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  1. Non-therapeutic circumcision: The problem of advocacy-based medicine

    Non-therapeutic circumcision is a contentious issue on which most readers will drift toward the position that reflects their backgrounds or affirms their cultural affinities. Unfortunately, the efforts of various self-appointed "experts" have done little to clarify the issues, and some are notorious for cherry-picking a vast and inconclusive medical literature in order to advance their prior agenda.

    We invite readers to take the time to read the 29 self-citations that Brian Morris provided in the latest e-letter[1], check out the veracity of the claims contained therein, read the studies attacked by the letters to editor and the responses to these, perform their own literature searches, and reach their own independent, fully-informed judgments. Such a review will show that Morris is simply out of line with most other authorities.

    For example, Morris and a colleague have recently disclaimed the Hippocratic Oath,[2] thereby rejecting a venerable medical principle.[3] Even the American Academy of Pediatrics is unwilling[4, 5] to support Morris' assertions that circumcision is a "biomedical imperative"[6] that "should be made compulsory"[7]. Finally, apart from a legally questionable[8] German law protecting religious circumcision,[9] Europe has begun to see circumcision as a violation of an infant's human rights[10-11], medical ethics,[12] and even criminal law.[13-14]

    1 Morris BJ, Tobian AAR, Hankins CA, et al. Veracity and rhetoric in paediatric medicine: a critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision. J Med Ethics 2013; epub ahead of print.

    2. Morris BJ, Tobian AAR. Reply to 'Circumcision is a Religious/Cultural Procedure, Not a Medical Procedure.' JAMA Pediatrics 2014;168(3):294.

    3 Miles S. The Hippocratic Oath and the Ethics of Medicine. New York: Oxford University Press; 2005.

    4 American Academy of Pediatrics Task Force on Circumcision. Technical report: male circumcision. Pediatrics;2012:130:e757-e785.

    5 American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics;2012:130:585-586.

    6 Morris BJ. Why circumcision is a biomedical imperative for the 21(st) century. Bioessays 2007;29:1147-58.

    7 The kindest cut? Sunday Night program. Seven Television Network. May 24, 2009. YouTube. Available on: http://www.youtube.com/v/7yDvL4hNny4. Accessed March 23, 2014.

    8 Merkel R and Putzke H. After Cologne: Male circumcision and the law. Journal of Medical Ethics 2013;39: 444-449.

    9 German Civil Code (Burgerliches Gesetzbuch)1631d.

    10 Council of Europe. Resolution: Children's right to physical integrity. Available on: http://www.assembly.coe.int/nw/xml/XRef/Xref-DocDetails-EN.asp?FileID=20174???=EN. Accessed March 23, 2014.

    11 KNMG (Royal Dutch Medical Association). Non-therapeutic Circumcision of Male Minors (Utrecht, Netherlands: KNMP, 2010).

    12 Suomen Laakariliitto. Poikien ymparileikkaus. Available on: http://www.laakariliitto.fi/uutiset/kannanotot/ymparileikkaus.html. Accessed March 23, 2014.

    13 Landgericht Koln; 7 May 2012; Urteil Ns 169/11.

    14 OLG Hamm; 30 August 2013; Az. 3 UF 133/13.

    Conflict of Interest:

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  2. Unethical not to recommend circumcision

    Evidence-based policies[1-6] concur that medical male circumcision (MC), best performed early in life[7] under local anaesthesia by a trained provider, is a simple, safe procedure conferring lifetime protection against numerous adverse medical conditions that together affect half of all males[2,7]. Data from numerous clinical trials and hundreds of research studies show benefits greatly exceeding risks[2,7], particularly in resource-poor communities. Claims of adverse effects on sexual function, sensitivity, and satisfaction are not supported by scientific evidence[8]. Opponents often deny confirmed benefits and overstate or fabricate the harms[9]. While the AAP concluded that the benefits of neonatal MC exceed the risks, it nevertheless acknowledged that for some families other considerations might be more important[1]. This is also true for other neonatal interventions that physicians strongly recommend such as vaccinations and genetic screening that some families oppose. However, given the strong data on MC's substantive health benefits, we are concerned that widespread vocal unscientific opposition to neonatal MC may hamper the ability of health care workers to offer it, or may lead to the stigmatization of those who request it. Policies that are embraced by the medical, scientific, and bioethics communities in support of parent-approved elective newborn MC should be implemented just as any other safe, effective, approved public health measure. REFERENCES 1. American Academy of Pediatrics. Circumcision policy statement. Task Force on Circumcision. Pediatrics 2012;130:e756-e785. 2. Morris BJ, Wodak AD, Mindel A, et al. Infant male circumcision: An evidence-based policy statement. Open J Prevent Med 2012;2:79-82. 3. American Urological Association. Circumcision. http://www.auanet.org/about/policy-statements/circumcision.cfm 2012. (accessed 10 Mar 2014) 4. Centers for Disease Control and Prevention. Male Circumcision. http://www.cdc.gov/hiv/prevention/research/malecircumcision/ 2013. (accessed 4 Mar 2014). 5. WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention. 2007. http://www.who.int/hiv/mediacentre/news68/en/index.html (accessed 10 Mar 2014) 6. Mayo Clinic. Circumcision (male): Why it's done. http://www.mayoclinic.com/health/circumcision/MY01023/DSECTION=why-its-done 2012. (accessed 10 Mar 2014) 7. Morris BJ, Waskett JH, Banerjee J, et al. A 'snip' in time: what is the best age to circumcise? BMC Pediatr 2012;12(article20):1-15. 8. Morris BJ, Krieger JN. Does male circumcision affect sexual function, sensitivity or satisfaction? - A systematic review J Sex Med 2013;10:2644-2657. 9. Morris BJ, Tobian AAR, Hankins CA, et al. Veracity and rhetoric in pediatric medicine: A critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision. J Med Ethics Epub ahead of print 16 Aug 2013.

    Conflict of Interest:

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  3. Reply to "Circumcision: A bioethical challenge" by Svoboda & Van Howe

    I thank Mr Svoboda and honorary adjunct clinical professor Van Howe (S&VH) for their Letter [1] responding to our critique [2] of their article [3] criticizing the 2012 American Academy of Pediatrics (AAP) infant male circumcision (IMC) policy statement [4]. Their Letter provides little in the way of material disagreement with our critique [2], in which we pointed out the extensive factual errors in their article [3]. Instead, their Letter is replete with personal attacks and ad hominems, mostly directed at me. Our conclusion that, "their arguments against male circumcision are based on a poor understanding of epidemiology, erroneous interpretation of the evidence, selective citation of the literature, statistical manipulation of data, and circular reasoning" thus stands.

    Here I respond to S&VH's new points and the personal attacks.

    S&VH begin with a quote from a book review in 1999 by a friend of mine in Sydney, Professor Basil Donovan. He and other senior academic colleagues in Australia have come a long way in the past 15 years and now universally congratulate me for being right about IMC all those years ago.

    Although the AAP Task Force did not comprise members with an extensive academic track record on the topic, it did a reasonable job in developing an evidence-based policy statement on IMC [4]. The same cannot be said for the policy committees of medical bodies in other countries to date. In formulating their policy the AAP Task Force did consider all of the evidence up until early 2010, including that of opponents. For example, on page e766, column 1, end of paragraph 4, the AAP policy refers to a publication by Van Howe, stating, "one methodologically poor meta- analysis found no effect of male circumcision on chancroid" [4]. On page e761 the policy states, "case reports, case series, ecological studies, reviews, and opinions were excluded from the review. Although case reports and case series are important for generating hypotheses, the Task Force, limited itself to reviewing analytic studies" [4]. Page e761 and Table 3 describe the conventional system used to rate articles for quality of evidence. The AAP's policy was not, however, prescriptive. While it concluded that the benefits exceeded the risks, it also recognized that for some families cultural and religious factors might be more important than medical considerations. The policy therefore emphasized education, access and affordability for those families who choose to have their boy circumcised.

    The AAP's response [5] to S&VH's attack on their policy [3] was polite, calling for, "respectful dialogue" [5]. The fact that the AAP did not, "engage in the debate" was why we decided to point out the factual errors in S&VH's article [3]. The AAP did, however, provide a sensible response [6] to an attack by Europeans who accused the Task Force of cultural bias [7]. The AAP argued convincingly that it was Europe that was culturally biased, not the USA, given the wide regional and ethnic variation in male circumcision (MC) prevalence in the USA [6]. While the European Letter (by Frisch et al.) was published in Pediatrics, the same journal as the AAP policy statement appeared, S&VH's critique did not.

    Rather than personal attacks it would have been more appropriate for S&VH's Letter to address the critiques of claims by opponents. Such criticisms have been published not just by me, but by many different researchers [2,8-36]. The critics include a "who's who" of prominent academics in the field of MC. I am not an author of many of the critiques.

    S&VH defend criticisms [18] of statistics in a paper Van Howe co- authored [37]. Further criticisms of the statistics in this and other articles by opponents have been published since then [38]. But Van Howe's statistics have been the subject of ongoing criticisms by many workers over the years. His first meta-analysis, in 1999, that concluded MC did not protect against heterosexual acquisition of HIV [39], was disputed on statistical grounds by Moses et al. [8], and by O'Farrell et al. [9]. Moses et al. pointed out that Van Howe's method of simple data pooling [40] led to a Simpson's Paradox [41] inverting the outcome. Such confounding is particularly apparent when frequency data are unduly given causal interpretations [42]. Van Howe's article became an illustrative example in a textbook [43] and a review [44] of meta-analyses showing how Simpson's paradox can lead to incorrect results.

    This may have prompted Van Howe to use expensive software requiring fast computers that can calculate "exact" odds ratios (ORs). Doing this not only made replication by others difficult, their use as input into a meta-analysis is largely an exercise in futility because meta-analysis is an approximate method. His use of these rather than adjusted ORs has been criticized [11]. Others, who criticized him for reporting a meta- regression OR rather than a crude OR [10], stated they, "were unable to reproduce" his calculations. Van Howe's adjustments of randomized controlled trial (RCT) data for "lead time bias" have been refuted [16,45]. His adjustments of HPV data for, "sampling bias" [46-48] have also been criticized [10,45,49]. Instead, Tobian et al. suggested their own particular, "analyses may underestimate the protective effect of male circumcision" [50] and Auvert et al. had not only considered Van Howe's accusation of sampling bias [47], but had conducted an experiment to test for it [51]. Moreover, Van Howe's "correction" would not apply to data from urethral sampling [51]. The sampling bias issue has now been rendered invalid by RCT data demonstrating that MC reduces HPV at the urethra, coronal sulcus, and penile shaft [45,51,52].

