Episode 6.9 Male Circumcision: A Global, Historical, and Ethical Debate

Well, something a bit more peripheral to OBGYN, but we’re going to talk about male circumcision. You and I both have done them on newborn baby boys in our roles as obstetricians, so that’s the main context to talk about it in this episode anyway. But there are also some other questions about whether it affects rates of HPV-related cancers or transmission of STDs, for example

Howard 00:47

Yeah, it’s a controversial topic for sure, and you’ve drawn comparisons between male circumcision and female general mutilation, which, of course, most Americans probably have never encountered, unless you do our job, but it’s still a very entrenched practice. Female general mutilation is in other parts of the world. I’m not sure that the two things are directly comparable, but we can talk about that a little bit and tell some of the arguments are similar as well.

Antonia 01:13

Yeah, I think it all comes down to whether there’s a benefit, because children can’t consent. So if you’re going to restrain a child and do anything to them, especially anything invasive, I think there has to be a clear benefit. So, for example, I’d argue that vaccines are a clear benefit and you usually have to hold a kid down to give them a vaccine. Or if they have, say, a heart defect or appendicitis or a tumor that requires surgery, then it’s a clear benefit to do that surgery, regardless of how much they want to or not.

01:48

But on the flip side, female genital mutilation cutting off a little girl’s clitoris and sowing her labia shut is 100% not beneficial. It’s abusive and harmful. No matter what the cultural and social implications may be for it. There’s literally no medical or health value or nothing to gain in that practice. So if a woman grows up in such a culture and then, for some cultural reason, desires that procedure to be done, as an adult, she can decide for herself to have it done. So that’s different than doing that same thing to a little girl against her will. So back to our topic for male circumcision. I would want to know is there a clear benefit? Because if the benefits and risks at least cancel each other out so that on the whole there’s really no harm. I’d still consider that potentially acceptable to do on the parent’s request, as long as they’re appropriately counseled. So that’s where I think there is still a lot of controversy on this topic.

Howard 02:52

Yeah, this is the kind of thing that definitely exists on a really broad spectrum when you start to talk about cultural norms, religious beliefs and things like that and how that impacts individual folks’ autonomy, like the young child who can’t consent, and where our societal duty is to intervene or to give some boundaries on what’s acceptable behavior or not, and sometimes that goes against people’s religious beliefs potentially.

03:17

Another comparison though that I think we can make that is also, I understand, perhaps a verifiably false comparison is ear piercing for infant girls or young girls who can’t give consent. Now, there’s not even an argument to be made at all that piercing ears is anything but a cultural experience, or a cultural norm, if you will, but it’s painful and potentially causes a permanent change to her body. It is associated with infections and permanent alterations of the anatomy in some cases. Another common thing is that children are all the various tongue tie releases, buckle releases, lip releases, different things like that which do sometimes have a benefit to aid in breastfeeding, but which clearly are also being way overperformed, with no benefit at all to the child, just potential injury and harm. And I do find it ironic sometimes that many parents who would never consider circumcision for their child would have no problem at all with getting their child’s ears pierced when they’re very little, or perhaps with many of these unnecessary and inappropriate oral surgeries that are taking place.

Antonia 04:23

Yeah, but I’m sure at least with the tongue tie surgeries they’re definitely being told that these have a benefit. It’s not like they’re asking for it without a reason. So I think if they’re being told that it’s more beneficial than it actually really is, then they’re not really getting to make a fully informed decision on that.

Howard 04:43

Sure, but in circumcisions they’re probably being told that there’s benefits there too. That might not really be true.

Antonia 04:48

Yeah well, so, as you can tell, there’s a lot to get into with this, but we’ve almost, let’s not forget our thing. We do for no reason today.

Howard 04:58

Sure, okay. Well, how about ordering what people often call preeclampsia labs in a normotensive patient because they’ve had an ultrasound-based diagnosis of fetal growth restriction?

Antonia 05:08

Okay, yeah, we’ve talked a lot about ordering these labs in past episodes and this one is a little bit new for me. I’ve heard of it happening but I haven’t really seen it done anywhere that I’ve practiced. I suppose the idea is that one of the potential causes of fetal growth restriction is either preeclampsia or possibly some other underlying vascular problem that could also lead to preeclampsia, just as it leads to fetal growth restriction. And that’s why when people are hypertensive or preeclamptic, we check them for fetal growth restriction, because it’s a risk factor for fetal growth restriction, but it doesn’t mean the opposite is true that if you start with fetal growth restriction, that is necessarily a risk factor for preeclampsia. It’s not part of the diagnostic criteria. It’s not considered a risk factor.

06:03

I get running the labs for a patient that has symptoms like headache, visual change right over quadrant, pain, even in certain circumstances where they might be normotensive, but they’re exhibiting all those classically established symptoms of severe preeclampsia. But for fetal growth restriction there’s just too many other possible causes that are not related to hypertension at all that if you adopt a policy of looking for lab evidence of preeclampsia in all fetal growth restricted patients, then you’re really you’re massively wasting resources, honestly and you’re probably going to find some false positives that then you don’t know what to do with. And again, I really haven’t seen this as a common practice at any point in my training or career. We will get those labs, of course, if they have the growth restriction and they’re hypertensive or they have some of those symptoms like I mentioned. But I’m assuming maybe you’ve been seeing this done.

Howard 06:55

Yeah, this was sent to me by a listener who’s seeing this done at an academic medical center. And sure, help syndrome, for example, occurs 15% of the time in norm-otensive patients. So don’t ignore classic right of quadrant pain and even eclampsia in Sabai series happened without hypertension. But now we’re just talking about fetal growth restriction which, depending on how you define it, is present in 10% of all pregnancies. So we use more labs than we used to in the potential diagnosis of preeclampsia.

07:25

When we change the criteria to include creatin and other things that could help you have preeclampsia without proteinuria, but it always starts with hypertension. So I’ve made a point in the past of culturally making sure that we don’t say preeclampsia labs in our training programs because it implies to people that those labs are the salient characteristics of the diagnosis of preeclampsia. A better name might be HELP syndrome labs because, frankly, if you’re checking platelets in hemoglobin and an AST and an ALT, what you’re really doing is evaluating the patient for HELP syndrome which, as I said, occurs one in six times in a normotensive patient. But if a patient presents to the hospital with hypertension and all those blood tests are normal, then it certainly doesn’t mean that you’ve ruled out preeclampsia. It just means that they don’t have HELP syndrome or perhaps preeclampsia with severe features when you consider the creatin and other platelet individual characteristics. But honestly, it doesn’t change your probability that they have preeclampsia because it doesn’t really have negative predictive value. You still need the urine and the other traditional ways that we would diagnose preeclampsia.

