I would agree with many of the points that Moen raises in his
intersting journal especially that many of the problems prostitutes face
are secondary to external factors.
Despite this I feel that the analogies he uses almost ridicule many
of the sensitive points he argues. I do not feel you can compare
hairdressing to prostitution because of the act involved. Our morals
around sex form such an integral part of...
I would agree with many of the points that Moen raises in his
intersting journal especially that many of the problems prostitutes face
are secondary to external factors.
Despite this I feel that the analogies he uses almost ridicule many
of the sensitive points he argues. I do not feel you can compare
hairdressing to prostitution because of the act involved. Our morals
around sex form such an integral part of who we are and the act of having
intercourse is far more personal and intrusive than having a haircut.
Mr Koch is mistaken about the question of whether the Report by the
Royal Society of Canada expert panel that I chaired was peer reviewed.
It was extensively externally peer reviewed.
As to the journal's purported refusal to publish criticisms of the
Report. We received only one request to publish an article critical of the
Report. The author of said paper requested not only that we accept his
manuscript without...
Mr Koch is mistaken about the question of whether the Report by the
Royal Society of Canada expert panel that I chaired was peer reviewed.
It was extensively externally peer reviewed.
As to the journal's purported refusal to publish criticisms of the
Report. We received only one request to publish an article critical of the
Report. The author of said paper requested not only that we accept his
manuscript without peer review but also that we display it prominently
alongside the Report. The former violates basic publishing standards of
peer reviewed international journals. We declined.
in his recent article Bioethics Journal editor Udo Sch?klenk speaks
grandly about academic freedom and bioethical journals "under seige". And
yet, academic freedom and honesty must go together.
His journal's website carries under a "new" banner a link to the 2012
Royal Society Expert Panel report on End of Life Decision Making. Mr.
Sch?klenk was a principal author of this report.
The report was not peer reviewed. Request...
in his recent article Bioethics Journal editor Udo Sch?klenk speaks
grandly about academic freedom and bioethical journals "under seige". And
yet, academic freedom and honesty must go together.
His journal's website carries under a "new" banner a link to the 2012
Royal Society Expert Panel report on End of Life Decision Making. Mr.
Sch?klenk was a principal author of this report.
The report was not peer reviewed. Requests to Mr. Sch?klenk that balanced
critical reviews be included have been politely declined.
So his journal advances as new an old report he helped author as if it
were the last and only word on a complexlly contentious subject
This seems to make some hash of his calls for vigilance, balance, and
forthrightness in journals.
A recent Commentary piece by Lang1 contains a substantial historical error. He writes "Milah is
merely a token clip of the very tip (the overhang flap or akroposthion) of the prepuce, which leaves most of
the organ system (including all its essential functions) intact." No reference is cited, but the source appears to
be Wallerstein2. Medical considerations make this unlikely,...
A recent Commentary piece by Lang1 contains a substantial historical error. He writes "Milah is
merely a token clip of the very tip (the overhang flap or akroposthion) of the prepuce, which leaves most of
the organ system (including all its essential functions) intact." No reference is cited, but the source appears to
be Wallerstein2. Medical considerations make this unlikely, and the available historical evidence
contradicts it. From the medical perspective, if the circumcision scar can migrate in front of the corona
glandis it tends to shrink and create a secondary phimosis or a trapped penis. If treated early this can be
remedied without further operation3 but re-circumcision may be necessary4. Leaving it
untreated can have serious consequences5. Successful outcomes, with or without further surgery, result
in a fully exposed glans. Deliberate removal of only the excess foreskin, without subsequent retraction and
exposure of the glans, therefore poses a serious risk of creating an intractable secondary phimosis.
All available evidence suggests that Jewish circumcision did expose the glans. There is no pre-Hellenic
representation of Jewish circumcision - there is almost no surviving early Jewish iconography, and the Jewish
prohibition of exposing the genitals6 means that in any case penises would not be depicted. However,
Egyptian circumcision long predates Jewish circumcision, and there is good reason to believe that the Jewish
practice was derived from the Egyptian7. Iconography of circumcised Egyptians is abundant, and
detailed7. One can see from these that the glans was completely exposed, though there could be a 'cuff'
of residual inner foreskin behind the glans. This is exactly what would be expected from descriptions of the
chituch operation (described by Lang1 as milah). The foreskin is forcefully stretched
forward and severed in front of the glans. The outer layer springs back behind the glans and the residual inner
foreskin is pushed back to meet it7. There is a 5,000 year old Egyptian illustration of the
technique7, and the same technique is still used today in both medical and ritual circumcisions. There
is also much textual evidence that Jewish circumcision exposed the glans. It is recorded that Jewish athletes
competing in Graeco-Roman games wore a cap to cover the glans8.
