Group Think and Circumcision

Famous Psychologist Irving Janis Study on Group Think, with my additions in bold italics as it relates and to circumcision group think

Symptoms.  In my studies of high-level governmental decision-makers, both civilian and military, I have found eight main symptoms of groupthink. 

1.    INVULNERABILITY.  Most or all of the members of the in-group share an illusion of invulnerability that provides for them some degree of reassurance about obvious dangers and leads them to become over-optimistic and willing to take extraordinary risks.  It also causes them to fail to respond to clear warnings of danger.  In  circumcision group think people like Professor Brian Morris minimize the risks of circumcision and amplify the its benefits.  The African Circumcision trials were full of group think exaggerating the benefits of circumcision and minimizing the potential harms, and now we see behavioural disinhibition and circumcised men being infected with HIV at higher rates.  What a massive risk it was to say to African Men that if you get circumcised you are protected from HIV, the non-circumcision world was pointing out the obvious that circumcised men still became infected with HIV, and this message could lead to behavioural disinhibition, but these were all ignored facilitated by the group think of the procircs.

2.    RATIONALE.  Victims of groupthink ignore warnings:  they also collectively construct rationalizations in order to discount warnings and other forms of negative feedback that, taken seriously, might lead the group members to reconsider their assumptions each time they recommit themselves to past decisions.  James C. Thompson, Jr., a Harvard historian who spent five years as an observing participant in both the State Department and the White House, tells us that the policy-makers avoided critical discussion of their prior decisions and continually invented new rationalizations so that they could sincerely recommit themselves to defeating the North Vietnamese.  When the WHO recommended mass circumcision campaigns in Africa they ignored the warnings of behavioural disinhibition, that circumcised men still became infected with HIV, and that condoms being a barrier method was the only safe way to prevent HIV.  They used inadequate mathematical health models to project millions of HIV infections would be prevented if mass circumcision campaigns were implemented in Africa, however if the mathematical health models had of used variables such as behaviural disinhibition, lower condom usage and increased sexual risk taking behaviour, the predictions of hiv infection prevention may have disappeared completely.  This suggests the mathematical model were left to exaggerate the protective effects of circumcision because of group think.

3.    MORALITY.  Victims of groupthink believe unquestionably in the inherent morality of their in-group.  This belief inclines the members to ignore the ethical and moral consequences of their decisions.  Evidence that this symptom is at work usually is of a negative kind - the things that are left unsaid in group meetings.  Circumcision campaigners believe they are doing a moral good by advocating for circumcision, and view its opponents as fanatics.  They would have ignored the evidence that behaviural disinhibition, lower condom usage and increased sexual risk taking behaviour, were serious and real risks of mass circumcision campaigns.  Group think would never have allowed the risks associated with circumcision to have been given any weight or consideration.

4.    STEREOTYPES.  Victims of groupthink hold stereotypes views of the leaders of enemy groups:  they are so evil that genuine attempts at negotiating differences with them are unwarranted, or they are too stupid or too weak to deal effectively with whatever attempts the in-group makes to defeat their purposes, no matter how risky the attempts are.  Intactivists are seen as a radical lunatic fringe that only get their information from the internet, ignoring the leading medical organisations of the world who recommend against circumcision.  Intactivist are also seen as foreskin fetishists, as if the foreskin has no inherent value other than what intactivists have magically bestowed upon it.  This allows them to ignore any valid claims that people make against circumcision.

5.    PRESSURE.  Victims of groupthink apply direct pressure to any individual who momentarily expresses doubt about any of the group's shared illusions or who questions the validity of the arguments supporting a policy alternative favored by the majority.  This gambit reinforces the concurrence-seeking norm that loyal members are expected to maintain.  We are not privy to the private discussions behind closed doors and whether there were any dissenting voices, and if so what pressure tactics were used to silence dissent. That no dissenting voce is ever heard suggests this is probably the case. A guess would be that Anyone who questions circumcision are negatively labelled shamed and coerced into circumcision.

6.    SELF-CENSORSHIP.  Victims of groupthink avoid deviating from what appears to be group consensus; they keep silent about their misgivings and even minimize the importance of their doubts.  Again no-one is privy to the private thoughts or self-sensorship that may have occurred with procirc organizations like the AAP, CDC, WHO? You certainly wouldn't know if any procirc like brian morris ever had the slightest doubt or misgiving about circumcision.