Antonia 08:27

Yeah Well, under the current diagnostic criteria for preeclampsia it’s possible to get that diagnosis even without having proteinuria. That’s one of the things that changed several years ago. That might still be confusing some people out there. If you just have elevated blood pressure in the setting of any severe feature, you don’t have to have proteinuria. So it could be the thrombocytopenia, elevated creatinine, the unremitting headache or even just severe hypertension by itself. You’ve got preeclampsia with severe features in those cases. But again, none of that gives any role for factoring in the fetal size when you’re determining if someone has preeclampsia.

Howard 09:07

Yeah, we actually removed fetal growth restriction as a characteristic of preeclampsia with severe features a few years ago.

09:12

But the important thing you said is all that starts with hypertension and most of the time, even when you diagnose hypertension on somebody whether it’s gestational hypertension or preeclampsia or preeclampsia with severe features those labs are normal.

09:25

They’re almost always normal, frankly, and when they’re abnormal you should think about lab errors or other diagnoses that could cause them.

09:32

So it’s a really rare occurrence that you’ll find these labs to be abnormal. But now, in the case of fetal growth restriction in a normotensive patient, you’re not going to discover incidentally undiagnosed severe preeclampsia in a normotensive patient as the cause of fetal growth restriction, because you happen to check their labs and discover that their platelets were low or their creatinine was elevated and of course the diagnostic criteria doesn’t support that, even if you found it. In fact, as I said, if you find those things it’s probably something different, like gestational thrombocytopenia or idiopathic thrombocytopenic purpura or some other cause of renal insufficiency. So the appropriate maternal evaluation for fetal growth restriction is merely checking the patient’s blood pressure. That’s how you screen and it is true that fetal growth restriction sometimes predates the development of the blood pressure. That’s true, so check their blood pressure and therefore, if they have fetal growth restriction, maybe you keep a closer eye on that You’re gonna have them back for extra checks, but you don’t need to order the labs in the absence of hypertension.

Antonia 10:28

Yeah, you’re already gonna be bringing them back for extra monitoring of the baby, so that’s the perfect time to also be checking their blood pressures. But, as we mentioned earlier, if they’re normo-tensive with right upper quadrant pain, you could have help syndrome even without the hypertension. So check labs then.

Howard 10:46

Yeah, and I had that just recently. I’ve had it a few times in my life where you think it’s acid reflux or something else, but in survives classic series. As I said before, 15% of patients with help syndrome are normo-tensive. So definitely think about that. So this gets into again the idea of pretest probability If you don’t have the appropriate pretest probability to order these tests, then you’re gonna end up over diagnosing or misdiagnosing patients with something.

11:12

So we don’t check labs if the patient doesn’t have the sufficient pretest probability for the diagnosis of preeclampsia, which is the presence of hypertension. In the same way, make sure that the ultrasound you’re doing to test for fetal growth restriction has an appropriate pretest probability associated with it. The most common reason why patients have fetal growth restriction is just normal variation or just variation in genetics or even error in the ultrasound machine. If the definition of fetal growth restriction is less than the 10th percentile, which it is, it’s one definition that actually means that 10% of all of your patients, if you care to do the ultrasounds, are going to be labeled as having fetal growth restriction, but they don’t really. So we avoid the trap of overdiagnosis in those patient populations by not doing the ultrasounds routinely on patients who don’t have an indication that would raise their pretest probability, like diabetes or hypertension.

Antonia 12:02

I’m sure a lot of extra unnecessary practices probably get started because someone tries to implement a change with great intentions whether it’s according to established guidelines or more for anecdotal reasons but then their implementation isn’t perfect and then it gets down the line. It gets maybe twisted or overlaps with other things that it never was meant to overlap with, and after a few years later people forget why they were even doing it. They just say, well, this is how we’ve been doing it and this is our order set, or whatever. So, for example, I could easily imagine a scenario where I’m just making this up.

12:41

Let’s say a low risk patient had an unexpected fetal demise and everyone is, of course, torn up about it, going back and seeing did they miss something? The only thing that pops up abnormal when they’re looking back is, let’s say, she had proteinuria and was normal-tensive. Or maybe she had one abnormal value on her three-hour GTT but was considered passing it. Now that well-meaning but reactionary provider that took care of her and never wants this to happen again is gonna start ordering NSTs on all of their patients that are normal-tensive with proteinuria, or everyone that failed their one hour and passed their three hour, or something like that. And again, that’s just a completely made up example, but that’s probably how checking these labs these help labs, as you say, for normal-tensive growth-restricted patients probably got started.

Howard 13:31

I’m sure it did, and when we have this sort of reactionary stuff it’s hard to consider in isolation. In that situation you described, which I’m positive has happened to many of us, it’s hard to consider the unintended consequences and how the extra testing will harm patients. And that’s why we have to act out of large trials, controlled trials, not out of single anecdotal experiences or hypothetical models, because testing has consequences.

Antonia 13:56

Yeah, yeah, if you read the practice bulletin on fetal growth restriction, that’s ACOG, practice bulletin 227, there’s a long list of possible causes of fetal growth restriction. Some of them include pregestational diabetes, renal insufficiency, autoimmune diseases, substance abuse, genetic or chromosomal abnormalities and of course also the pregnancy-related hypertensive diseases. And I don’t know if the same people who are getting help labs for every growth-restricted patient are also going down the whole rest of those list and also ordering autoimmune lab panels and extra drug screens or a karyotypes, because by their own logic they should. If it’s a possible cause for fetal growth restriction, then they’re testing for one of them. Why not test for all of them? But I bet they’re not. And if they’re not, then whatever the reason is, that they’re not working up those other causes should also be why they don’t get those help labs either.

Howard 14:53

Yeah, I would encourage people, just in general, to periodically every six months, every year anything that you have as standard protocols, standard order sets, treatment algorithms, things like that revisit it and see if it’s supported by current recommendations, see if you understand the reason why you’re doing it, ask the questions of how it changes the outcome or how it changes your practice or decisions. We have to constantly reassess and I’ll put a link to the practice bulletin that you mentioned, but nowhere in there or in any Society for Return to Field Medicine statement about this that I’m aware of, is there a recommendation that these labs be checked when you discover isolated growth restriction?