The chituch type of circumcision does leave sufficient loose skin for foreskin reconstruction by
stretching to be possible, and there is Biblical evidence that this did occur9. Roman surgeons wrote
about techniques for foreskin restoration to re-cover the glans after circumcision8. Many Jews became
Hellenised and wished to compete in athletic events9, for which a reconstructed foreskin was a more
seemly solution than a cap (especially since the cap could be lost in the heat of competition8). It has
long been accepted that periah - ablation of the inner foreskin - was a later introduction into Jewish ritual
circumcision10. This technique is also still currently used in both ritual and medical
circumcision7. Foreskin restoration would have been virtually impossible after the introduction of
periah so periah could not have been part of the operation before the Hellenistic period, and it was a
prescribed part of the rite in the Talmudic period three of four centuries later. It is therefore hard to escape
the idea that periah was introduced to hinder circumcision reversal1,2,7. Following the
destruction of Palestinian Jewish culture in AD 70 Jewish populations were dispersed. Since new ideas would not be
adopted everywhere at the same time, it would be unlikely that periah was adopted by all Jewish communities
at the same time. Circumcision reversal was still a topic of discussion late in the first century AD11.
The important point is that periah did not affect the exposure of the glans penis, it just made circumcision
reversal more difficult.
We would also add, as a postscript, that Lang's use of the sale of Viagra as a metric of erectile dysfuntion1
seems curious when many studies in the developed and developing countries have actually investigated the topic
directly. Large-scale studies in the US12, Australia13 and Africa14 have shown
that circumcised men are significantly less likely to suffer from erectile dysfunction. Sales of Viagra in the
richest country of the world reflect nothing more than the ability to pay for it.
REFERENCES
1. Lang DP. Circumcision, sexual dysfunction and the child's best interests: why the anatomical details matter.
J Med Ethics 2013. (Epub ahead of print May 28. doi 10.1136/medethics-2013-101520).
2. Wallerstein E. Circumcision - An American Health Fallacy. New York: Springer, 1980:281pp.
3. Blalock HJ, Vemulakonda V, Ritchey ML et al. Outpatient management of phimosis following newborn
circumcision. J Urol 2003;169:2332-4.
4. Patel H. The problem of routine infant circumcision. CAMJ 1966;95:576-581.
5. Sancaktutar AA, Kilincaslan H, Atar M et al. Severe phimosis leading to obstructive uropathy in a boy with
lichen sclerosus. Scand J Urol Nephrol 2012;46:371-4.
6. Genesis 9, verses 20-24
7. Cox G, Morris BJ. Why circumcision, from prehistory to the 21st century. In: Bolnick DA, Koyle M, Yosha A
(eds), Surgical Guide to Circumcision London: Springer. 2012:243-59.
8. Rogers BO. History of external genital surgery. In: Horton CE (ed). Plastic and Reconstructive Surgery of
the Genital Area. Boston: Little Brown & Co. 1993:3-15.
9. 1 Maccabees 1, verses 15-16
10. Bryk F. Circumcision in Man and Woman. (tr. Felix Berger). New York: American Ethnological Press,
1934:342 pp. (Facsimile reprint New York: AMS Press, 1974)
11. 1 Corinthians 7, verse 18
12. Laumann EO, Maal CM, Zuckerman EW. 1997. Circumcision in the United States. Prevalence, prophylactic effects,
and sexual practice. JAMA 1997; 277:1052-7.
13. Richters J, Smith AMA, de Visser RO, Grulich AE, Rissel CE. Circumcision in Australia: prevalence and
effects on sexual health. Int J STD AIDS 2006;17:547-554
14. Krieger, JN. Circumcision, sexual function and sexual satisfaction. In: Bolnick DA, Koyle M, Yosha A (eds),
Surgical Guide to Circumcision London: Springer 2012:233-239
Sir,
Waleed Al-Herz and colleagues have posed a common yet not so easy-to
answer situation. No doubt, honourary authorship is to be discouraged in
medical reporting, yet it's easier said than done.The authors have tried
to delve in deep into the problem, however, the overbearing impact of the
"publish or perish" conundrum has to be taken at the face of it. We have
to evolve methods of evaluating the scientific contribut...
