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  responding to our critique  of their article  criticizing the 2012 American Academy of Pediatrics (AAP) infant male circumcision (IMC) policy statement . Their Letter provides little in the way of material disagreement with our critique , in which we pointed out the extensive factual errors in their article . 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 . 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" . 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" . 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  to S&VH's attack on their policy  was polite, calling for, "respectful dialogue" . 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 . The AAP did, however, provide a sensible response  to an attack by Europeans who accused the Task Force of cultural bias . 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 . 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  of statistics in a paper Van Howe co- authored . Further criticisms of the statistics in this and other articles by opponents have been published since then . 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 , was disputed on statistical grounds by Moses et al. , and by O'Farrell et al. . Moses et al. pointed out that Van Howe's method of simple data pooling  led to a Simpson's Paradox  inverting the outcome. Such confounding is particularly apparent when frequency data are unduly given causal interpretations . Van Howe's article became an illustrative example in a textbook  and a review  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 . Others, who criticized him for reporting a meta- regression OR rather than a crude OR , 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"  and Auvert et al. had not only considered Van Howe's accusation of sampling bias , but had conducted an experiment to test for it . Moreover, Van Howe's "correction" would not apply to data from urethral sampling . 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 . Indeed in response to criticisms  of one meta-analysis , Van Howe admitted that, "the data ... was improperly extracted" and Van Howe published an erratum . 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 .
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. , 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  and that of a Belgian group , while failing to cite the scholarly critiques of the latter studies [27,29], as well as failing to cite RCT data , meta-analyses  and a recent extensive rigorous systematic review . The emotional response by Frisch  to the initial critique of his study  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 .
S&VH criticize our article  by saying, "no fewer than 31 of the references are to other publications by Morris and his co-authors" . 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  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)" . 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)" . 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'" . 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 .
S&VH fail to point out that the RACP's policy , 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 . Most of the authors of the critique were the same individuals who co-authored the CFA's IMC policy . These included Fellows of the RACP and of other Colleges and medical bodies .
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  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  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 .
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 .
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.
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Conflict of Interest: