Case against circumcision overstated.

In his eLetter George Hill asserts, of circumcision, that "The evidence of injury to the child's sexual function is now conclusive". However, this view is not supported by the literature he cites. He tells us that Podnar found that the penilo-cavernosus reflex is harder to elicit in circumcised men (or those with their foreskins retracted)1. So it is harder to elicit a contraction of the anal sphincter by squeezing the glans. What sexual functions are impaired by this?

Mr. Hill's third reference2 is unobtainable, beyond an abstract for a conference presentation, making it impossible to judge its credibility.

The papers by Frisch3 and by Bronselaer4 that Mr. Hill cites both had shortcomings. Being based on self-selected convenience samples, with mediocre response rates, they were compromised by participant bias, in addition to various other problems pointed out by critics5,6. In reply, Frisch conceded that his study's findings "suggest, but by no means prove" that a minority of individuals sometimes experience a few negative effects from circumcision6. This is anything but "conclusive".

In his reply to his critics8, Bronselaer stated that the circumcision rate in Belgium is 15 % as opposed to the 22.6 % of participants in his study, but seemed not to appreciate the significance of this - his sample cannot have been a representative one. A more recent commentary points out that 12.1 % of his sample were homosexual9 leaving one wondering just how unrepresentative this sample was.

For every study Mr. Hill might cite indicating a negative effect from circumcision there are others finding no difference, or even an improvement. Rather than list examples I refer readers to the recent meta -analysis by Tian et al10 which finds no significant adverse consequence of circumcision on male sexual function.

Mr. Hill also overstates his case when he asserts that the three famous African HIV prevention trials "have been sharply questioned and even debunked" and proceeds to cite three articles, one of them his own. Unfortunately for Mr. Hill, each one of these articles has itself been "sharply questioned and even debunked" in follow up critiques in the very journals in which they were published. The one following his own was particularly detailed and thoroughly rebuts the arguments he and his co- author put forward11. The WHO, CDC, UNAIDS, and other professional bodies dealing with this ghastly epidemic, also do not agree with Mr. Hill's assessment.

It is worrisome that circumcision opponents overstate their case so much. Telling circumcised males that they are sexually damaged can only cause them anxiety and distress. And to tell them it when the evidence does not support this view makes the distress entirely needless. And claiming that the African trials are "debunked" when this is clearly not so, whilst failing to acknowledge detailed rebuttals of the very articles one cites in support of this claim, only invites accusations of denialism.

Finally, Mr. Hill writes as Vice-President of an activist organization, "Doctors Opposing Circumcision", so has a clear interest in promoting his organization's agenda. Fair enough, that is what a Vice- President should do. However, this agenda extends to denying the established benefit of circumcision in the context of African AIDS, pitting it against major professional bodies and a large volume of peer- reviewed research. It does not reflect mainstream medical opinion on this matter. Furthermore, only two of its five officers are medically qualified (Mr. Hill is not) which is a little surprising, given its name. All this could easily tempt cynics to express doubts about its credibility. Perhaps Mr. Hill could kindly allay such doubts please by telling readers how many members this campaigning group has, and how many are medical doctors?

References.

1. Podnar, S. Clinical elicitation of the penilo-cavernosus reflex in circumcised men.BJU Int. 2011;209:582-5.

2. Solinis, I., Yiannaki, A. Does circumcision improve couple's sex life? J Mens Health Gend. 2007;4(3):361.

3. Frisch, M., Lindholm, M., Gr?nb?k, M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol. 2011;40(5):1367-81.

4. Bronselaer, G.A., Schober, J.M., Meyer-Bahlburg, H.F.L., et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. 2013;111(5):820-27.

5. Morris, B.J., Waskett, J.H., Gray, R.H. Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol. 2012;41(1):310-2.

6. Morris, B.J., Kreiger, J.N., Kigozi, G. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. 2013;111(5):E269-70.

7. Frisch, M. Author's Response to: Brian Morris et al, Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol. 2012;41(1):312-4.

8. Bronselaer, G. Reply. BJU Int. 2013;111(5):E270-1.

9. Wang, K., Tian, Y., Wazir, R. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. 2013;112(1);E2-3.

10. Tian, Y., Liu, W., Wang, J-Z., et al. Effects of circumcision on male sexual functions: a systematic review and meta-analysis. Asian J Androl. 2013:1-5.

11. Wamai, R.G., Morris, B.J., Waskett, J.H. et al. Criticisms of African trials fail to withstand scrutiny: Male circumcision does prevent HIV infection. J Law Med. 2012;20(1):93-123.

