been exceedingly busy irl recently. I would like to say that I am in the middle here - the RFC that was held at best ended with "no consensus for inclusion, and a weak consensus against it being a 'fringe' view, as well as no consensus whether inclusion is due or not" - but this was for specifically criticism of the African studies, so I don't think it applies here. As such, I don't think there's a consensus based reason for a blanket ban on inclusion of things such as "risk compensation" or beliefs at this time. That being said, WP:MEDRS and due weight still apply here. The text as it stands now is cited to four articles, which I will attempt to discuss individually followed by my commentary as a whole:
  • First source: https://www.jstor.org/stable/25764321?seq=3#metadata_info_tab_contents - while it was externally peer reviewed, this would be like an oncologist going to the Ear and Hearing journal to find a new chemotherapy regimen. While the information may be located there, one must wonder why it was published in such a "off" journal and not in a more directly applicable one. Put a different way, why was this published in the "ethics" journal the BMJ publishes, and not in a more applicable one such as BMJ Sexual & Reproductive Health or Sexually Transmitted Infections? Note also that peer review for articles in certain journals is directed towards that content - which means that the peer review for this journal likely consisted of experts in ethics, but not necessarily experts in HIV as one would expect for the other two journals. This means that while it was "peer reviewed", the peer review would have been focused on the ethics issues presented in the article, and not necessarily the science of HIV prevention. This article is also from 2010 - and MEDRS discourages the use of articles that old.
  • Second source: https://doi.org/10.1080/17441692.2018.1427277 - this is a primary source, but sometimes primary sources are acceptable per MEDRS, so I'll evaluate the source first then discuss whether it's an appropriate use of a primary source. The short version is I see no potential negative points from the journal it's published in (which is a reputable journal expected to cover public health issues such as HIV/prevention), nor the authors, nor the paper itself. However, it is a survey, not a clinical trial of any sort - and as they say in that article, it was a convenience-based survey - meaning the people who responded were those convenient to the author (not randomized/representative) and those who chose to respond. For these reasons, this is the lowest possible quality of primary source for MEDRS content, and while it is acceptable, it should not be used as the primary or sole source for any information from it, and the information must be clarified as being based on a optional-response non-randomized survey (if no other source is used). I recommend not trying to use this source unless others are found as well, and likely other sources would contain the same information with stronger MEDRS compliance.
  • Third source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4412625/ - I'll be short and sweet with this one. While the journal is open access, it is a reputable open access journal cited over 20k times on Misplaced Pages. It is however a primary study, but one I see no immediate issue with. It's a relatively small study, but that's not necessarily a problem - again, this would require in-text clarification/attribution of the information to "one study" and likely the number of participants given its small size, but it may be workable.
  • Fourth source: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040138 - Again from PLOS, so no issue with the journal, however this was published in the "correspondence" section with no evidence or claim of peer review. This does not meet MEDRS requirements, and cannot be used in this article unless it is attributed directly to the authors and there is some reason to believe that these authors opinions would be due weight.
So, we have two sources that are unusable, and two that are primary sources - all being used to support "wikipedia voice" prose in the article (i.e. without clarification of "a study" or similar). This is not appropriate and does not meet the requirements for using primary sources present in MEDRS guidelines. I also note that none of the sources can be used to support the text However, reduced risk of HIV transmission may be offset by an increased incidence of risky sexual behaviors, in a pattern known as 'risk compensation' - none of them directly examine whether the risk compensation offsets or negates the reduced risk of HIV transmission. The two primary sources may be useful, but must be used for carefully crafted prose that puts it in perspective - that these are single studies that found certain things. I also think that this should be discussed in the "efficacy" section under a sub-heading dedicated to "risk compensation" - but if and only if better sourcing and prose can be worked out here first. Otherwise, I do not feel that two primary studies, without any secondary review articles, is due weight for inclusion in this article. Given that the text as written fails WP:V in that neither of the two acceptable MEDRS (primary sources) states what is being claimed, and they are not properly qualified in the text, I've removed the second paragraph here for further discussion and work before it's readded, and removed the first paragraph altogether as I feel it duplicates information in the Efficacy section. There is no deadline on Misplaced Pages, and when editing medical articles it is better to get it right than to have potentially incorrect text in the article while it is being discussed here. For this reason, I think it would be best to attempt to come to an agreement here before any more text is attempted to be added to the article.
TLDR: This may merit inclusion in the article. Better sources (preferably secondary sources such as review articles) need to be found, especially more recent ones if possible. If they cannot be, text must be attributed and qualified as required by WP:MEDPRI. In any case, it must be considered whether the studies themselves are large enough or noteworthy enough to merit inclusion based on WP:DUEWEIGHT. Any discussion of behaviors/beliefs as they relate to health (such as risk compensation or beliefs about efficacy/etc) is by definition biomedical information, and requires MEDRS sourcing. As it stands now, with only two primary sources to be used regarding risk compensation, it likely does not merit inclusion per due weight. That being said, it has potential, if and only if better sourcing (such as secondary sources or much larger primary studies) can be found. Please feel free to ask me for clarification if necessary on any of the points I made. -bɜ:ʳkənhɪmez (User/say hi!) 02:29, 25 January 2021 (UTC)
  • Removed text: However, reduced risk of HIV transmission may be offset by an increased incidence of risky sexual behaviors, in a pattern known as 'risk compensation'. This is because many subjects become overconfident in the effects of circumcision, treating them as protection (a 'natural condom') as opposed to partially reducing risk of transmission. Transmission risk is also greatly increased if the subject engages in sexual activity in the time window before the circumcision wound has finished healing.

References

  1. Fox, Marie; Thomson, Michael (December 2010). "HIV/AIDS and circumcision: lost in translation". Journal of Medical Ethics. 36 (12). BMJ: 798–801. JSTOR 25764321. S2CID 39693618.
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6396304/ (2018)
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4412625/ (2015)
  4. Kalichman S, Eaton L, Pinkerton S (March 2007). "Circumcision for HIV prevention: failure to fully account for behavioral risk compensation". PLOS Medicine. 4 (3): e138, author reply e146. doi:10.1371/journal.pmed.0040138. PMC 1831748. PMID 17388676.{{cite journal}}: CS1 maint: unflagged free DOI (link)
@Berchanhimez: thank you for, err, injecting some rigour into the discussion. I wonder if there's a secondary source discussing the "risk compensation" aspect. Alexbrn (talk) 03:51, 25 January 2021 (UTC)
Per Berchanhimez's analysis of the sources, I am not opposed to using source #3. But I do not have any proposed wording at this time. Prcc27 (talk) 11:11, 25 January 2021 (UTC)
I would oppose the use of an old, weak, primary source as WP:UNDUE. It may be possible to cite some secondary literature which cites it; PMID 26526758 looks likely (in fact I believe this is the only secondary literature which cites that study, which further confirms how its use would be undue). Alexbrn (talk) 11:20, 25 January 2021 (UTC)
this was a surprisingly fair critique. to respond:
Put a different way, why was this published in the "ethics" journal the BMJ publishes, and not in a more applicable one such as BMJ Sexual & Reproductive Health or Sexually Transmitted Infections? because this is about policy, implementation, and the ethical considerations thereof, which is covered in the abstract. I also disagree with the ear/cancer analogy, there's a closer association in this case.
the peer review would have been focused on the ethics issues presented in the article, and not necessarily the science of HIV prevention. the science is cut and dry here, it's not tackling complex issues (eg the vulnerability of langerhans cells in the foreskin to infection). the issue here is that risky, unprotected, promiscuous sex spreads HIV (especially with a wound on one's genitals) which is bordering on SKYISBLUE, given how well-established that is. This article is also from 2010 - and MEDRS discourages the use of articles that old. as I said, not every issue is time-sensitive. HIV and its vectors have not changed substantially over the past decade, whereas for covid-19, you need up-to-the-minute info.
I also note that none of the sources can be used to support the text incorrect. I transcribe from the medical ethics journal: ...For instance, it is predictable that risk compensation behavior may follow circumcision since the procedure is likely to enhance an individual's perception of invulnerability or may even 'become a popular marker for lack of HIV infection'. This clearly has the potential to diminish the impact of safer sex campaigns. The AIDS Vaccine Advocacy Coalition warns that any 'benefits of male circumcision could be offset by an increase in high-risk acts like unprotected sex or an increase in the number of partners'. Such behavior is particularly risky should it occur before the wound has properly healed. Men who have sex in this period have an enhanced vulnerability to HIV infection, while those already infected may increase the risk of their female partners acquiring HIV. One recent study ... demonstrated that the HIV acquisition