Evaluations of circumcision should be circumscribed by the evidence

David Benatar

doi:10.1136/medethics-2013-101519

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Evaluations of circumcision should be circumscribed by the evidence

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Re:The evidence demand protection of children from circumcision.
Stephen Moreton
Published on: 18 July 2013
The evidence demand protection of children from circumcision.
George Hill
Published on: 13 June 2013

Published on: 18 July 2013
Re:The evidence demand protection of children from circumcision.
- Stephen Moreton, Scientist
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 co...
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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
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Conflict of Interest:
None declared.
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Published on: 13 June 2013
The evidence demand protection of children from circumcision.
- George Hill, Vice-President
Dear Editor:
Benetar argues:
"If circumcision is a net benefit to a child, parents do not violate his rights to bodily integrity or self-determination by circumcising him. Careful attention to (the evidence for) the costs and benefits of circumcision to the child himself is thus essential."¹
The evidence of injury to the child's sexual func...
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Dear Editor:
Benetar argues:
"If circumcision is a net benefit to a child, parents do not violate his rights to bodily integrity or self-determination by circumcising him. Careful attention to (the evidence for) the costs and benefits of circumcision to the child himself is thus essential."¹
The evidence of injury to the child's sexual function is now conclusive. Podnar has demonstrated the adverse effect of circumcision upon the penilo-cavernosus reflex.² Furthermore, several international studies demonstrate the injury of male circumcision to the sexual relations of both male and female.^3-5
Benetar relies on "three major studies" as evidence of the efficacy of male circumcision in reducing HIV infection; however, those studies have been sharply questioned and even debunked.^6-8
Therefore, the evidence against circumcision is conclusive, while the alleged evidence for circumcision has collapsed.
By Benetar's own standards, circumcision is not a benefit, but instead is a malefit; thus the circumcision of male children is an unethical operation.
References

Benetar D. Evaluations of circumcision should be circumscribed by the evidence. J Med Eth. 2013; published online first 31 May 2013.

Podnar S. Clinical elicitation of the penilo-cavernosus reflex in circumcised men.BJU Int. 2011;209:582-5. doi:10.1111/j.1464-410X.2011.10364.x

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

Frisch M, Lindholm, Grønbæk 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.

Bronselaer GA, Schober JM, Meyer-Bahlburg HFL, et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. 2013;111(5):820-27. doi:10.1111/j.1464-410X.2012.11761.x

Van Howe, Storms MS. How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa 2011; 2:e4 doi:10.4081/jphia.2011.e4

Ncayiyana DJ. The illusive promise of circumcision to prevent female-to-male HIV infection - not the way to go for South Africa. SAMJ 2011;101(11):775-6.

Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J Law Med (Melbourne) 2011;19:316-34.

Conflict of Interest:
None declared
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Conflict of Interest:
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