    Other problems include Van Howe's use of data for a different control group than appeared in the original studies [46,53,54], thus risking bias. His adjustments for "publication bias" should also be questioned, as indeed Van Howe did himself in a meta-analysis [46]. Indeed in response to criticisms [11] of one meta-analysis [53], Van Howe admitted that, "the data ... was improperly extracted"[55] and Van Howe published an erratum [56]. His more recent meta-analyses omitted RCT and other important data and many studies listed in his Tables were not included in his meta- analysis [54].

    If one reads the numerous critiques of the studies by opponents one might conclude that the critics of those studies have a better understanding of appropriate study design, methodology, data analysis and the field of research than do the opponents.

    S&VH have accused me of "abuse" for circulating an extensive peer- review of a paper by Frisch et al. [57], but seem unaware that once a paper has been published a reviewer is free to reveal their identity and provide critical comments to others. My criticisms of that study were later published [29,38]. Despite this Frisch ignored the criticisms as he continued his campaign to have IMC banned in Denmark and elsewhere in Europe. He persists in selectively citing his own flawed research [57] and that of a Belgian group [58], while failing to cite the scholarly critiques of the latter studies [27,29], as well as failing to cite RCT data [59], meta-analyses [60] and a recent extensive rigorous systematic review [38]. The emotional response by Frisch [61] to the initial critique of his study [29] was mostly an ad hominem attack on me, so undermining his reputation. In a radio interview of Frisch on the BBC his study was subjected to scathing criticisms by Professor Michael King, a University College London clinician who studies sexual dysfunction [62].

    S&VH criticize our article [2] by saying, "no fewer than 31 of the references are to other publications by Morris and his co-authors" [2]. A similar criticism was made recently by a reviewer of a manuscript I submitted to a good journal, leading the Editor to comment, "we do not mind self-citation (especially since you all have produced much of the good literature on the topic - that's why we invited you to write this paper!". My academic publications on MC exceed 60 of my total of 341. Readers can make up their own mind about the veracity of the information contained therein.

    Our critique [2] did not imply that the Circumcision Foundation of Australia (CFA) or its policy statement, "operates with the approval of the Royal Australasian College of Physicians (RACP)" [1]. Rather, we stated, "Similar to the AAP's policy, a peer-reviewed policy statement was published in 2012 by fellows of the Royal Australasian College of Physicians (RACP), and fellows of other medical bodies on behalf of the Circumcision Foundation of Australia (CFA)" [2]. I did not initiate or establish the CFA. The CFA's website states, "On 21 Jan 2010 several leaders in public health policy and medical science, together with other interested parties, met at the National Centre for HIV Epidemiology & Clinical Research to form a new organization named the 'Circumcision Foundation of Australia'" [63]. I was present at that meeting, was asked to set up and maintain the CFA website, and was first author of the 12- author peer-reviewed CFA policy statement that was published in 2012 [64].

    S&VH fail to point out that the RACP's policy [65], placed on the RACP's website in 2010, was the subject of a withering critique published in an official journal of the RACP after peer-review [31]. Most of the authors of the critique were the same individuals who co-authored the CFA's IMC policy [64]. These included Fellows of the RACP and of other Colleges and medical bodies [63].

    I would also like to correct S&VH's understandable assertions about my involvement with the RACP's policy development. S&VH's misunderstanding stems from obfuscatory statements made by David Forbes, a paediatric gastroenterologist who chaired the RACP's IMC policy writing group. I was in fact engaged by a member of that committee to critically evaluate successive drafts of the policy as it developed. That prominent health policy expert was seriously concerned at the lack of due process and resistance of several on the committee to an evidence-based approach. At a teleconference held by the committee on 30 Jan 2009 the only item on the agenda was my most recent detailed critique of their policy draft. Members of the committee were then allocated different subject areas to correct in accordance with my advice. Despite this, the policy released 1.5 years later remained quite flawed. Because of the strong disagreement between committee members about the policy's contents, their names did not appear. In contrast, the heavily criticized [26] 2004 RACP policy listed the committee members' names.

    David Forbes came under fire from within the RACP in the lead-up to release of the policy. This related to his alleged disclosure to The Age newspaper that the new RACP policy would advise against IMC [66] a year before it was completed and approved by the RACP. He also caused an unapproved summary of the RACP policy to be posted on the RACP website. The uproar that followed led to the removal of that posting. Considerable disagreement exists within the RACP over its IMC policy and other matters.

    S&VH refer to a statement I made in a television interview in 2009. That interview was prerecorded and selected segments were taken out of context, as is common practice in the television industry. For a better appreciation of my position on IMC I suggest that the reader view an extended interview that appeared online in 2013 in conjunction with an episode of "60 Minutes" I appeared in [67].

    While S&VH and the outlier publications they cite disagree, the balance of evidence shows that the neonatal period is the simplest, safest, cheapest and most convenient time of life for IMC, since it maximizes benefits, minimizes risks and gives the best cosmetic outcome [4,32,68-70]. Delay will mean barriers that reduce the likelihood of the procedure occurring, even if the boy or man wishes to be circumcised.

    S&VH seem unable to comprehend that ethical and legal arguments in support of IMC are stronger and more logical than the arguments of opponents. This should be apparent to most who have read the articles published in J Med Ethics in 2013 and in other journals since [28,71,72].

    Authors worldwide have made the logical comparison of IMC and childhood vaccination [73-75]. The ethics of each are comparable [64].

    S&VH finish with Victorian wisdom. The medical, if not the ethical, advice they quote remains valid today, even though the science and benefits are now much more extensive and thoroughly documented.