rate in partners of circumcised men who resumed sexual activity before wound healing was 27.8%. This compared with 9.5% in partners of men who underwent circumcision but delayed sex until healing and 7.9% in the partners of uncircumcised men. As commentators have noted, such studies raise serious questions about the ethics of trials which appear to increase the risk of HIV transmission to partners who were HIV-free when the trials commenced. This is taken from the paragraph just before the 'conclusion' section, and it directly supports the text you removed from the article.
Any discussion of behaviors/beliefs as they relate to health (such as risk compensation or beliefs about efficacy/etc) is by definition biomedical information, and requires MEDRS sourcing. fair enough. however, I think there's a difference in degree between the efficacy of a drug vs health implications of behavior, especially when those implications are very well-documented (as is the case for promiscuous, unprotected sex spreading HIV, especially with an existing wound on the relevant parts). As it stands now, with only two primary sources to be used regarding risk compensation, it likely does not merit inclusion per due weight. That being said, it has potential, if and only if better sourcing (such as secondary sources or much larger primary studies) can be found. I believe the ethics journal should qualify as a secondary source, and it directly supports the content (as I showed above). also, I'm not attempting to rewrite the whole article, I'm adding a mention, which I don't think exceeds DUEWEIGHT. I suppose sourcing can be improved, although I still think this standard is being applied fairly stringently. I'd like to add another important point: the MEDRS policy is not written with this particular article in mind. it applies to all sorts of medical articles; thus, we sometimes have to use judgment in how to apply policies to a particular topic. I think this is particularly relevant when it comes to primary and older sources, which may be appropriate for one topic, but not another.
pardon the long post, I found it necessary to use a lengthy quotation. Xcalibur (talk) 19:24, 26 January 2021 (UTC)

quick update: I tried to point out that a few sources critique the African studies for methodological flaws, but I suppose that does count as OR, unless I can find a proper secondary source for this. in the meantime, I'd like to park a few sources here which I think are relevant:

a critique of circumcision, which backs up criticism of the African studies' methodology.

a WHO statement which points out confounding factors, namely: cultural and human rights considerations associated with promoting circumcision; the risk of complications from the procedure performed in various settings; the potential to undermine existing protective behaviours and prevention strategies that reduce the risk of HIV infection; and the observation that the ideal and well-resourced conditions of a randomized trial are often not replicated in other service delivery settings. these points should all be addressed in the article. the brief mentions that are there could be expanded.

a strong critique against the correlation of circumcision with reduced HIV risk.

a meta-analysis which finds insufficient evidence for the proposed link between circumcision & HIV risk reduction.

for convenience, I'll also put the two critiques of the African studies here: Xcalibur (talk) 11:33, 7 April 2021 (UTC)