Conflict of Interest:

None declared

The Health Research Authority (HRA) is fully supportive of, and strongly encourages, the involvement of patients and the public as active partners in all aspects of the research process. Such involvement produces high quality ethical research consistent with the HRA's mission to 'protect and promote the interests of patients and the public in health research'. The HRA will shortly launch a three-month consultation on its public involvement strategy which sets out our proposed approach for involving patients and the public in our work, and how we can support and enable the research community to involve patients and the public more in their work.

The HRA agrees that patient involvement (PI) offers real benefits as described in this article. However, it does take issue with the author's central thesis that the role of lay members on research ethics committees (RECs) is to be understood as primarily providing a "patient perspective" involving "checking the accessibility of written materials" and ensuring that researchers produce "a summary for a lay audience". The HRA is proud of, and is grateful to all its volunteer REC members who give up their valuable time to review health research in the NHS in order to ensure that the rights, safety, dignity and well-being of research participants are protected. Whilst checking written materials and lay summaries are important aspects of that review we do not recognise this somewhat narrow conception of the lay member's contribution put forward in this article.

Staley correctly states that NRES (a Directorate of the HRA) identifies one aspect of the lay contribution as "taking a balanced view of the likely harms and benefits of a research project by bringing a lay perspective..." but neglects to point out that the Department of Health's 'Governance arrangements for research ethics committees - A harmonised edition' (updated April 2012), states that:

"4.2.2 RECs are expected to reflect current ethical norms in society as well as their own ethical judgement. REC members may come from groups associated with particular interests but they are not representatives of those groups. REC members are appointed in their own right to participate in the work of a REC as equal individuals of sound judgement, relevant experience and adequate training in research ethics and REC review. 4.2.3 A REC should contain a mixture of people who reflect the currency of public opinion ('lay' members), as well as people who have relevant formal qualifications or professional experience that can help the REC understand particular aspects of research proposals ('expert' members)."

The important role of lay members as "equal individuals of sound judgement" reflecting "the currency of public opinion" is thus an integral part of an ethics committee's function. Lay members are already charged with taking the very perspective that Staley argues will be necessary as a result of increasing levels of patient involvement, namely the contribution of "their views as a 'member of the public'" as a "general citizen - or reasonable person".

Staley suggests that "If the patient perspective is incorporated into research projects through early PI, then the quality of these PI processes will need to be assessed as part of the REC review". In fact RECs already assess the level of patient involvement through consideration of the answer given to question (A14-1) of the current Integrated Research Application System (IRAS) application form: "In which aspects of the research process have you actively involved, or will you involve, patients, service users, or members of the public?". This question draws the attention of both researchers and RECs to the importance of patient involvement with researchers being challenged to justify any absence of patient and/or public involvement to the committee.

The HRA welcomes and actively promotes the involvement of patients and public in the design of health research but this is, unfortunately, a long way from becoming standard practice, with some researchers still taking patient involvement to mean that patients are sufficiently 'involved' by virtue of their simply being research participants. So, whilst REC members do already assess and promote patient involvement in health research, reflect public opinion and ensure transparency and public accountability, the "patient perspective", brought not just by lay members but expert members too (who we should not forget are also patients and members of the public), will continue to play an important part in the ethical review of health research in the UK.

Joan Kirkbride (Director of Operations, Health Research Authority) & Prof. Andrew George (NREAP Chair)

Conflict of Interest:

Joan Kirkbride is the Health Research Authority's Director of Operations with responsibility for the operation of research ethics committees within the National Research Ethics Service. Prof. Andrew George is the Chair of the Health Research Authority's National Research Ethics Advisors' Panel (NREAP) and an expert member of the West London & GTAC REC

Javier Hidalgo's response[1] to my commentary[2] was unsatisfactory and is likely to mislead the readership of JME. First, biomedical journals often discourage authors from citing unpublished studies. After reading Hidalgo's response, one can see the wisdom of that rule. He quotes several incorrect assertions made by Michael Clemens in 2007 in an unpublished paper[3] about my article with Frederic Docquier.[4]

Second, Hidalgo repeats the misleading quote from page 6 of Clemens[3] in his response: "Bhargava and Docquier note that the fraction of physicians abroad has a positive and significant effect on the number of adult deaths due to AIDS in general, while - interestingly--- it has a negative and significant effect on AIDS deaths in countries where HIV prevalence is low." In fact, I had spelled out how the net effect of physician emigration rate on adult deaths due to AIDS is computed in non-linear models[2] and stated that: "Thus, the net effect at the sample midpoint was positive; net effect was very close to 0 (-0.005) when computed at the start of the sample in 1991." Thus, Clemens is wrong about the negative effect being significant-- it is not statistically different from zero at the start of the sample. In fact, to show that the negative net effect is statistically significant for countries with low HIV prevalence rates, one would have to evaluate its standard error that in turn depends on standard errors of two other estimated coefficients and their sample covariance.[2] Such computations could not have been performed by Clemens since the covariance between the estimated coefficients was not reported by Bhargava and Docquier.[4] Further, the net effect was positive at the sample midpoint where the expectation should be evaluated in such models. This is because the net effect is a function of the random variable HIV prevalence rates that varies across countries and over time. Thus, evaluating the net effect at the sample midpoint is a reasonable approximation for its mathematical expectation.