    References 1. Svoboda SJ, Van Howe RS: Circumcision: A bioethical challenge. J Med Ethics. 2014;eLetter(20 Jan) 2. Morris BJ, Tobian AAR, Hankins CA, et al: Veracity and rhetoric in pediatric medicine: A critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision. J Med Ethics. 2013;XX:Aug 16 [Epub ahead of print]. 3. Svoboda JS, Van Howe RS: Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision J Med Ethics. 2013;39:434-441. 4. American Academy of Pediatrics. Circumcision policy statement. Task Force on Circumcision. Pediatrics. 2012;130:e756-e785. 5. AAP Task Force on Circumcision 2012. The AAP Task Force on neonatal Circumcision: a call for respectful dialogue. J Med Ethics. 2013:39:442- 443. 6. Task Force on Circumcision. Cultural bias and circumcision: The AAP Task Force on Circumcision Responds. Pediatrics. 2013;131:801-804. 7. Frisch M, Aigrain Y, Barauskas V, et al: Cultural bias in the AAP's 2012 technical report and policy statement on male circumcision Pediatrics. 2013;131:796-800. 8. Moses S, Nagelkerke NJD, Blanchard JF: Commentary: Analysis of the scientific literature on male circumcision and risk for HIV infection. Int J STD AIDS. 1999;10:626-628. 9. O'Farrell N, Egger M: Circumcision in men and the prevention of HIV infection: a 'meta-analysis' revisited. Int J STD AIDS. 2000;11:137-142. 10. Castellsagu? X, Albero G, Cleries R, et al: HPV and circumcision: A biased, inaccurate and misleading meta-analysis. J Infect. 2007;55:91-93. 11. Waskett JH, Morris BJ, Weiss HA: Errors in meta-analysis by Van Howe. Int J STD AIDS. 2009;20:216-218. 12. Morris BJ, Waskett JH, Gray RH, et al: Expos? of misleading claims that male circumcision will increase HIV infections in Africa. J Public Health Africa. 2011;2(e281):117-122. 13. Banerjee J, Klausner JD, Halperin DT, et al: Circumcision denialism unfounded and unscientific. [Critique of Green et al., "Male circumcision and HIV prevention: Insufficient evidence and neglected external validity"] Am J Prevent Med. 2011;40:e11-e12. 14. Wamai R, Morris BJ: 'How to contain generalized HIV epidemics' article misconstrues the evidence. Int J STD AIDS. 2011;22:415-416. 15. Wamai RG, Morris BJ, Bailis SA, et al: Male circumcision for HIV prevention: current evidence and implementation in sub-Saharan Africa. J Int AIDS Soc. 2011;14:Article ID 49: 1-17 pages. 16. Wamai RG, Morris BJ, Waskett JH, et al: Criticisms of African trials fail to withstand scrutiny: male circumcision does prevent HIV infection. J Law Med 20(1):93-123. 2012; 17. Wamai RG, Weiss HA, Hankins C, et al: Male circumcision is an efficacious, lasting and cost-effective strategy for combating HIV in high -prevalence AIDS epidemics: Time to move beyond debating the science. Future HIV Ther. 2008;2:399-405. 18. Waskett JH, Morris BJ: Fine-touch pressure thresholds in the adult penis. (Critique of Sorrells ML, et al. BJU Int 2007;99:864-869). BJU Int. 2007;99:1551-1552. 19. Waskett JH, Morris BJ: Re: 'RS Van Howe, FM Hodges. The carcinogenicity of smegma: debunking a myth.' An example of myth and mythchief making? (Letter to the Editor) J Eur Acad Dermatol Venereol. 2008;22:131. 20. Morris B, J., Waskett JH: Claims that circumcision increases alexithymia and erectile dysfunction are unfounded. Int J Men's Health. 2012;(11:177-181) 21. Morris BJ: Circumcision for phimosis and other medical indications in Western Australian boys. (Critical comment) Med J Aust. 2003;178:588-589. 22. Morris BJ: Circumcision in Australia: prevalence and effects on sexual health. (Critique of Richters et al. Int J STD AIDS 2006;17:547- 554) Int J STD AIDS. 2007;18:69-70. 23. Morris BJ: Circumcision facts trump anti-circ fiction. The Skeptic. 2007;27(4):52-56. 24. Morris BJ, Bailey RC, Klausner JD, et al: Review: a critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries AIDS Care. 2012;24:1565-1575. 25. Morris BJ, Bailis SA: Circumcision rate too low? (Critical comment) ANZ J Surg. 2004;74:386-387. 26. Morris BJ, Bailis SA, Castellsague X, et al: RACP's policy statement on infant male circumcision is ill-conceived. Aust NZ J Publ Hlth. 2006;30:16-22. 27. Morris BJ, Krieger JN, Kigozi G: Male circumcision decreases penile sensitivity as measured in a large cohort. [Critique of Bronselaer et al. BJU Int 2013; 111: 820-827] BJU Int. 2013:111: E269-E270. 28. Morris BJ, Tobian AA: Legal threat to infant male circumcision JAMA Pediatr. 2013;167(10):890-1. 29. Morris BJ, Waskett JH, Gray RH: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol. 2012;41:310-312. 30. Morris BJ, Wodak A: Circumcision survey misleading. Aust NZ J Public Health 2010;34:636-637. 31. Morris BJ, Wodak AD, Mindel A, et al: The 2010 Royal Australasian College of Physicians policy statement 'Circumcision of infant males' is not evidence based. Intern Med J. 2012;42:822-828. 32. Schoen EJ: Benefits of newborn circumcision: Is Europe ignoring the medical evidence? Arch Dis Child. 1997;77:258-260. 33. Schoen EJ: Ignoring evidence of circumcision benefits. Pediatrics. 2006;118:385-387. 34. Schoen EJ: Critique of Van Howe RS. Incidence of meatal stenosis following neonatal circumcision in a primary care setting. Clin Pediatr (Phila) 2006;45:49-54. Clin Paeiatr (Phila). 2007;46:86. 35. Schoen EJ, Wiswell TE, Moses S: New policy on circumcision - Cause for concern. Pediatrics. 2000;105:620-623. 36. Morris BJ: Science supports infant circumcision, so should skeptics. The Skeptic (UK). 2013;24(4):30-33. 37. Sorrells ML, Snyder JL, Reiss MD, et al: Fine-touch pressure thresholds in the adult penis. BJU Int. 2007;99:864-869. 38. Morris BJ, Krieger JN: Does male circumcision affect sexual function, sensitivity or satisfaction? A systematic review J Sex Med. 2013;10:2644- 2657. 39. Van Howe RS: Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD AIDS. 1999;10:8-16. 40. Dickersin K, Berlin JA: Meta-analysis: state-of-the-science. Epidemiol Rev. 1992;14:154-176. 41. Rothman KJ Modern Epidemiology., Little Brown and Company, Boston, MA 1986. 42. Pearl J Causality: Models, Reasoning, and Inference., Cambridge University Press, Cambridge, UK 2000. 43. Borenstein M, Hedges L, Higgins JPT, et al Introduction to Meta- Analysis., John Wiley and Sons, West Sussex 2009. 44. Barker FG, 2nd, Carter BS: Synthesizing medical evidence: systematic reviews and metaanalyses. Neurosurg Focus. 2005;19:E5. 45. Tobian AAR, Serwadda D, Gray RH: Authors Reply: Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med. 2009;361:307-308. 46. Van Howe RS: Human papillomavirus and circumcision: a meta-analysis. J Infect. 2007;54:490-496. 47. Van Howe RS: Sampling bias explains association between human papillomavirus and circumcision. J Infect Dis. 2009;200:832. 48. Van Howe R, S., Storms MR: Circumcision to prevent HPV infection. (Comment on: Male circumcision: a cancer prevention strategy? Lancet Oncol 2009;10:431) Lancet Oncol. 2009;10:746-747. 49. Auvert B, Lissouba P, Sobngwi-Tambekou J: Reply to Van Howe J Infect Dis. 2009;200:833. 50. Tobian AAR, Kigozi G, Gravitt PE, et al: Human papillomavirus incidence and clearance among HIV-positive and HIV-negative men in sub- Saharan Africa. AIDS. 2012;26:1555-1565. 51. Auvert B, Sobngwi-Tambekou J, Cutler E, et al: Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: results of a randomized controlled trial conducted in Orange Farm, South Africa. J Infect Dis. 2009;199:14-19. 52. Tobian AAR, Kong X, Gravitt PE, et al: Male circumcision and anatomic sites of penile human papillomavirus in Rakai, Uganda. Int J Cancer. 2011;129:2970-2975. 53. Van Howe RS: Genital ulcerative disease and sexually transmitted urethritis and circumcision: a meta-analysis. Int J STD AIDS. 2007;18:799- 809. 54. Van Howe RS: Sexually transmitted infections and male circumcision: a systematic review and meta-analysis. ISRN Urology. 2013;2013(article 109846):1-42. 55. Van Howe RS: Reply to letter from Mr Waskett, Professor Morris and Dr Weiss. Int J STD AIDS. 2009;20:592. 56. Van Howe RS: Erratum. "Genital ulcerative disease and sexually transmitted urethritis and circumcsiion: a meta-analysis. Int J STD AIDS 2007;18:799-809" Int J STD AIDS. 2009:20(8):592. 57. Frisch M, Lindholm M, Gr?nbeck M: Male circumcision and sexual function in men and women: a survey-based-cross-sectional study in Denmark. Int J Epidemiol. 2011;40:1367-1381. 58. Bronselaer GA, Schober JM, Meyer-Bahlburg HF, et al: Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. 2013:111:820-827. 59. Krieger JN, Mehta SD, Bailey RC, et al: Adult male circumcision: Effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med. 2008;5:2610-2622. 60. Tian Y, Liu W, Wang JZ, et al: Effects of circumcision on male sexual functions: a systematic review and meta-analysis Asian J Androl. 2013;15(5):662-6. 61. Frisch M: Author's Response to: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol. 2012;41:312-314. 62. BBC radio, Woman's Hours, presented by Jenni Murray. Male circumcision (23 June). http://www.bbc.co.uk/programmes/b011zzh8, 2011. 63. Circumcision Foundation of Australia. http://www.circumcisionaustralia.org. 2010; 64. Morris BJ, Wodak AD, Mindel A, et al: Infant male circumcision: An evidence-based policy statement. Open J Prevent Med. 2012;2:79-82. 65. Royal Australasian College of Physicians, Paediatrics & Child Health Division. Circumcision of infant males. http://www.racp.edu.au/index.cfm?objectid=65118B16-F145-8B74- 236C86100E4E3E8E (last accessed 8 May 2013), 2010. 66. Cauchi S: Doctors to leave our baby boys intact. http://newsstore.fairfax.com.au/apps/viewDocument.ac?page=1&sy=age&kw=david+forbes&pb=all_ffx&dt=selectRange&dr=5years&so=relevance&sf=text&sf=headline&rc=10&rm=200&sp=0&clsPage=1&docID=SAG090607LL7GP701LMN The Sunday Age. 2009;June 7, page 12 67. 60 Minutes. Extra Minutes. Fore and Against: The case for circumcision. http://sixtyminutes.ninemsn.com.au/extraminutes/8620215/fore -and-against-the-case-for-circumcision. 2013; 68. Morris BJ, Waskett JH, Banerjee J, et al: A 'snip' in time: what is the best age to circumcise? BMC Pediatr. 2012;12(article20):1-15. 69. Schoen EJ: Should newborns be circumcised? Yes. Can Fam Physician. 2007;53:2096-2097. 70. Wiswell TE, Geschke DW: Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics. 1989;83:1011-1015. 71. Jacobs AJ: The ethics of circumcision of male infants. Isr Med Assoc J. 2013;15:60-65. 72. Bates MJ, Ziegler JB, Kennedy SE, et al: Recommendation by a law body to ban infant male circumcision has serious worldwide implications for pediatric practice and human rights. BMC Pediatr. 2013;13(1 article 136):1 -9. 73. Schoen EJ: Circumcision as a lifetime vaccination with many benefits. J Men's Hlth Gender. 2007;382:306-311. 74. Morris BJ: Why circumcision is a biomedical imperative for the 21st century. BioEssays. 2007;29:1147-1158. 75. Ben KL, Xu JC, Lu L, et al: [Male circumcision is an effective "surgical vaccine" for HIV prevention and reproductive health](in Chinese). Zhonghua Nan Ke Xue. 2009;15:395-402.

    Conflict of Interest:

    None declared

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  4. Circumcision: A bioethical challenge

    "Professor Morris is a man on a mission to rid the world of the male foreskin."

    -- Dr. Basil Donovan, Clinical Professor in the School of Public Health and Community Medicine, University of Sydney, reviewing "In Favour of Circumcision" by Brian Morris.[1]

    "I have some good friends who are obstetricians outside the military, and they look at a foreskin and almost see a $125 price tag on it. Each one is that much money. Heck, if you do 10 a week, that's over $1,000 a week, and they don't take that much time."

    -- Dr. Thomas Wiswell, co-author with Brian Morris of the latest defense of the AAP's proposal for government funding of circumcision.[2]

    Infant male circumcision is one of the most divisive issues in contemporary society. When the American Academy of Pediatrics (AAP) issued its policy statement on circumcision in August 2012, it was met with international criticism for its cultural bias and lack of academic rigor. [3,4]. The AAP's response was disappointing. Rather than engage in debate, the AAP reacted defensively and simply reiterated its position.[5,6] In response to our own critique of the AAP[3], Professor Brian Morris--along with his familiar team of co-authors, including Dr. Thomas Wiswell (quoted above)[7]--takes the opportunity to rehearse his longstanding conviction that circumcision is a "biomedical imperative" for the 21st century.[8] The paper is nearly identical in content to a number of similar reviews and op eds by Morris et al. [Morris REFS: 21, 24, 46, 47, 52 , 55, 78, 79, 82], offering the same anthology of misleading claims and self-citations. We here call attention to a few of the most conspicuous.

    Firstly, their description of the AAP as "a major, possibly the most pre-eminent, paediatric authority internationally" (p. 1, emphasis in original) is an example of a well-known rhetological fallacy, the appeal to authority. What is breathtaking about this particular example is that Professor Morris has criticised others for committing the very same fallacy--but only when such paediatric bodies failed to be as enthusiastic about circumcision as he is[i]. As Morris writes on his personal pro- circumcision website: "The policy statements of professional pediatric bodies have been misused by others as part of an 'appeal to authority' fallacy... Those who write the policy statements are often physicians with little or no academic expertise."[9] Thus, medical organizations which issue statements that are comparatively friendly toward circumcision (see footnote 1) are "pre-eminent" in Morris' view; whereas when their statements are less friendly, they are the work of mere "physicians" with "little or no academic training." As Morris then goes on to say, "Not surprisingly, [these statements] have been criticized by academic experts."[9] Note that Morris is using the term "academic experts" here as a covert , third-personal reference to himself, in conjunction primarily with his regular collaborators and other well-known circumcision promoters. This is a theme to which we will return.

    At numerous points in his reply to our critique, Morris cites his own and his co-authors' opinions and seeks to pass them off as orthodox medical fact . This appears to be part of a larger strategy employed by Morris to distort the body of research on infant circumcision. As has been noted by others,[10] Morris scans the literature for any new published study that does not conform to his pro-circumcision stance, and then writes an article, letter, or blog post attacking it, enabling him later to claim that it was "refuted by experts" (i.e., by himself and his co-authors). One example of this is an attack on the statistical methods used by Sorrells et al. in a study showing that circumcision reduces sensitivity of the penis [Morris REF: 12]. The "numerous flaws exposed by experts" (p. 2) in this study were "exposed" by none other than Brian Morris himself, along with Mr. Jake Waskett--a 34-year-old "computer software engineer" and "web designer"[11] with no known academic expertise[ii]--in the form of a non-peer-reviewed letter exhibiting a manifest lack of statistical competence[iii]. This same self-citation tactic was employed multiple other times in his critique of our article [Morris REFS: 10, 12, 14, 62, 75, 76, 77, 91] and has been documented by other scholars subjected to the same abuse[iv]:

    [As] in critical letters to the editor following other recent studies that failed to support their agenda, Morris et al. air a series of harsh criticisms against our study. As seen, however, the points raised are not well founded. It seems that the main purpose, as with prior letters, is to be able in future writings to refer to our study as an "outlier study" or one that has been "debunked", "rejected by credible researchers" or "shown wrong in subsequent proper statistical analysis." ... As these critics repeatedly refer to Morris' pro-circumcision manifesto as their source of knowledge, their objectivity must be questioned.[10]

    Morris et al. are to be congratulated, of course, for their sheer energy in producing these unwarranted attacks. In doing so, they have managed to generate a sizable pro-circumcision canon, ready to be cited by like-minded writers whenever needed [Morris REFS: 24, 46, 47, 52, 55, 58, 65, 78, 79, 82, 102]. In the current critique, no fewer than 31 of the references are to other publications by Morris or his co-authors. Unfortunately, well-meaning peer-reviewers do not have the time to go down a "rabbit hole" of self-citations in order to properly evaluate each claim for its veracity.