7.    UNANIMITY.  Victims of groupthink share an illusion of unanimity within the group concerning almost all judgments expressed by members who speak in favor of the majority view.  This symptom results partly from the preceding one, whose affects are augmented by the false assumption that any individual who remains silent during any part of the discussion is in full accord with what the others are saying.  When a group of persons who respect each others' opinions arrives at a unanimous view, each member is likely to feel that the belief must be true.  This reliance on consensual validation within the group tends to replace individual critical thinking and reality testing, unless there are clear-cut disagreements among the members. To avoid such an unpleasant state, the members often become inclined, without quite realizing it, to prevent latent disagreements from surfacing when they are about to initiate a risky course of action.  The group leaders and the members support each other in playing up the areas of convergence in their thinking, at the expense of fully exploring divergences that might reveal unsettled issues.  Recent papers by the AAP and CDC clearly indicate this probably occurred within their organizations, which led to their unscientific and uncritical and inadequate papers on circumcision being published and then widely criticized by the worlds medical community.

8.    MINDGUARDS.  Victims of groupthink sometimes appoint themselves as mindguards to protect the leader and fellow member from adverse information that might break the complacency they shared about the effectiveness and morality of past decisions. Again it;s hard to know whether this occurred but we never hear a dissenting voice or criticism about circumcision within AAP, CDC, WHO which tends to suggest that this is exactly what happens.

Support.  The search for explanation of why groupthink occurs has led me through a quagmire of complicated theoretical issues in the murky area of human motivation.  My belief, based on recent social psychological research, is that we can best understand the various symptoms of groupthink as a mutual effort among the group members to maintain self-esteem and emotional equanimity by providing social support to each other, especially at times when they share responsibility for making vital decisions.  Here I would speculate that one's circumcision status and the cultural practice of circumcision leads members to need to maintain their self-esteem that their cultural practice of circumcision and their own circumcised penises are indeed  as magically fantastic as they would like to believe.

RACP Medical Journal of Australia response to push for routine infant circumcision in Australia

In a recent editorial, Cooper and colleagues recommend increasing infant circumcision to combat increasing rates of heterosexual transmission of HIV infection, and contend that the major obstacle to increasing male circumcision in Australia is a Royal Australasian College of Physicians (RACP) policy. [1]

“The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV” . . . and now the case against

David A Forbes, John W Travis, Sarah J Buckley, Paul Mason, Ken McGrath, Robert S Van Howe, George Williams, Anthony N Lyons, Marian Pitts, Anthony Smith, Jeffrey Grierson, Niall Conroy, Gregory J Boyle, George Hill, Robert J L Darby, Bruce R Paix, Jeremy J Chin, David A Cooper, Alex D Wodak and Brian J Morris

Med J Aust 2011; 194 (2): 97.
Published online: 17 January 2011

In September, after a literature review and analysis, the RACP released a revised policy on infant male circumcision, concluding 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 and New Zealand. [2] While evidence of HIV prevention by circumcision is strong in high-prevalence settings with predominantly heterosexual transmission, [3] this is not so in low-prevalence environments where homosexual transmission is more important. [4] Evidence of the protective effect of circumcision against other sexually transmitted infections in Australia is limited. [5]
Cooper et al’s comparison of circumcision with vaccines is misleading. Protection against HIV by circumcision is predominantly for males, and the risk for females may increase. [6] There is minimal protection against homosexual acquisition of HIV. [4]
The RACP acknowledges the strong and differing opinions on this topic, ranging from the strong pro-circumcision views of Cooper et al to the equally strong diametrically opposed views of the Royal Dutch Medical Association, which believes that (for reasons of ethics and medical risks) legal prohibition of infant circumcision is warranted. [7]
The RACP recognises the important role of parents in decision making, and recommends that parents contemplating circumcision of their newborn sons be carefully apprised of the risks and benefits. If they elect to proceed with circumcision, the procedure should be undertaken in a safe child-friendly environment, with appropriate analgesia, and by an appropriately trained, competent practitioner who is capable of dealing with complications. We believe that this approach safeguards the social and community interests of children, and offers protection from unnecessary surgical risks. [2]
The RACP does not accept that its policy on circumcision of infant males represents an obstacle to effective public health policy — it believes that, at present, the evidence does not allow a recommendation for widespread infant male circumcision and that Cooper et al have misrepresented this evidence. In the interests of children, and of public health more generally, it is important that this evidence be kept under review and decisions that could lead to increased morbidity and mortality of children only be made when it is clear that the benefits very clearly outweigh any risks.
David A Forbes, Chair, Policy and Advocacy Committee Paediatrics and Child Health Division, Royal Australasian College of Physicians, Sydney.
1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.
2. Royal Australasian College of Physicians. Circumcision of infant males. Sydney: RACP, 2010.
3. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev 2009; (2): CD003362. 
4. Templeton DJ, Jin F, Mao L, et al. Circumcision and risk of HIV infection in Australian homosexual men. AIDS 2009; 23: 2347-2351. 
5. Templeton DJ, Jin F, Prestage GP, et al. Circumcision and risk of sexually transmissible infections in a community-based cohort of HIV-negative homosexual men in Sydney, Australia. J Infect Dis 2009; 200: 1813-1819. 
6. Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-237. 
7. Royal Dutch Medical Association. Non-therapeutic circumcision of male minors. Utrecht: KNMG, 2010. 