Antonia 15:28

Okay, well, let’s get into it with circumcisions. So I think the US seems to be one of the outliers on male circumcision compared to the rest of the world.

Howard 15:39

Right, and you’re more keenly aware of that than I am, since you have some Finland connections. But yes, we definitely are. So newborn circumcision is very commonplace in the United States and in at least a handful of other countries around the world. But yeah, most other developed countries outside of the US are either neutral or perhaps even firmly against a newborn circumcision, or what people sometimes call non-therapeutic newborn circumcision. This is all despite the same studies around the world and the same evidence about circumcisions being available worldwide. So it really seems like the evidence is being interpreted in very different ways depending on where you live, who you ask. I think we also have to be mindful of just prevailing cultural bias, or the general term for that is prevailing bias. If circumcision is culturally acceptable and normalized in your society, then you’re going to be more prone to interpret the risk benefit evidence and the stuff we’re gonna talk about today in a more favorable way towards circumcision, and if it’s not culturally acceptable, then you’ll do the opposite. Bias in one form or the other is why perfectly intelligent people can look at the same data and come up with different conclusions. But we can look at what a few of the other English speaking countries, what their commentaries are from their professional societies with circumcision and see some of these attitudes.

16:58

So I’ll give you a few quotes from some different medical societies around outside of the US.

17:03

So here’s one from Canada. While there may be a benefit for some boys in high risk populations and circumstances where the procedure could be considered for disease reduction or treatment, the Canadian Pediatric Society does not recommend the routine circumcision of every newborn male. Now from the United Kingdom, the BMA, which is the British Medical Association, has never taken a position in the debate about the acceptability or otherwise of non-therapeutic male circumcision. Instead, as with other procedures involving children who lack the capacity to consent, we’ve made clear that those wishing to authorize a procedure for their children need to demonstrate that it’s in the child’s best interest. And also from Australia after reviewing current evidence, the Royal Australasian College of Physicians, or RACP, believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia or a terroa, new Zealand. I know I butchered that the RACP recommends that circumcision should be considered for male infants with significant urinary tract abnormalities.

Antonia 18:08

What was that word you said before New Zealand?

Howard 18:11

Okay, I promise I actually looked this up to certainly how it was pronounced, but it’s a terroa and that’s the Maori name for New Zealand that they try to use in their official documents as well.

Antonia 18:22

Oh, that’s cool. Okay, well, I don’t speak Maori but I do speak Finnish, of course, so I always have to bring in Finland into this podcast whenever I can. So their medical society says just English translation that while non-medical male circumcision is not currently prohibited under Finland’s legislation, it is considered to violate the child’s bodily integrity and self-determination and is not part of publicly funded healthcare. So one would have to pay for it outside of the system if they wanted it.

Howard 18:53

And I think that Finland, that statement pretty closely represents the stances of the national medical societies throughout most of continental Europe. Some of them have even come close to legally banning male circumcision. So you do have to wonder why the US deviates fairly dramatically from other developed countries on this point when in almost all aspects we tend to have similar standards of medical care, and not that everybody agrees about it. You and I were talking about a statement, a publication from an Australian group that is trying to get circumcision normalized, and these are medical people. So there are disagreeing factions around the world, but for the most part people outside the United States are not getting circumcised.

Antonia 19:30

Yeah, and I’m sure there’s. Even in Finland, where the rate of male circumcision is 2%, I’m sure there’s some very vocal pro circumcision groups as well. On the flip side, obviously, it’s not that all Americans are gung-ho about circumcising all the baby boys. I’ve heard American pediatric urologists really strongly counsel against it. Of course there’s also lots of anti-circumcision lobby groups in the US and some of them are notorious for protesting at our annual meetings at ACOG and also the pediatric meetings.

Howard 20:03

So here’s some you saw some of them this year, yeah.

Antonia 20:06

Yeah, some of them can be jarring. So some quotes from their websites too. So this is from Doctors Opposing Circumcision. It’s an American group. They say there’s no medical reason for infant circumcision. It’s non-therapeutic because there’s no disease or injury requiring treatment. No medical organization recommends circumcision as a routine procedure for all males. So that actually includes the US.

20:29

But they go on to say the foreskin is no more prone to problems than any other part of the body and, if needed, conservative treatments are available and effective for any foreskin related problems. Disease is best prevented by attention to simple hygiene and proven behavioral risk factors. And I’ll just give one more just for fun, from a more aggressive group called blood-stained men. They say if your doctor did not warn you that emotional distress is a common side effect of circumcision, both for the victim and his parents, then you were not properly informed and you may want to file a complaint against your doctor. So on their website they of course feature the most horrifying cases of circumcision complications, including one where a three-day-old boy bled to death from a circumcision site. He probably had some de novo undetected coagulopathy or something which is rare but it can happen. And then they feature another case where a teenage boy, who had ongoing chronic complications from his circumcision as a baby, ended up taking his own life.

Howard 21:32

Yeah, sort of extreme examples and hard to prove causality and things like that too so be leery, just like in. We see these same sort of graphic and emotional rhetoric from both sides about anything pro-abortion, anti-abortion, pro-vax, anti-vax, pro-mask, anti-mask.

21:49

Some of the anti-vaccine stuff is jarring and graphic as well, and when you dig into it deeper you see that most of it is made up or making assumptions that are not in fact and trying to show a causal relationship that doesn’t exist things like that. So we need to look for facts and not shock value anecdotes. And of course, we certainly aren’t going to recommend that listeners report their doctor for how they might not have been counseled before their child’s circumcision. I know a lot of men and I’ve never met one who told me he was emotionally scarred from the fact that he was circumcised. But and I wonder how those groups would feel about ear piercing in infants. I might try to co-lab with them on that.

Antonia 22:25

Yeah Well, ACOG, of course, doesn’t have a statement about ear piercing, nor does it have its own position statement for us obstetricians, who are often requested or expected by patients and hospitals to do this procedure. But ACOG does endorse the recommendations of the AAP, the American Academy of Pediatrics. So this is what the AAP says, which is in quite stark contrast to all of the quotes we’ve just read above. Before I read it, I’ll also preface that this statement is from a task force that convened in 2007. And this most recent update to their statement is from 2012. And they’ve actually listed it as being an expired policy. So they just, I guess they have a standard process for when do their policies expire and they have not gone through the process of reaffirming or further updating it in the 10 years.