  1. ^ https://www.sciencedirect.com/science/article/abs/pii/S1571891307001100
  2. https://www.who.int/mediacentre/news/statements/2006/s18/en/
  3. https://www.jstor.org/stable/20638120
  4. https://jamanetwork.com/journals/jama/article-abstract/279008
  5. Svoboda, Steven; Van Howe, Robert (July 2013). "Out of Step: Fatal Flaws in the Latest AAP Policy Report on Neonatal Circumcision". Journal of Medical Ethics. 39 (7). BMJ: 434–441. doi:10.1136/medethics-2013-101346. JSTOR 43282781. PMID 23508208. S2CID 39693618.
  6. Boyle, G. J.; Hill, G. (2011). "Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns". Journal of Law and Medicine. 19 (2): 316–34. PMID 22320006.
  • In general it's best not to try to "find" sources in support a POV you want to include, but disinterestedly to find the best sources on the topic and summarize them. Is there, for example, a top-quality recent source we're not currently citing? Alexbrn (talk) 11:43, 7 April 2021 (UTC)
generally we should avoid cherry-picking. however, the consensus view dominates this article, so it's worth looking into alternatives. after all, we're supposed to document significant minority views in addition to majority views. as for recent/best, I'd have to go on another search. Xcalibur (talk) 11:55, 7 April 2021 (UTC)

Process section

Failed verification and reversion. According to the WHO (page 2/18) at https://www.who.int/publications/i/item/978-92-4-000854-0 "Risk compensation. There has been no evidence of significant risk compensatory behaviour post-circumcision – that is, more risky sexual behaviour following circumcision driven by perception of lower HIV risk." The person who reverted the edit uses a primary source. The WHO is an authoritative source, and should take precedence. The link in the article is to the summary of this longer document, but the full document is only available as a download link. Should I link to the download or the summary? Is it possible to link to a download? I would appreciate the help. Petersmillard (talk) 11:27, 30 May 2021 (UTC)

Per WP:V the cited document should be the one that directly supports the material it's cited for, obviously so if it is quoting some text. Whether the cited text can be downloaded or not is a side issue, so long as sufficient identifying bibliographic material is given (e.g. authors, publisher, page number, title, date, etc.) One wrinkle for this is journal articles where by convention the "landing page" for the PMID, DOI, etc. often has just the abstract, while the whole text is a further click away, sometimes via paywall. Alexbrn (talk) 11:35, 30 May 2021 (UTC)

This engenders another question. If the reference is the link to the download (freely available in this case), is it possible to archive it and include the link to the archive, as is preferred? Petersmillard (talk) 11:40, 30 May 2021 (UTC)

I'd use that URL (https://www.who.int/publications/i/item/978-92-4-000854-0) as it's obvious this links through to the full 160 page report. (User-assisted) bots might sweep through later and add archive URLS, but you expect a URL from the WHO to be stable for the useful life of the document! Alexbrn (talk) 11:44, 30 May 2021 (UTC)

Perfect. i will fix the link but dare not revert the edit, because I won't want to edit war. Petersmillard (talk) 11:46, 30 May 2021 (UTC) I tried several variations in fixing the reference but end up with error messages. In the latest attempt, I removed the URL label (because it caused an error) and then I get the error that there is no url to correspond to the access date. I will next try to remove the access date. Petersmillard (talk) 11:53, 30 May 2021 (UTC)

Fair enough with that new source. That just wasn't the source I was seeing in that paragraph. I did a CTRT + F and "no evidence" and I the text you were referring to wasn't there. This must be a different document??
I think the original wording Petersmillard had is somewhat problematic: "According to the WHO there is 'no evidence' that men who have been circumcised engage in more risky sexual behavior." It's missing the word "significant". If you add that word, and change the wording a little bit– it doesn't necessarily contradict the other statement we use: "Some circumcised men might have a false sense of security that could lead to increased risky sexual behavior." I don't think we necessarily need to remove this. We need more information in the stub section, not less. Prcc27 (talk) 16:59, 30 May 2021 (UTC)