Link to Intact America = http://intactamerica.org/

The mindset difference of American Medical Scientists when it comes to Female circumcision vs Male circumcision Research

Below I have cut and paste the research presentation "Female Circumcision and HIV Infection in Tanzania:

for Better or for Worse?" by Rebecca Y. Stallings, from Missouri State University.

The research was conducted to try and gather data to validate the hypothesis by K.E. Kun that female circumcision caused an elevated risk for HIV infection.  

Note the political/medical discussions of that time, that epidemic levels of HIV infections in Africa were being blamed on lack of circumcision in males, and a positive incidence of circumcision in females.  A bit of opposing logic here.  Cut genitals on one gender, the females, will increase the likelihood of HIV infection, versus uncut genitals in the male gender, being the cause of 

increased likelihood of HIV infections in men?  Logical?

The question needs to be posed, as to how much the culture of the American researchers influences such logic?  Americans support and practice male circumcision, but abhor the practice of female circumcision.  Could this have influenced such an a priori hypotheses?

The results of the research showed that female circumcision reduced HIV infections by a significant margin, and the researchers were not happy, as per following "The surprising and perplexing significant inverse association between reported female circumcision and HIV seropositivity remained highly statistically significant in the final logistic regression model, despite the presence of other significant potential confounders, namely, geographic zone, household wealth index, woman´s age, lifetime sex partners, and current/past union status".  Rather than be happy for the women that they were protected from HIV they were palpably disappointed.

Further Findings "The couples analysis also suggests a protective effect, real or not, of female

circumcision" "The surprising and perplexing significant inverse association between reported female circumcision and HIV seropositivity has not been explained by other variables available and examined in these analyses"

This next statement is telling for their lack of curiosity or unwillingness to speculate, as seems to be so common with male circumcision research.   "As no biological mechanism seems plausible, we conclude that it is due to irreducible confounding".  If American researchers are willing to speculate or hypothesise that male genitals have virus entry points, why isn't it permissable to speculate that female genitals have viral entry points also?  Cultural bias?

Female Circumcision and

HIV Infection in Tanzania:

for Better or for Worse?

Rebecca Y. Stallings,

χ

2

Statisticus Consultoris, USA and

Emilian Karugendo,

National Bureau of Statistics,

Tanzania

Data Source

This analysis and its findings are

derived from the 2003-04 Tanzania

HIV/AIDS Indicator Survey (the THIS),

which is currently available for public

use. The first author received

permission from the National Bureau of

Statistics in Tanzania to conduct this

work prior to the official release of the

data set to the public.

Introduction

Female circumcision, also referred to

as female genital cutting (FGC) and

female genital mutilation (FGM), is

most prevalent in Africa. The practice

has been linked to obstetrical and

gynecological problems in addition to

mental and physical trauma that may

result from the more severe forms of

the procedure and has hence been

widely condemned for both ethical and

health reasons by the World Health

Organization and other entities

involved with Human Rights.

(continued)

WHO has defined 4 types of circumcision:

I. Clitoridectomy

II. Excision (cutting of both the clitoris and

part or all of the labia minora)

III. Infibulation (cutting of all external

genitalia with stitching of the vaginal

opening)

IV. Other less radical forms including

pricking and piercing

It has been estimated that 80-85% of female

circumcision is either type I or II.

K.E.Kun proposed 4 hypothetical

mechanisms by which female

circumcision could result in an

elevated risk of HIV infection

(ref. K.E.Kun, 1997, Intl J Gynecology

and Obstetrics)

I.

Female circumcision

Infection/scarring

Partial/complete occlusion of the vagina

Greater risk of inflammation/bleeding during

intercourse

Disruption of the genital epithelium/exposure

to blood/penile abrasions which have been

reported to enhance risk of HIV infection

II.

Female circumcision

Painful/difficult vaginal penetration

Increased practice of anal

intercourse, which has been

shown to enhance the efficiency

of HIV transmission

III.

Female circumcision

Higher incidence of obstructed

labor and tearing

Hemorrhage

Higher risk of blood transfusion;

blood supply may not be optimally

screened for HIV

IV.