Howard 23:14

I bet there’s some background drama, we don’t know.

Antonia 23:17

Yeah, maybe, maybe, but regardless, this is what we have and it’s the most recent thing from the AAP and it’s what we’re still going by in the US, at least as we record this right now.

23:26

So they say evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedures benefits justify access to this procedure for families who choose it. Specific benefits identified include prevention of urinary tract infections, penile cancer and transmission of some sexually transmitted infections, including HIV. And of course, I think, going together with this kind of statement, usually in most cases in the US circumcision is fully covered, so the parents don’t have to pay out of pocket for it, like they would in Finland, for example. But if you compare all of this, it’s a bit of an awkward disagreement, I think, and maybe just because I’m part Finnish, I have a hard time just taking their recommendation at face value when practically the rest of the English speaking world and our European colleagues and a very passionate minority in the US as well, are very emphatically shouting the opposite. So I just wanted to try to dig into what the evidence is that everyone the same evidence everyone’s looking at, and then see if we can objectively judge the issue or not.

Howard 24:34

We’re solving all the world’s problems on this podcast.

Antonia 24:37

But yeah, I wish.

Howard 24:38

Yeah, the AAP’s position has actually changed over the last 20 years with different leadership in that organization and I suspect something’s afront now. So there are obviously cultural influences on our medical societies and how they interpret evidence. And our medical societies ultimately represent what the membership does and they represent pragmatic things like we want insurers to pay for these because our patients want it, and if you say it’s not beneficial, then they won’t pay for it, and things like that. So it’s honestly not too surprising that a group that represents members physician members in the United States would have a more favorable statement, as vague as it might be. And, that being said, groups in other countries they may have the same bias.

25:20

The important thing about bias is just recognizing that it’s real. We’re not taking a position on which bias is right, and you have to appreciate that, but recognize that bias infects our thought processes in the way that these professional societies have done that. So folks in other countries may have a bias against their circumcision because the members in their country don’t culturally accept it or believe in it. So we’ve got to look at the data and not emotions, as you said, and I think a good place to start would be a brief history of circumcision. We know it’s actually within the text of major world religions and it makes it an important tradition for lots of people.

Antonia 25:53

Yeah, unlike female genital mutilation, which is not mentioned in any religious text, so it doesn’t even have that as a basis.

Howard 26:01

Right. Well, both are still very ingrained traditions in some parts of the world, and just because something is tradition doesn’t make it right, also doesn’t make it wrong. But I like to look at why something became a tradition and have understanding about that, because then it helps us understand our bias. So male circumcision is actually the oldest known surgical procedure that we have a documentary sort of evidence about, and I think in the case of male circumcision it actually probably had some real benefits at the time that these traditions were born. So if you think about it, we live in a different world. 2000 years ago, 3000 years ago, 4000 years ago, they didn’t have anesthesia, they didn’t have good hygiene baths and showers, things like that, soaps, they certainly didn’t have antibiotics or condoms or the Gardasil vaccine.

26:44

And I think it’s very likely that young boys and adult men saw a lot more complications with things like phimosis and balanitis and other painful conditions, and they viewed childhood or infant circumcision as a way of avoiding these problems, before they became old enough to be traumatized by remembering having such a painful procedure done in an era with no anesthetics or things like that, and in an age when you can get erections nocturnally, even unwillingly. So having done this at that point in time without the benefit of pain. Medicine is not an easy thing to do, when you imagine using sharpened stones. Basically, even today, we think that up to 11% of males and again this is highly dependent on hygiene and vaccination status and things like that might experience one of the problems of phimosis or balanitis or postitis, and that doesn’t mean they all need circumcisions or things like that. But these numbers, though, were likely much, much higher in pre-modern times, when we didn’t have the benefit of the hygienic changes in antibiotics and condoms, and vaccines, and STDs were just common and never cured, and things like that.

Antonia 27:48

Yeah, that makes sense. So if today it’s still up to 11% of males that’ll experience one of those problems, back then it was probably double. So let’s say one in five males eventually had to undergo circumcision by adulthood or just live with these medical problems of their foreskin. It makes sense that ancient civilizations would have at some point discovered how much easier it is to just remove that foreskin on an infant, even though it’s still not painless. At least they wouldn’t have the memory of it being done or having to go through the healing process of it.

Howard 28:24

Right, and this practice significantly predates the Old Testament. So there’s evidence that Egyptians routinely practice circumcision as far back as the 23rd century BC, and it likely grew out of Egypt to become popular with various Semitic tribes in that part of the world and in the Middle East and the Near East. It’s also likely the case that ancient cultures discovered that delaying it by a few days might be associated with less bleeding, and so of course it became commonly done in a Jewish law on the eighth day.

Antonia 28:52

Yeah, vitamin K is necessary for the synthesis of pro-thrombin and factors 7, 9, and 10. And newborns are born without any detectable levels of vitamin K but eventually it’s made by their gut flora. But a newborn less than one day old is born without even those flora in their gut initially.

Howard 29:11

Yeah, so waiting a little longer, they may bleed better. And also, just, you can’t have someone who’s skilled at performing circumcision around every time a baby’s born, but if you do it a few days later, you can find the one person who’s skilled and have a child attendant.

29:24

So you can see how this can become institutionalized in a religious culture and then it spread from Egypt obviously to the Israelites, but then also to Muslims and other cultures with a cultural relationship to Israelites. But it also simultaneously appeared in many unconnected areas of the world. So, for example, it was practiced by many South Sea Islanders and Aboriginal peoples of Australia, but also by the Incas and Aztecs and Mayans in South America. So this grew up in various unrelated and unconnected cultures, probably out of the same sort of common understanding that this would help prevent the need for adolescent or adult circumcision in a considerable number of men. Interestingly, the Egyptian hieroglyph for a penis actually we think there’s some controversy depicts a circumcised penis and the Greek writer Herodotus. He wrote and actually made fun of Egyptians and said that they practice circumcision for the sake of cleanliness, considering it better to be cleanly than comely. So we know that he viewed uncut penises as more attractive. The Greeks at that time did not practice circumcision.