Third, I had made several points about the importance of micro data that are essential for "integrating the epidemiological evidence from developing countries with the results from analyses of country-level data". One of the problems in policy oriented research is that some authors may not be familiar with quantitative analyses necessary for extracting information from longitudinal data sets covering heterogeneous individuals over time. While it is easy to base one's claims on analyses of country-level data, the ethical quandary is whether to incorporate the findings from elaborate micro studies that may support or contradict the assertions. For example, I had cited our study in South Africa[5] showing the benefits of uptake of healthcare services for AIDS patients' CD4 cell counts and quality of life indicators. There are numerous vacancies for nurses and physicians in South African clinics because many staff members have left for more lucrative venues in OECD countries. For a policy debate to be constructive, it is essential that the available evidence be examined. It would have been helpful if the micro evidence especially from sub-Saharan African countries received greater prominence in this discussion.

Finally, Clemens has claimed that our definition of emigrating physicians is "problematic"- a claim that Hidalgo repeats. Because the data agencies in OECD countries use three definitions, we compared the alternative definitions of emigrating physicians in a subsequent paper[6] and found this issue to be unimportant. In fact, correlations between bilateral stocks of emigrating physicians on the basis of countries of birth and countries of training were very high for countries such as the U.S. (0.98), France (0.97), and Canada (0.94). Moreover, developing countries are justified in recovering the investments made in educating the emigrating physicians.

In summary, policy debates surrounding the emigration of physicians need to be conducted in a scholarly manner. This can be achieved to some degree by conducting several empirical or analytical studies and summarizing the findings for a policy readership. As I had noted previously, "the policy of regularly recruiting physicians from developing countries runs contrary to the ethos of technology transfer". Hidalgo's response avoids addressing many issues that are important from a policy viewpoint.

REFERENCES

1. Hidalgo, J. Defending the active recruitment of health workers: a response to commentators. J. Med Ethics. Published online first: 31 may 2013. doi: 10.1136/medethics-2013-101325

2. Bhargava, A. Physician emigration, population health and public policies. J Med Ethics. Published online first: 26 January 2013. doi:10.1136/medethics-2012-101235.

3. Clemens, M. Do visas kill? Health effects of African health professional emigration. Center for Global Development Working Paper Number 114 2007:1-47.

4. Bhargava, A., Docquier, F. HIV pandemic, medical brain drain and economic development. World Bank Econ Rev 2008: 22:345-66.

5. Bhargava, A., Booysen, F. Healthcare infrastructure and emotional support are predictors of CD4 cell counts and quality of life indices of patients on anti-retroviral treatment in Free State Province, South Africa. AIDS Care 2010:22: 1-9.

6. Bhargava, A., Docquier, F., Moullan, Y. Modeling the effects of physician emigration on human development. Econ Human Biol 2011:9: 172-83.

Conflict of Interest:

None declared

To the Editor: Harassment and bullying are unacceptable in any workplace, let alone the health professions whose calling purportedly subscribe to healing, compassion and humanity. The highly publicised examples of sexism and exploitation serves notice to perpetrators fuelled by the perverse incentive of hierachical authority gradients. It goes without saying that we need a paradigm shift in standing up to the inertial stance of "it has always been thus, and ever will be." However, supervisors and senior staff still need a remit to act as fair and assertive counsellors to help underperforming and impaired junior doctors when poor attitudes and errors of diagnosis and treatment lead to harm in patient care. One wonders whether the recent media frenzy swirling around sexism, bullying and exploitation within the surgical specialities in training hospitals and through the two decades I have practiced as a doctor holds a negative sting in its tail. An unintended consequence that erodes our ability to train and graduate the competent specialist is that supervisors of training are now much more likely to walk on eggshells when it comes to fair-mindedly assessing junior staff not truly suited to advanced training in their chosen specialty, possess negative attitudes and are debilitated in their home and work lives. All of us must act against the inertia of institutionalised abuse and the intergenerational transference of the "we all go through it" ethos, but I fear training standards will be allowed to lapse and that supervisors will try avoid any necessary but difficult conversations and interventions with a trainee that is not genuinely performing to a minimum standard.

Conflict of Interest:

None declared