Use of unsterilized instruments to

perform the female circumcision

procedure

Exposure to blood contaminated by

the virus

(continued)

While WHO and the International Federation

of Gynecology and Obstetrics publicly

postulated that female circumcision might be

a risk factor for HIV infection as long ago as

1992, very little research has been published

to date examining this relationship.

In light of the alarming spread of HIV among

females in a number of African countries

where female circumcision continues to be

practiced, the dearth of work on this question

is somewhat perplexing.

Prior Studies

3 published studies were identified which

looked at the association between female

circumcision and HIV infection;

All 3 studies were conducted in the

Kilimanjaro region of Tanzania

•S.E.Msuya et al, 2002, Tropical Medicine

and Intl Health

0.64 [95% CI = 0.26<RR<1.57]; N=379

•S.H.Kapiga et al, 2002, JAIDS

1.29 [95% CI =0.88<RR<1.90];N=312

•E.Klouman et al, 2005, Tropical Medicine

and Intl Health

1.19 [95% CI=0.45<RR<3.16];N=392

Tanzania HIV/AIDS Indicator Survey

• All protocols were reviewed and given ethical

clearance by the National Institute for Medical

Research (NIMR)

• A nationally representative probability sample

of households was selected, excluding

Zanzibar, which had recently been similarly

surveyed

• Data collection took place from December

2003-March 2004 and was conducted by

trained interviewers, all of whom were nurses

from the Ministry of Health

(continued)

• Participants aged 15-49 were

interviewed and asked to give informed

consent for the collection of capillary

blood by finger-prick for HIV testing

• All participants were offered free VCT at

their closest center regardless of their

consent

• For participants consenting to the

procedure, a set of unique barcoded

labels was used to provide an

anonymous link

(Continued)

• HIV testing was conducted at the

national reference laboratory at

Muhimbili University College of Health

Sciences

• Cleaned questionnaire data was

anonymously linked to results from the

HIV testing using the barcodes after the

destruction of the end pages of the

questionnaires

Response Rates

Households selected: 6901

…interviewed 6499

…response rate 98.5%

Eligible women 7154

…interviewed 6863

…response rate 95.9%

…interview & HIV test result 6061

…response rate for both 84.7%

Distribution of reported female

circumcision

• The highest reported rates of female

circumcision were found in the Northern

regions of Tanzania bordering Kenya, and in

the regions directly south of those, ranging

from 20% in Iringa to 73% in Manyara. These

adjacent regions hence form a central belt

from North to South.

• Other than in the capital city of Dar es

Salaam (7%), the rate did not exceed 3%

elsewhere in the country

• Ethnicity was not collected but may explain

the regional clustering wrt female

circumcision rates.

Age at time of circumcison, type of

procedure, and practitioner

• Age at time of circumcision, type of procedure,

and practitioner were not collected in the 2003-

04 THIS, but were included in the 1996 DHS

• 74% of women in 1996 who self-reported

having been circumcised said that the

procedure was performed by a “circumcision

practitioner” (91% in Lake zone)

• Doctors or trained nurses/midwives were most

frequently reported by women in the Northern

Highlands (6.9%)

• The next 2 slides show distributions of age and

type by zone

Age at circumcision by zone

0

10

20

30

40

50

60

70

0-5 yrs 6-10 yrs 11-15 yrs 16+ yrs miss/dk

Coastal N Highlands Lake Central S Highlands

Type of procedure by zone

0

10

20

30

40

50

60

70

80

90

clitoridectomy

excision

infibulation

Coastal N Highlands Lake Central S Highlands

Distribution of female HIV infection

• HIV infection among women aged 15-44

ranged from 2.0-15.2% by region

• Among the 10 (of 21) regions with the highest

reported female circumcision rates (>=20%),

only 4 were among the 10 regions with the

highest female HIV infection rates

• The regions with female HIV infection rates

>10% were Mbeya, Iringa, Dar es Salaam,

and Pwani

Potential confounders available and

examined

Demographic characteristics

•Region

• Household wealth index

•Age

• Educational attainment

• Occupation

• Time in current residence

• Religion

(continued)

Marriage and sexual activity

• Age at sexual debut

• Age when began cohabiting

• Currently married or living with partner

• Number of wives of husband/partner

• Lifetime sex partners

• Sex partners in last 12 months

• Use of alcohol during recent sexual liasons

• Ability to say “no” to having sex with recent

partners

(continued)