Antonia 30:24

Interesting. Well, over time, somehow it did fall out of favor in most of the world, including among Christian dominated nations, which might be why it’s still not really that popular in Europe, even now.

Howard 30:37

Well, we don’t want to dig too deep, but probably continental European anti-Semitism had something to do with that. But yes, it did mostly go away but began to see a revival in the latter part of the 19th century. It was viewed negatively, as you said, by European Christians who largely just relegated it to something that the Muslims and Jews did, and certainly after the time of the Crusades it was just viewed as this barbaric thing that Muslims did or something like that, and they tied it purely to religious traditions of groups that they didn’t like. But towards the latter part of the 19th century it started to be viewed as something that was perhaps medically beneficial, because that argument had been rare before the latter part of the 19th century. So the main thing that led to this was the idea that circumcision would decrease the risk of STDs, particularly syphilis.

31:25

But the idea also came about because it was felt that circumcision would decrease the incidence of masturbation or what was called self-abuse among boys, and so in the Prudish Victorian era of the latter part of the 19th century it became popular again. In fact it’s thought that Queen Victoria introduced it back into the royal family and the noble class, but there’s no great evidence for that, but it does seem to be something that elite classes would have done because they thought it had some medical benefit and it was available to them and probably sold to them. And in that way it reminds me of how tongue-tie surgeries today are sold to breastfeeding moms by less than credulous providers, who often pay cash for these services because they think it gives them some benefit in breastfeeding. And so it came back in popularity in the latter part of the 19th century.

Antonia 32:12

Yeah, I think all of this is important, at least speculation. If there’s a historical scholar about circumcisions out there that wants to correct any of this, then please send us a message. But the point is obviously there’s a large religious background to this practice. But we can also respect that a lot of other ancient cultures simultaneously stumbled upon it even without that same religious underpinning, because it must have had some practical benefit for them. So the question is whether that practical benefit is still enough to justify the practice today. I suppose if you knew that an adult male had a one in five or so chance of meeting a circumcision during his life and that was going to be a painful procedure and possibly embarrassing or associated with sexual dysfunction or that would take him out of being productive in society for however long, then you can make a great argument for just universally doing it for all babies. But we need to get into the science about the potential benefits today, because it’s not the case that one in five men are going to need circumcision anymore.

Howard 33:18

Right, okay, so one thing you mentioned from the AAP bulletin was that it might prevent penile cancer, and I suppose if you cut away the foreskin you won’t get cancer of the foreskin. But the incidence is less than one in 100,000 men in the US for that sort of cancer, and in comparison to that, the incidence of vulvar cancer is one in 333. So by that logic, why don’t we proactively cut off portions of the women’s vulvas to prevent them getting cancer there? And of course, there’s also other ways to reduce the risk of penile and vulvar cancer. While we’re at it, yeah, yeah.

Antonia 33:52

The penile cancer argument by the AAP is interesting, I would say. It is most common in men over age 60. And most of those are squamous cell cancers and at least half of them are related to HPV, especially strains 16 and 18, which is exactly the worst strains. For cervical cancer as well, and that’s what the Gardasil vaccine protects against, and for penile cancer that’s HPV associated Gardasil is at least 70 up to 80% effective. The other important risk factors for penile cancer are smoking, which roughly doubles the risk, and hygiene also seems to make a pretty big difference. So if men wash regularly and by the time they’re adults, if they retract their foreskins while washing to clean under the foreskin, this can significantly impact the rate of cancer.

34:44

There was a study in Denmark. This was several decades ago, I think, but it showed decreasing penile cancer incidence over a 50-year period, even while their rate of circumcision remained very low. It was less than 2% the whole time but the incidence of penile cancer dropped significantly and that was attributed to an increase in the rate of housing per capita that contained bathtubs. So it increased from 35% of houses having bathtubs up to 90% over that 50-year period. And if you compare that to other countries where they also have a low circumcision rate but still have less hygiene amenities like bathtubs, the rate of penile cancer is much higher.

Howard 35:26

Yes, I don’t think that the penile cancer is going to be the best argument to make for routine circumcision, and again, there’s a not to be a nihilist about it. But the vulvar cancer argument, I think, makes that point. Unless you’re going to argue that we should be doing partial vulvectomies on little girls to reduce the rate of cancer, then you don’t have good footing for this. It’s just too rare and too preventable and too treatable, frankly. But let’s talk about phimosis though, which I mentioned before. So pathological phimosis is when the skin around the glands penis becomes scarred, swollen, painful, and then you’re unable to retract the glands or the skin over the glands, and that’s also the presence of that’s considered a strong risk factor for cancer. It’s an 11-fold increased risk. In fact, the risk for penile cancer in uncut males is the same as for cut males when you exclude those who went on to develop phimosis. So it’s the most important risk factor.

36:20

Perhaps it occurs generally in about 1% of uncircumcised men, but it can also occur in circumcised males due to scarring from the circumcision itself. So we don’t know the real numbers for this, but food for thought. In one small study the rate was 2.9% of newborns after they’d had a Gomko circumcision, which I think is the most common method used in the United States. But again, that’s probably an unfairly high number. But it can also be caused by forceful retraction. So people are afraid that it’s not retracting and they try to force it. For many boys, it’s normal for the foreskin not to retract until late into childhood, or even adolescence, depending on who. You ask different opinions about it, but people will try to force retraction because they think something’s wrong. Now, pathologic phimosis can be affected by many other risk factors that lead to inflammation or scarring, including being obese, poor hygiene, which you talked about, the presence of sexually transmitted infections, other inflammatory conditions, endematous skin or endematous conditions like digestive, heart failure, diabetes, prolonged use of catheters, allergies, other skin conditions.

Antonia 37:28

Yeah, so this is one of the key issues, because the definitive treatment of pathologic phimosis will be circumcision, but today, because of better hygiene and prevention of STDs and just access to medical care for more conservative treatments, this is a lot less common and less needed than it might have been in the past, and it’s possible that the rate of uncircumcised men getting therapeutic circumcisions later in life due to phimosis it’s possible that that rate is comparable to the rate of circumcised males needing a revision of their circumcision procedure for whatever reason. We really don’t have great data on this.