The most recent edits have totally contradicted the WHO's statement that "There has been no evidence of significant risk compensatory behaviour post-circumcision – that is, more risky sexual behaviour following circumcision driven by perception of lower HIV risk," using a primary reference from a journal "AIDS and Behavior" which is not WP:MEDRS compliant. Petersmillard (talk) 11:30, 31 May 2021 (UTC)

If you're referring to my edit, that is straight from the WHO report (the page is in the citation). The other reference is the one they cite; feel free to remove it, if it's not reliable. — 𝐆𝐮𝐚𝐫𝐚𝐩𝐢𝐫𝐚𝐧𝐠𝐚 (talk) 11:48, 31 May 2021 (UTC)

There is no page 42 in the reference. It is divided into sections. To which section are you referring? Petersmillard (talk) 12:50, 31 May 2021 (UTC)

It's a pdf; of course there is. Did you download it? — 𝐆𝐮𝐚𝐫𝐚𝐩𝐢𝐫𝐚𝐧𝐠𝐚 (talk) 13:35, 31 May 2021 (UTC)
In general PDF "page numbers" are of limited utility. Somebody with a print version of the document, for example, would be very puzzled by a reference using them. When citing a page number, it should be the page number as it appears on the page (e.g. "iii", "42", etc.) Alexbrn (talk) 13:39, 31 May 2021 (UTC)
Of course 42 is the page number as it appears on the page. Did you verify it? — 𝐆𝐮𝐚𝐫𝐚𝐩𝐢𝐫𝐚𝐧𝐠𝐚 (talk) 13:51, 31 May 2021 (UTC)

I did indeed download the document. Page 42 on the pdf is 2/22 in the document. Can you please give us the quote? Petersmillard (talk) 13:55, 31 May 2021 (UTC)

So you see, you're looking at the wrong page; page 22. Look at page 42 then:

Recent evidence also indicates that some risky sexual behaviours, specifically less condom use and a higher numbers of sexual partners, were associated with traditional circumcision (222).

— 𝐆𝐮𝐚𝐫𝐚𝐩𝐢𝐫𝐚𝐧𝐠𝐚 (talk) 14:00, 31 May 2021 (UTC)
That is page "3/42". Alexbrn (talk) 14:01, 31 May 2021 (UTC)
No, it isn't. The page is 42; 3 is the chapter. And it's not page 42 of chapter 3 even; it's of the whole document. — 𝐆𝐮𝐚𝐫𝐚𝐩𝐢𝐫𝐚𝐧𝐠𝐚 (talk) 14:09, 31 May 2021 (UTC)
Why do I get a sense you simply don't like what it says, and are just nit-picking on page numbers? (incorrectly even!) — 𝐆𝐮𝐚𝐫𝐚𝐩𝐢𝐫𝐚𝐧𝐠𝐚 (talk) 14:11, 31 May 2021 (UTC)
I have no opinion on what it says, I do however mind it had been misrepresented, by omitting obfuscating the fact this is about "traditional" circumcision. Also a letter had crept back in, failing WP:MEDRS. Alexbrn (talk) 14:14, 31 May 2021 (UTC); amended 15:07, 31 May 2021 (UTC)
it had been misrepresented, by omitting the fact this is about "traditional" circumcision.
You can edit the article, but you cannot change the record, Mr. Brown:

Some circumcised men might have a false sense of security that could lead to increased risky sexual behavior, specifically less condom use and a higher number of sexual partners, as it is associated with traditional circumcision.