Symptoms of sexually transmitted

diseases

• Genital sore or ulcer in last 12 months

• Bad smelling abnormal discharge in last

12 months

Potential exposure to contaminated blood

• Any injection in last 12 months

• Any blood transfusion in last 12 months

Methods

•The χ

2

test of association was used to

examine the bivariate relationships between

potential HIV risk factors with both

circumcision and HIV serostatus

• Logistic regression was used to reduce the

model to those factors remaining statistically

significantly associated with HIV serostatus

and to adjust circumcision status for those

factors

• All analyses were performed using the latest

version of the Statistical Analysis System

(SAS)

Results

The crude relative risk of HIV

infection among women reporting

to have been circumcised versus

not circumcised was

0.51 [95% CI =0.38<RR<0.70]

The power (1 – ß) to detect this

difference is 99%

Logistic Regression Models

• Each variable that was statistically significant in the

simple bivariate analyses was added to a separate

simple logistic regression model to predict HIV

serostatus, together with circumcision status

• Additional logistic models were run which

combined those variables which remained

significant in their individual models, together with

circumcision status

• Models were further restricted to include only those

women who had ever been sexually active

• A final model was selected in which all variables

remain statistically significant

Final Logistic Regression Model

n=5284 ever sexually active women

(continued on following slides)

0.880.410.60Circumsized

3.771.282.20Genital ulcer

in last 12

mos

UL 95% CILL 95% CIOR estimateEffect

(continued)

UL 95% CILL 95% CIOR estimateEffect

Regional

zone

1.00Central (ref).

2.250.721.27Northern

highlands

2.070.691.19Coastal

1.590.480.87Southern

5.091.632.88Southern

highlands

1.730.560.99Lake

(continued)

UL 95% CILL 95% CIOR estimateEffect

6.152.784.135th

(highest)

4.862.253.314th

2.761.211.833rd

2.050.861.332nd

1.001st

(lowest)

HH wealth

index

quintile

(continued)

UL 95% CILL 95% CIOR estimateEffect

3.250.811.6245-49

4.891.402.6240-44

5.121.562.8235-39

7.202.304.0730-34

4.561.462.5825-29

3.631.172.0620-24

1.0015-19 (ref.)

Age (years)

(continued)

UL 95% CILL 95% CIOR estimateEffect

6.871.763.476-10

4.892.173.265

5.282.233.434

3.591.802.543

3.081.642.252

1.001 (ref.)

Lifetime sex

partners

(continued)

UL 95% CILL 95% CIOR estimateEffect

5.212.003.23In 2+ prior

unions

4.812.653.57In 1 prior

union

2.501.331.82In 2+

union

2.241.041.53Never in

union

1.00In 1st

union (ref.)

Union

status

Discussion

• The surprising and perplexing significant

inverse association between reported female

circumcision and HIV seropositivity remained

highly statistically significant in the final

logistic regression model, despite the

presence of other significant potential

confounders, namely, geographic zone,

household wealth index, woman´s age,

lifetime sex partners, and current/past union

status

• Some additional analyses were undertaken

using those women for whom a male partner

was interviewed and could be linked (n=2305)

Couples analysis (male x female)

UL 95% CILL 95% CIRR estimate

that both

partners are

+ for the

factor

Factor

examined

19.96.911.7Genital

ulcer

9.03.35.4Abnormal

discharge

10.35.07.1Circum-

cised

15.88.511.6HIV

positive

Muslim women are more likely

than other women to be married

to a partner of the same religion

90.5 82 75.2 68.4

0

20

40

60

80

100

Muslim Catholic Protestant None

Percent of women married to partner of

same religion

Relative Risk of HIV infection for the

Female Partner by circumcision status

UL 95% CILL 95% CIRR estimateComparison

made

1.420.660.97Male circ

vs neither

0.960.310.55Both circ

vs neither

0.970.330.56Both circ

vs male

only

Discussion continued

• The couples analysis also suggests a

protective effect, real or not, of female

circumcision

• There are several important risk factors which

were not collected in the 2003-04 THIS which

might be explanatory confounders of this

perplexing conundrum, including ethnic

group, age at time of circumcision and type of

circumcision

• In 6 of the 10 regions with the highest female

circumcision rates, the HIV seroprevalence

among males is <5%, and is <3% in 3 of

them. In such cases, a lower transmission

risk may be an explanatory confounder.

Conclusions

• The surprising and perplexing

significant inverse association between

reported female circumcision and HIV

seropositivity has not been explained by

other variables available and examined

in these analyses

• As no biological mechanism seems

plausible, we conclude that it is due to

irreducible confounding

• Anthropological insights on female

circumcision as practiced in Tanzania

may shed light on this conundrum

Recommendations

• Similar analyses are needed

from other countries to

determine if this association

holds elsewhere.

• It is an understatement to say

that further research is

warranted.

Thank you for your attention !

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