Howard 38:10

Yeah, and I tried to find European versus US data or something like that and it just doesn’t seem to be a lot, so we’re speculating a little bit. But I think it’s not unfair to say that one-ish percent of adult men may need circumcision due to phimosis and, as you pointed out, a lot of people who’ve been circumcised may also need revisions or circumcisions older in life because of that. So we don’t really have a good comparison. But this, the next point, may be the biggest argument, I think at least worldwide, in favor of circumcision. So we’re seeing increasing rates of circumcision in HIV endemic areas of Africa due to the potential benefit of male circumcision to reduce the rate of the transmission of HIV. So this has support from multiple levels of health care organizations, including the World Health Organization. So let’s talk about this one.

Antonia 38:57

Yeah, this is based on numerous studies. I’ll briefly try to summarize a few of the initial landmark trials here. So in all of these trials they randomize adult males to either getting a circumcision or no procedure and then up to two years later they tested those males for HIV. So one was in South Africa. It was about 3700 men total. Half were offered circumcision electively and then the other half were not. And 18 months later 20 men that were circumcised had HIV, which was just under 1.3 percent, whereas 49 men in the uncircumcised group had HIV and that was 3 percent. So absolute risk reduction was 1.7 percent.

Howard 39:45

Yeah, so 1.7 men out of 100 didn’t get HIV because they were circumcised is what that would indicate.

Antonia 39:51

Right, right, but relative risk. It was more than a 50% protection if they got circumcised. Another trial in Uganda had just under 5,000 men, also randomized, one to one. So again similar numbers 20 men of the circumcised group got HIV, compared to 45 men in the uncircumcised group, which again is more than 50% protection. They noted a 3.6 percent rate of moderate to severe complications. And then finally, in Kenya, they found an increase in male circumcision rates from 32% up to almost 60% over just a four year period from 2009 to 2013. And during that time the HIV incidents also appeared to have declined from 11 per thousand to 5.7 per thousand. So that almost that also looks like about a 50% decline. And there’s been a lot of systematic reviews. What one of them also just aligns with all of these trials? That shows roughly 1% absolute risk reduction within high risk groups. So they’re saying that it seems like one in 100 men who get circumcised will be spared from HIV due to circumcision.

Howard 41:15

Yeah, okay. So on the surface, that seems like a compelling argument, at least for those areas, to increase the amount of circumcision, and that’s what health organizations have been encouraging, but, of course, there’s a lot of other things going on in those areas of the world, including increased use of antiretroviral therapies among infected people, which would decrease transmission rates, and just more awareness in those communities about HIV transmission, particularly among people who are coming in to get circumcised, and probably changes in sexual behaviors. Now, most of the data you talked about, though, was from randomized trials, but they’re not blinded trials or anything like that.

41:51

So there could still be some issues there. They’re not accounted for.

Antonia 41:54

Yeah. And some of the counterarguments, like from the doctors opposing circumcision group, say that it’s possible that the men who were circumcised after their procedure they had to abstain from intercourse while they were healing for an unspecified amount of time. But one of them said they were instructed to abstain for six weeks but they didn’t track the compliance of that, whereas during that same time period the uncircumcised men had no restrictions. They were just continuing to live their lives and do whatever sexual activity they wanted to. So that means that it’s possible that the uncircumcised men in those study groups had more opportunities to get exposed and infected just by virtue of not having to be healing from that procedure. And they also mentioned that these authors of these studies had already been advocating for circumcision to prevent HIV before they even started these trials. This was probably based on some prior observational data, which is a good reason to advocate for it. Who knows if they had other biases, so they may have already been biased towards a certain result.

Howard 42:59

Well, what about changes in the use of condoms over these time periods? If they had more awareness, were they wearing more condoms? Are there other reasons? Again, it’s randomized data, but there’s been a decline in HIV transmission for other reasons.

Antonia 43:11

Yeah, they all were given free access to condoms and the authors asked the participants about condom use and recorded it, and they didn’t record the actual rates, but they stated that the rates of condom use were roughly similar across the groups. You could even make the opposite argument, that some of the circumcised men might have been led to believe that now I don’t need a condom because I’m circumcised, which would have worked even against the benefit of circumcision. But we didn’t see that.

Howard 43:38

Well, and, like all studies, there was a significant loss to follow up in these studies that could change the results. Up to one in five men didn’t follow up in some of these studies and in one country 90% of people didn’t follow up, so you don’t really know how much of that HIV population didn’t follow up. We also don’t know whether their partners had HIV or whether they had HIV at the time they had their circumcisions things like that that could show some differences in the circumcised group versus the non-circumcised group.

Antonia 44:09

I’ve seen a lot of different follow-up questions get studied as well, and these all seem to strengthen the evidence in favor of circumcision, at least as a protective strategy against HIV. So one study in the New England Journal drilled down on men that have HIV-positive female partners and they found that it appears that the circumcision status appeared to be protective compared to non-circumcised status If the males were starting out uninfected and their female partners were known to be infected. So three out of 29 circumcised men ultimately got HIV, which was about 10%, versus 46 out of 195 uncircumcised men, and that’s over 20%. So this wasn’t a very powered this wasn’t sufficiently powered to make a definitive conclusion, but it seems compelling. And then there was another study that for males who already had HIV, they were more likely to transmit HIV to their female partners only if they were recently circumcised. So it’s still in the healing phase. So all that really tells you is they should heal.

Howard 45:21

Well, we do know, just by analogy, that circumcision appears to reduce the risk of transmitting other infections to female partners, including HPV and subsequently cervical cancer, hsd2 or herpes virus. In general, chlamydia syphilis, based on systematic review I’ll put a link to, and it also doesn’t appear to have an effect on bacterial vaginosis or yeast. I think we think about that a lot in the United States but for other infections, by analogy, it does work. I’m not sure that we can really question whether or not it decreases the rate of HIV transmission in Africa. I think the question might be whether or not that applies to the United States.

Antonia 45:58

Yeah, there’s still a lot we don’t know about all the moving targets of circumcision, in Africa at least, and I’ve had a harder time finding verification for all of the counterarguments that I read on those anti-circumcision sites. So some of them will say, for example, that the HIV incidence has increased throughout African countries where they’ve had major campaigns promoting circumcision, even though at least in I think it was in that Kenya study I mentioned, they found the opposite, so I wasn’t able to verify that claim. But even if we agreed that it’s a good thing for men in Africa to be circumcised because it’ll protect them against HIV, it still is stretch to equate that To infants born in the US or UK, Australia, Canada, etc. Or really almost any country that has a lower HIV incidence and perhaps paired with higher standards of living and hygiene and sex education.

Howard 46:55

And studies, specifically in the US and Europe have not found this protective benefit of circumcision for HIV prevention, and it doesn’t appear, importantly, to be a protector in many of sex with men, where HIV transmission is relative, the risk is significantly higher. And the United States in Europe, at least as a methodology, the overall incidence of HIV in the US and Europe is so low that it doesn’t appear to make a difference. So again, even though this arguably might be very important in Africa, in countries with endemic HIV, particularly among men who have sex with women, that doesn’t necessarily translate to any measurable benefit in other countries where those circumstances are not the same. So, okay, well, what about your own air tract infections? Obviously, I think the AP argument led with that one. Now, adult males don’t get as many urinary tract infections in the first place compared to women, but this isn’t the case for infants and circumcision is said to be a benefit for this right.

Antonia 47:50

Yeah, it’s a pretty clear benefit actually. So most UTIs that happen in babies happen in males instead of females, and we know it seems to be the opposite as they get older. But mostly they happen in baby males and among baby males there’s more than a four to one ratio according to circumcision status. So the uncircumcised males are about four times more likely to get it. Then circumcised male and just for comparison, baby girls have a different gender, the same rate of UTIs as circumcised baby boys and of course, the rate of UTIs is much more common than the rate of HIV.

48:30

In the United States I think it’s something like three percent of uncircumcised boys will get a UTI, compared to less than one percent Each of girls or a circumcised boys. And of all infants presenting with fever, fifteen percent of them ultimately are found to have a UTI, and that doesn’t include all the UTI cases where they presented with something else, like fuzziness or poor feeding or vomiting without fever. So it’s a pretty common thing to see when primary care and in the ER setting and circumcision appears to protect it. But even though it’s so much more common, so much more of an obvious protective effect, it’s probably, I’d say, pretty easily arguably a much lower stakes and much lower acuity issue than HIV prevention. The protective effect of circumcision against UTIs really only applies during the first year of life and of course in most cases UTIs are easily treatable.

Howard 49:27

Right. I don’t think we’re seeing in Europe or other countries that don’t have our rates of circumcision, we’re not seeing some epidemic of your sepsis in infant boys leading to significant mortality or ability.

Antonia 49:39

Yeah, your sepsis is such a rare complication of UTI I think the number needed to treat of how many circumcisions to prevent one death from your sepsis and a baby, it’s not calculable, it would just be so high I can’t find the numbers and it’s probably at least as high or higher than the number needed to harm For severe circumcision complications. So it seems like circumcision may be most beneficial. Like there was not one policy statement for boys who are at higher risk of UTIs, like those with genital urinary anatomic abnormalities, or another risk factor actually is maternal history of recurrent UTIs.

Howard 50:20

Okay, well, so we’ve talked about potential benefits. Let’s talk about risks then. So a lot of the risks are relatively minor and treatable and self-limited. Now, in that you gone to an HIV study, you mentioned that up to 3.6% of the men had complications, and those weren’t neonatal circumcisions. Those were mostly adult men or adolescents. In contrast, in one study in Israel, where circumcision obviously is very common, the complication rate for neonatal circumcision was just 0.34%. Of course, it all depends on how you define a complication too, and most of these complications were minor, easily treatable issues like some focal bleeding or infection that was easily treated, or pain, obviously, but they also can include things like need for reoperation or poor cosmesis or adhesions that need treatment or things like that. And the scariest and also fortunately the rarest complications would be things like amputation of the glands, but these are honestly so rare that they only really exist in case reports and they probably don’t occur at all, with proper technique being utilized.

51:22

If you think about the United States alone, there’s probably more than 100 million men I don’t know the number, but easily that have been circumcised and we’re only able to find rare case reports of those sorts of complications. And none of the HIV circumcision studies that you looked at mentioned anything that serious or life threatening complications, anything of that sort.

Antonia 51:42

Yeah, that is correct. But a pretty high number of pediatric urology referrals are for circumcision related complications and of course most of those are minor, so they’re easily treatable. No permanent sequelae. The cost of those minor revisions might be a few thousand dollars per patient, depending on how extensive it is or what their insurance coverage is, so maybe not even a big deal. From that sense it probably adds up a bit more on the population health care spending level.

52:12

So one of the most common minor complications that require a circumcision revision in the US is considered to be redundant foreskin, or basically when too little foreskin was initially removed and then it just telescopes up around the glands and it’s mainly a cosmetic concern. Sometimes it can cause just abnormal scarring. So this is what this is where I get back to the question of is that risk the risk of the minor stuff, the really rare risk of the major stuff worth the benefits that we’ve just spent so long talking about? So again, to summarize the benefits, in the US Circumstances would lead to less infant urinary tract infections, including probably some cases of sepsis, that that develop from UTIs, and also maybe some fewer adult circumcisions being needed due to phimosis complications.

Howard 53:03

Yeah, we’re talking about a permanent change to the anatomy of a child who cannot consent to the procedure for some very minor benefits. It’s always about risk versus benefit and what our ethical role is here in exposing someone who’s not able to give consent to any amount of risk without a really quantifiable and verifiable amount of benefit. So I won’t keep bringing up ear piercing, but I will put a link to a case report of necrotizing soft tissue infections of the ear after a set of 19 day old female twins newborns received ear piercing and they both had this issue. Sounds like they have a sterilization problem, but everything has a risk of complications and so we have to weigh out the benefit to it.

53:44

I also think about all this. It’s like we wouldn’t be having this conversation. I don’t think that if someone came today and we’d never heard a circumcision, and someone came to present a paper at the American Academy of Pediatrics annual meeting and said, hey guys, if we routinely cut the foreskins off of everybody’s penises when they’re born, we’ll reduce the risk of infant urinary tract infections by X percent, I don’t think that we would consider adopting that. So, yeah, it’s when benefits are very minor and risks are very minor, it’s easy for things to just get punted along the way they are because no one’s super passionate one way or the other.

Antonia 54:21

Yeah, I agree, that’s I pretty much never get questions on. Well, what’s the benefit? That’s not how people are approaching circumcision for their infants, at least where I practice. So let’s try to talk about ethics if we have a few minutes left. So I think we can distill it down to three different possibilities. Either it’s beneficial, meaning benefits outweigh the risk, which would mean it is ethical. Or it’s harmful, meaning the risks outweigh the benefits, in which case I would say it’s unethical. Or the third option is the gray area, where the benefits cancel out the harms, in which case it’s essentially ethically neutral. And that’s where, then, you can bring in other elective, maybe cultural, considerations. So I think, even after looking at all the hard numbers, it’s hard to weigh the risks and benefits because they’re different. They’re like apples and oranges. So how many apples equals one orange?