— 𝐆𝐮𝐚𝐫𝐚𝐩𝐢𝐫𝐚𝐧𝐠𝐚 (talk) 14:25, 31 May 2021 (UTC)
Yes, tacking it on as a meaningless clause at the end and elevating an association to "could lead to" is very bad, especially when preceded by an unreliable source. If whoever wrote this had put "but this is only associated with traditional circumcision" that would at least have been honest, if clunky. The whole point here is the WHO are recommending against trad. circumcision and for medical circumcision, for which no RS says there is "risky" behaviour. As we had it, the POV was being pushed in the opposite direction. Alexbrn (talk) 14:37, 31 May 2021 (UTC)
Yes, saying that I was omitting the fact this is about "traditional" circumcision is a straight up lie. The record shows I did not omit it. You generously dish off accusations of WP:ACTIVISM and POV pushing, but it's pretty clear you're the one doing lion share of it here. Even if you have to lie about it. — 𝐆𝐮𝐚𝐫𝐚𝐩𝐢𝐫𝐚𝐧𝐠𝐚 (talk) 14:58, 31 May 2021 (UTC)
I don't care who did it, I do care about the misrepresented source. Now fixed. Alexbrn (talk) 15:06, 31 May 2021 (UTC)

MEDRS

Prcc27 and Stix1776 are trying to force pmid:17388676, a "comment", into the article. Don't do that; Misplaced Pages is build on reliable sources and for medical information use WP:MEDRS. Also, please read sources before using them - if you'd done so you'd have seen this is not suitable. Alexbrn (talk) 06:51, 18 July 2021 (UTC)

That's a mischarecterization of my actions. You made a WP:BOLD edit claiming the source was a "letter", and have repeatedly failed to explain how it is a "letter", when a user asked you to explain your initial edit summary. You finally explained that the article says "comment" at the top, but only after enganging in an edit war and disruptively reverting the page several times. The onus is on you to get consensus for your edit and/or to fully explain yourself in the edit summary. I am not trying to "force" anything on the article– your reasoning for your edit was unclear to me. For the record, I wouldn't have reverted you, if you were more clear in your edit summary and explained that it says "comment" at the top of the article. Prcc27 (talk) 07:16, 18 July 2021 (UTC)
I never "claimed" it was a letter (though it is: it's a letter written as a comment on another article), but even a cursory look at the content shows it is not suitable. The WP:ONUS for getting consensus lies with an editor wanting to add it, so you are reversing the burden of responsibility - and adding unreliable content to Misplaced Pages in the process. Alexbrn (talk) 08:15, 18 July 2021 (UTC)
  • On May 29th you said "this is a letter?!". Also, please correct me if I'm wrong, but hasn't this source been on the article for several years..? I've seen the source used in the article going back as far as 2017. If so, it is the default consensus, and the onus is on you to get a consensus to change the article, and remove a source we have used for years. Prcc27 (talk) 08:43, 18 July 2021 (UTC)
Asking a question is different from making a claim. And as it turns out, it is a letter, so not reliable. Per WP:ONUS, "The onus to achieve consensus for inclusion is on those seeking to include disputed content" - so you would appear to be misrepresenting the policy now to boot. Alexbrn (talk) 08:46, 18 July 2021 (UTC)
  • I'm reading and I'm not reading the text "comment". Nothing in this says that it's a letter or a comment. Regardless of whether you're correct or not, you should be finding consensus with other editors for bold edits. If you think it's a comment or a letter, we can talk about it here. You're reverting against two editors, and you're claiming that we're edit warring.
Can we please start from the very basic standard of not reverting those reverting our bold edits? Stix1776 (talk) 10:24, 18 July 2021 (UTC)
Any editor not able to determine a clearly-labelled source type is not competent to edit medical content. WP:V is a core policy so editor warring a 14-year old letter, an unreliable source, into an article to undercut the WHO in Misplaced Pages's own voice, looks like blatant POV-pushing. In this case it is compounded with rules-mongering and misrepresentation of policy. We start with the "basic assumption" of not warring crappy sources into Misplaced Pages, and trying to work to improve content rather than otherwise. Alexbrn (talk) 11:24, 18 July 2021 (UTC)
  • @Alexbrn: WP:CIR is not a policy. Regardless, you obviously need to brush up on WP:CIRNOT. You are making this into a bigger deal than it needs to be. Just be more clear in your edit summaries, and take things to the talk when necessary. Simple. Prcc27 (talk) 17:15, 18 July 2021 (UTC)
I see that you've moved to avoiding discussion of the "letter" and WP:BOLD, and now you're onto personal insults. Per WP:CIRNOT "It does not mean we should label people as incompetent. Calling someone incompetent is a personal attack and is not helpful. Always refer to the contributions and not the contributor, and find ways to phrase things that do not put people on the defensive or attack their character or person." Other editors here are trying to work with you, and this isn't helping. Stix1776 (talk) 16:16, 18 July 2021 (UTC)