    Morris points to a "policy statement" by the Circumcision Foundation of Australia (CFA), implying that it operates with the approval of the Royal Australasian College of Physicians (RACP) (p. 1). However, nothing could be further from the truth. Morris fails to disclose[v] that he himself established the CFA[vi] (as well as drafted its "policy statement") in opposition to the RACP, which released a statement in October 2010 that failed to endorse routine circumcision[vii].[14] So misleading were Morris's claims that the RACP felt obliged to distance itself from him when he insinuated that he had been engaged as a reviewer for their College.[15] In a letter to Australian newspapers, Dr. David Forbes, Chair of the RACP Paediatrics & Child Health Policy & Advocacy Committee, stated: "Professor Morris ... is not a member of the RACP and is not and has not been engaged as a reviewer for the College."[16] As the CFA website now admits: "The Foundation is not aligned with any medical body."[13]

    While Morris seeks, in this reply, to defend the AAP against its critics, even the AAP does not endorse the extreme conclusions that he and his co- authors draw (see footnote 1 for further discussion). As Morris has publicly insisted, circumcision "should be made compulsory ... [and] any parents not wanting their child circumcised really need a good talking to."[17] Morris's striking lack of objectivity concerning infant circumcision was noted by a leading sexual health researcher in a review of Morris's trade book, "In Favour of Circumcision"[18]: "Even the most naive reader can see that [the book] is very unbalanced. ... He preys on parental fears with his (unreferenced) claims. [Such claims are] so dangerous that it provides sufficient grounds for the publishers to withdraw the book."[1] As noted above, this same lack of objectivity is apparent throughout his reply to our critique.

    Medical issues aside, however, the real challenge is to establish the ethical propriety of advocating, without qualification, the needless removal of healthy and functional body parts from non-consenting children. While the AAP at least recognizes the relevance of this basic bioethical issue (but fails adequately to address it, along with the actual anatomy and function of the tissue being removed)[3], Morris and colleagues offer arguments that are quite a bit more extreme. They float the idea that circumcision is less risky if performed in infancy, and then cite an opinion piece as supportive evidence.[Morris REF: 4][viii] They then repeat Morris' discredited analogy between circumcision and vaccination,[24] ignoring the fact that vaccination does not remove functional tissue, and is both the safest and most effective means of achieving the desired health outcomes--neither of which can be said of male circumcision. And they dismiss autonomy, the concept that is the very basis of modern bioethics,[25] as "radical."

    In the final analysis, Professor Morris' exhortations ring of the same Victorian paternalism that held sway long before modern child protection measures or foundational concepts in medical ethics had ever so much as been proposed: "So great are the evils resulting not only from congenital phimosis, but from an abnormally long, though not phimotic, prepuce," wrote Erichsen in the late 1800s, "that it is only humane and right from a moral point of view, to practise early circumcision in all such cases."[26]

    Modern doctors know better--or at least they should.

    End Notes

    i. Note that while the AAP cannot actually bring itself to recommend anything even approaching Professor Morris' stated ideal (i.e., "imperative" universal circumcision) it appears that Professor Morris has recognized that their recent policy statement is about as close as any respectable pediatric authority is ever going to get--hence, it would seem, his obsequious defense of them against our critique.

    ii. Waskett does, however, have a long history of pro-circumcision activism, see Frisch[10]. Waskett has personally edited the Wikipedia pages on circumcision several thousands of times to reflect a pro- circumcision bias[11], leading it to become the 6th most "controversial" Wikipedia page (as measured by edits, re-edits, and re-re-edits) of all time.[12]

    iii. In this and other "critiques," rather than provide reasoned arguments, the authors typically reject well-established and conventional statistical methods. Their ostensible lack of understanding of meta- regression [Morris REF: 91], mixed-marginal models [Morris REF: 22], representative cross-sectional survey sampling methods [Morris REF: 14], and attributable risk [Morris REF: 62], does little to boost the reader's confidence in their assessment of others' work.

    iv. Morris does not limit himself to the tactics of letter-writing and passively-phrased self-reference. Instead, as was recently documented in the International Journal of Epidemiology, Morris also disregards the norm of confidentiality in peer-review, exhorting journal editors to reject well-conducted studies if they suggest that circumcision may be harmful. Responding to one such episode, a Danish sexual health researcher reported that Morris had been a "particularly discourteous and bullying reviewer who went to extremes to prevent our study from being published. In an email, Morris ... called people on his mailing list to arms against our study, openly admitting that he was the reviewer and that he had tried to get the paper rejected. ... Breaking unwritten confidentiality and courtesy rules of the peer-review process, Morris distributed his slandering criticism of our study to people working for the same cause."[10]

    v. Morris not only routinely fails to acknowledge his affiliation with the CFA; he also outright denies it, violating conflict of interest disclosure rules. For example, in an article discussing the CFA on a popular Australian news site, Morris explicitly states: "The authors do not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article. They also have no relevant affiliations " (emphasis added). See: http://theconversation.com/male-circumcision-policy-ignores-research-showing-benefits-8395

    vi. Some of whose members, such as C. Terry Russell and Anthony Dilley, have incomes that come primarily or substantially from performing circumcisions: see http://www.russellmedical.com.au/; http://dranthonydilley.ypsitesmart.com.au/.

    vii. The RACP statement reads: "After reviewing the currently available evidence, the 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 and New Zealand."[13]

    viii. Citing an opinion piece in the AAP newsletter [Morris REF: 4] (which itself includes no references for its assertions) Morris et al. suggest that circumcision is "riskier" if left to adulthood. Complications may certainly be better documented for adults, who have the knowledge and wherewithal to complain if something goes wrong[19]; but there is no consistent evidence that properly-performed adult circumcision is actually riskier. It is true that it can be more costly, but only if proper pain control is used: general anaesthesia is contra-indicated in infants, meaning that the surgery is performed either with no pain control or with sub-optimal pain control, driving down costs at the expense of humane treatment. Only three studies have directly compared the complication rates of infant and later circumcision. One found no difference;[20] another found a significantly greater rate following infant circumcision;[21] and a third found the opposite when using a Plastibell device.[22] See also Ungar-Sargon[23] for further discussion.

    References

    1 Donovan B. Book reviews: In favour of circumcision. Venereology 1999;12(2):68-9.

    2 Lehman BA. The age-old question of circumcision. Boston Globe, 22 June 1987; 43.

    3 Svoboda JS, Van Howe RS. Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision. J Med Ethics 2013;39:434-41.

    4 Frisch M, Aigrain Y, Barauskas Y, et al. Cultural bias in the AAP's technical report and policy statement on male circumcision. Pediatrics 2013;131:796-800.

    5 The AAP Task Force on Circumcision 2012. The AAP Task Force on Neonatal Circumcision: a call for respectful dialogue. J Med Ethics 2013;39:442-3.

    6 Task Force on Circumcision. Cultural bias and circumcision: the AAP Task Force on Circumcision responds. Pediatrics 2013; 131: 801-4.

    7 Morris BJ, Tobian AAR, Hankins CA, et al. Veracity and rhetoric in paediatric medicine: a critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision. J Med Ethics 2013; epub ahead of print.

    8 Morris B. Why circumcision is a biomedical imperative for the 21(st) century. Bioessays 2007;29:1147-58.

    9 http://www.circinfo.net/the_circumcision-debate.html

    10 Frisch M. Author's Response to: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol 2011;41:312-4.

    11 User: Jakew. http://en.wikipedia.org/wiki/User:Jakew

    12 Yasseri T, Spoerri A, Graham M, Kert?sz J. The most controversial topics in Wikipedia: A multilingual and geographical analysis. In: Fichman P, Hara N, editors, Global Wikipedia: International and cross-cultural issues in online collaboration. Scarecrow Press, 2014. Available at: http://arxiv.org/vc/arxiv/papers/1305/1305.5566v1.pdf.

    13 Royal Australasian College of Physicians, Paediatrics & Child Health Division. Circumcision of infant males. [cited 2010 Sep 29]. Available from URL: http://www.racp.edu.au/page/policy-and- advocacy/paediatrics-andchild-health

    14 Circumcision Foundation of Australia website: http://www.circumcisionaustralia.org/

    15 Hall L. Doctors circumspect on circumcision. Brisbane Times, September 11, 2009. Available at: http://www.brisbanetimes.com.au/national/doctors- circumspect-on-circumcision-20090910-fjep.html [Accessed September 4, 2013].

    16 Forbes D. No evidence to support routine circumcision. Sydney Morning Herald, 12 September 2009; http://www.smh.com.au/news/opinion/letters/no- evidence-to-support-routine- circumcision/2009/09/11/1252519635874.html?page=fullpage

    17 The kindest cut? Sunday Night program. Seven Television Network. May 24, 2009. YouTube. http://www.youtube.com/v/7yDvL4hNny4 (8 August 2011, date last accessed).

    18 Morris B. In favour of circumcision. Sydney: University of New South Wales Press; 1999.

    19 Geisheker JV. The completely unregulated practice of male circumcision: human rights' abuse enshrined in law? New Male Studies 2013;2(1):18-45.

    20 Yegane R-A, Kheirollahi A-R, Salehi N-A, Bashashati M, Khoshdel J-A, Ahmadi M. Late complications of circumcision in Iran. Pediatr Surg Int 2006;22:442-5.

    21 Machmouchi M, Alkhotani A. Is neonatal circumcision judicious? Eur J Pediatr Surg 2007;17:266-9.

    22 Moosa FA, Khan FW, Rao MH. Comparison of complications of circumcision by 'Plastibell device technique' in male neonates and infants. J Pak Med Assoc 2010;60:664-7.

    23 Ungar-Sargon, E. On the impermissibility of infant male circumcision: a response to Mazor (2013). Journal of Medical Ethics 2013; epub ahead of print.

    24 Lyons B. Male infant circumcision as a 'HIV vaccine'. Publ Health Ethics 2013;6(1):90-103.

    25 O'Neill O. Autonomy and trust in bioethics. Cambridge: Cambridge University Press; 2002.

    26 Erichsen JE. The science and art of surgery. 7th edition, London: Longmans; 1877;2:932 .

    Conflict of Interest:

    None declared

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