Howard 55:15

or vice versa.

Antonia 55:18

Yeah, probably because I don’t really like apples, which is oranges.

Howard 55:22

So I think oranges are more valuable, but we value things differently.

Antonia 55:26

Yeah. So just from my perspective, I strongly dislike even having the most minor procedural complication of anything I do. But especially when it involves a newborn, and especially if it’s the newborn’s genitals, even the most minor complication just is very distressing to me, especially when I’m considering the alternative is something that you can just treat with a short course of antibiotics against a UTI, for example, or some steroid cream for phimosis. But if you believe the point that the risks and benefits either cancel each other out or the benefits are more valuable than the risks, then it’s certainly easier to ethically justify its use, especially in cultures where it’s already an integral part of the religious tradition.

Howard 56:12

I think we can agree, though, that circumcision is not considered beneficial at all in many European countries Canada or Australia. This is likely because, again, the high standards of living include ready access to basic hygiene, like baths, and ready access to basic medical care for early treatment and intervention for phimosis, and also just ready access to sex education and education about condoms and how to clean your penis. But it’s considered legal in those countries, but as an elective procedure, and that’s obviously just due to the cultural significance for some of its populations.

Antonia 56:45

Yeah, so I don’t think we’ve really answered this question in any definitive way and obviously all we can really do is provide the facts and the studies and maybe some kind of ethical framework for discussion. And there’s still a lot we haven’t talked about as far as potential effects on sexual function, although those studies are probably the weakest and maybe the most far-fetched claims that there are regarding circumcision.

Howard 57:09

Yeah, but people do claim that uncut men have greater sexual satisfaction. It’s just how do you study that?

Antonia 57:14

Yeah.

Howard 57:14

I also think there’s a difference between saying that something is not beneficial and saying that something is harmful, and I feel like in the past hour we’ve drilled down on the balance of risk and benefit being somewhere between neutral meaning that the benefits just cancel out potential harms to slightly beneficial, depending upon individual risk factors and the population involved. But I don’t think we’ve made a case necessarily for it being overtly harmful. In this sense it’s not comparable, I think, to female general mutilation, which has zero potential benefits, I guess maybe reduction of vulvar cancer, right, but very significant and very measurable harms.

Antonia 57:50

Yeah.

Howard 57:51

In which case we could say, given the framework you outlined, that it is unethical, even if you argue that it’s something done for cultural considerations that are important. But I don’t think we can say that about male circumcision.

Antonia 58:03

Yeah, I think many of the things that made circumcision a sensible option in pre-modern times don’t apply anymore to developed nations today. Maybe to some extent they still do apply in some other really underdeveloped countries or just wherever hygiene is poor, vaccines are unavailable, HIV is endemic, etc. But, like I said, my experience has been that the cultural factors overwhelmingly predominate, at least where I practice. Most of the families that I’m serving that are requesting circumcision. They don’t ask a bunch of questions before they request it. They lead with I want them circumcised. They don’t need any convincing and probably if I tried to talk them out of it, they wouldn’t be talked out of it.

Howard 58:45

Do you try to talk them out of it?

Antonia 58:46

No, I do not try to talk them out of it, but I don’t try to talk them into it either. I try to stay neutral. I’m in that, I guess that gray zone, because really, maybe this is because I’ve looked at too many case reports. But the way I see it, an amputation of a penis, which is the complication I fear probably more than anything else, is so rare and unlikely. But also nothing in the world to me is worth risking. A penile amputation of a baby boy like nothing.

Howard 59:15

I think most men would agree with you.

Antonia 59:16

Well, yeah, so I don’t lead with a discussion if they say, hey, I want to circumcise, I don’t lead with a. He could have a penile amputation, because that’s just unnecessary, it’s jarring and catastrophizing. I do tell them about the protection against UTIs, but also about the common risks of maybe some focal bleeding or possibly needing a re-operation later for any number of reasons. But it’s literally in my job description to do this procedure when the parents have requested it and consented for it. And I think, with how culturally popular it is where I practice and really throughout most of the US, and how the AAP and CDC and World Health Organization all basically promote it, there’s not really a lot of room to conscientiously object to it. I’d say.

Howard 01:00:01

And it’s also true that most Americans who are circumcising their children are not Jewish or Muslim.

Antonia 01:00:06

They’re not doing it for religious reasons.

Howard 01:00:08

It is a purely cultural tradition, but as opposed to Europe. So too bad you’re not in Finland, where you wouldn’t have to do it, I guess. What do you tell your patients about neonatal ear piercing?

Antonia 01:00:18

Okay, well, thankfully I don’t get asked that. I think we might already be getting an explosion of hate mail about this episode from probably both sides of the fence, so I’m just going to try to stay neutral on that one as well.

Howard 01:00:29

Okay, well, I’ll take the hate mail again then. I guess just hit forward and we’ll see what happens. The practice of neonatal ear piercing is more common among Latino cultures and I think there’s no argument that again, that it’s done for anything other than purely cultural reasons. But the interesting thing is and it’s just interesting about the arguments to me it’s defended by a lot of folks for the reason that it’s a cultural tradition, and I’ll bring that up because I think it’s thought provoking. Some cultures would cite bodily autonomy as a reason to not circumcise but then ignore the bodily autonomy argument when it comes to ear piercing or vice versa. We don’t have really time left to talk about that, but I’ll put a link to an article I looked at that has a pro and con discussion about ear piercing, because I think a lot of the arguments and the pros and cons in there relate to this cultural aspect of circumcision that we’ve been talking about. So I think it’s an interesting comparison.

Antonia 01:01:20

Well, in case anyone’s wondering, I got my ears pierced when I was 18. So there you go.

Howard 01:01:25

I did not.

Antonia 01:01:26

Well, I think we should wrap it up for today, but hopefully everyone enjoyed listening and let us know if you have any comments or any thoughts. We’d like love to hear them. The thinking about OBGYN website will have links to a lot of the stuff we discussed today and we will be back in a couple of weeks.

Episode 6.9 Male Circumcision: A Global, Historical, and Ethical Debate

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