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.
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Conflict of Interest:
None declared
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.
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Conflict of Interest:
None declared