Recommendations section outdated

Given the new WHO recommendations, I feel like the Kim Dickson paragraph needs to be removed and/or replaced with information from the new source. Prcc27 (talk) 08:22, 4 September 2021 (UTC)

Circumcision and Risk of HIV Among Males From Ontario, Canada

A study of circumcision and the risk of HIV in 569,950 males in Ontario, Canada, was published online on 23 September 2021 in the Journal of Urology. It found the following:

"We found that circumcision was not independently associated with the risk of acquiring HIV among males from Ontario, Canada. Our results are consistent with clinical guidelines that emphasize safe-sex practices and counselling over circumcision as an intervention to reduce the risk of HIV."

This study could be mentioned in the article. Michael Glass (talk) 09:19, 25 September 2021 (UTC)

Yup, I saw that study too. Maybe we could include it in the society and culture section? Prcc27 (talk) 09:38, 25 September 2021 (UTC)
I think the study touches on efficacy rather than society and culture. Of course, there is a possibility that the variant in southern Africa (HIV-1C)is different from the variant in other places like the United States (HIV-1B). This possibility is discussed here:
I read an article that touched on a similar point: circumcision efficacy for HIV in Africa vs. USA may be different due to the differing HIV variants. Should we include this in the article as well? Maybe create a new subsection called Developed and Developing regions. Prcc27 (talk) 03:38, 26 September 2021 (UTC)
I agree that it is difficult to work out where to add a mention of this study. The article, as it stands, is based on the conviction that circumcision is effective in reducing the spread of HIV. We could, however, add something like this either to the lead or to the efficacy section:
  • In September 2021, The Journal of Urology published a study of 569,950 males in Ontario, Canada. It found that "...circumcision was not independently associated with the risk of acquiring HIV among males from Ontario, Canada." It concluded, "Our results are consistent with clinical guidelines that emphasize safe-sex practices and counselling over circumcision as an intervention to reduce the risk of HIV." It may be that the HIV variant in southern Africa (HIV-1C) is different from HIV elsewhere (HIV-1B). Michael Glass (talk) 07:09, 26 September 2021 (UTC)
I would use the source I provided, because the harvard source doesn't seem to be WP:MEDRS. In fact, the Ontario source might not be WP:MEDRS either, if it's a primary source, but perhaps we can make an exception, since it seems to be the strongest evidence we have for the developed world? I wouldn't put it in the lead though, until we get a secondary source on the matter. Also, we have to be careful about not violating WP:SYNTH. I'll make a proposal in my sandbox and post it here very shortly. Prcc27 (talk) 17:38, 26 September 2021 (UTC)
  1. https://pubmed.ncbi.nlm.nih.gov/34551593/
  2. https://aids.harvard.edu/qa-with-max-essex-is-african-aids-different/?fbclid=IwAR1Gn-XOF_BWnC2kv_R7R-R2KMfy5R77MG_Xa1ZgvzYUwdW4ZTjFqxnxudQ
  3. https://afju.springeropen.com/articles/10.1186/s12301-019-0005-2
  4. https://pubmed.ncbi.nlm.nih.gov/34551593/
  5. https://aids.harvard.edu/qa-with-max-essex-is-african-aids-different/?fbclid=IwAR1Gn-XOF_BWnC2kv_R7R-R2KMfy5R77MG_Xa1ZgvzYUwdW4ZTjFqxnxudQ
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