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

Brian J. Morris, ,
March 04, 2014

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

Conflict of Interest

None declared