Circumcision: A History of the World's Most Controversial Surgery

By David L. Gollaher | Go to book overview

APPENDIX:
Evaluative Research and the
Nature of Medical Evidence

Because the medical circumcision debate has grown so heated, it is useful to review what physicians agree on. First, everyone concedes that the foreskin cannot be the cause of diseases that occur in both uncircumcised and circumcised males. Most men, whatever their state, remain free from diseases associated with the foreskin.

If not a direct antecedent of disease, though, the foreskin could be a risk factor, something that increases the odds of a man's developing one or more disorders. Indeed, most of the medical literature revolves around risk factors, yet the problem is how to calculate their relative influence. A high level of HDL cholesterol is commonly understood to be a pressing risk factor for coronary artery disease; the higher the level, the greater the hazard. Moderate consumption of alcohol, in contrast, may or may not be a risk factor. Older studies indicated a weak link between drinking and heart disease, but more recent studies have shown that drinking moderate amounts of alcohol, particularly red wine, confers protective benefits (though the physiochemistry of the protective effect remains cryptic). While the latter studies are better designed, both sets suffer from a common problem: namely, the weaker the risk factor, the weaker the evidence, thus the harder to demonstrate any effect conclusively.

What intellectual tools are available to ascertain how any surgery affects patients? The oldest and still the most widely applied is expert opinion, the judgment of physicians based on experience with patients. Of more recent vintage is the randomized controlled trial, which has become the standard for testing the safety and efficacy of new medicines at the U.S. Food and Drug Administration (FDA). The evidence marshaled by most papers published in peer-reviewed journals (an eclectic category characterized by enormous variations in scientific standards) falls somewhere in between these two approaches. Most of the time we are confronted by case reports (often of just one case), clinical series, nonrandomized controlled trials, case-control studies, and meta-analyses (an increasingly popular avenue of research that combines and abstracts data from multiple studies).

It is essential to remember that: for any surgical procedure applied to large populations there is variation, often wide variation, with respect to its benefits and harms.

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Circumcision: A History of the World's Most Controversial Surgery
Table of contents

Table of contents

  • Title Page iii
  • Contents vii
  • Acknowledgments ix
  • Preface xi
  • One - The Jewish Tradition 1
  • Two - Christians and Muslims 31
  • Three - Symbolic Wounds 53
  • Four - From Ritual to Science 73
  • Five - The Fabric of the Foreskin 109
  • Six - Circumcision and Disease: the Quest for Evidence 125
  • Seven - Backlash 161
  • Eight - Female Circumcision 187
  • Appendix - Evaluative Research and the Nature of Medical Evidence 209
  • Notes 213
  • Index 241
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