Sir,
Waleed Al-Herz and colleagues have posed a common yet not so easy-to
answer situation. No doubt, honourary authorship is to be discouraged in
medical reporting, yet it's easier said than done.The authors have tried
to delve in deep into the problem, however, the overbearing impact of the
"publish or perish" conundrum has to be taken at the face of it. We have
to evolve methods of evaluating the scientific contribution to biomedical
research including an "Integrity Index". Now what all would be included in
this index would require like-minded ethicists to put their heads together
and evolve.
Conflict of Interest:
Member of Institutional research & Ethics Committeee
I believe that the practical framework produced by Sofaer, Lewis and
Davies, is the best document available for research ethics committees on
post- trial obligations and responsible transition of research
participants from the last visit of a study to the appropriate healthcare.
This document should be taken into account for future discussion of the
Declaration of Helsinki 2013 draft paragraph on post-trial obligations
(...
I believe that the practical framework produced by Sofaer, Lewis and
Davies, is the best document available for research ethics committees on
post- trial obligations and responsible transition of research
participants from the last visit of a study to the appropriate healthcare.
This document should be taken into account for future discussion of the
Declaration of Helsinki 2013 draft paragraph on post-trial obligations
(see DoH, paragraph 34).
I've written my PhD dissertation on the topic of these guidelines. And
I've attended the seventh consultation at the Brocher Foundation in Geneva
and translated into Spanish an advanced draft of "Care After Research"
Guidelines, that it's available open access to download here:
http://philpapers.org/rec/SOFADD
I hope these materials reach the suitable audience in time.
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]
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.
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...
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
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...
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.
Whilst it is right and proper that the circumcision issue be debated,
it is disturbing that many of those who oppose circumcision rely heavily
upon selective literature citations, untested speculations about foreskin
function, fear-mongering aimed at making circumcised males feel they have
been sexually damaged, and denialism about the proven benefits of the
procedure, while ignoring pub...
Whilst it is right and proper that the circumcision issue be debated,
it is disturbing that many of those who oppose circumcision rely heavily
upon selective literature citations, untested speculations about foreskin
function, fear-mongering aimed at making circumcised males feel they have
been sexually damaged, and denialism about the proven benefits of the
procedure, while ignoring published criticisms of their arguments.
Predictably all these academic sins are committed by circumcision
opponents in the current issue of the Journal of Medical Ethics. Rather
than rebut each author in turn, which would be tedious, I will concentrate
on just one, the article by David Lang, "Circumcision, sexual dysfunction
and the child's best interests: why the anatomical details matter"1. Most
of the usual academic sins are repeated in his opinion piece, making it a
good example of anti-circumcision polemic.
Part of the reason Lang's piece is so bad is his use of popular, non-
peer-reviewed, or biased sources. Lang is heavily reliant on an opinion-
piece by Fleiss in a popular magazine called "Mothering: the Magazine of
Natural Family Living"2. To anyone familiar with popular but unscientific
views, the word "natural" always sets alarm bells ringing, as it is so
often associated with the appeal to nature fallacy. Lang's reference list
also reads like a "Who's Who" of the anti-circumcision movement: Fleiss,
Cold, Taylor, Bollinger, Van Howe, Darby, Svoboda ... all well known to be
passionately anti-circumcision and therefore, it may be argued, not
impartial, and some of whom have clocked up impressive tallies of
rebuttals and critiques in the medical literature.
Proceeding now to the technical points, citing Fleiss2 Lang tells us
that the foreskin contains "more than 20000 nerve endings". Fleiss gives
no experimental data in support of this, but instead refers to an old
paper3 which does not give the 20000 figure, directly. It has to be
inferred by extrapolation, and exaggeration, from a single square
centimetre of a single foreskin which contained 212 nerve endings. It is
not clear where on the foreskin the sample came, which is important as the
distribution of nerve endings may vary. Nor is it stated how old the donor
was, which matters as nerve ending density may decline with age. It
includes nerve endings of any kind, including temperature receptors, but
there were only two of the touch receptors (Meissner's corpuscles) that
circumcision opponents harp on about. There is no indication of how
typical this particular sample was, nor any comparison with other body
parts to provide a control. And to arrive at 20000 one has to multiply by
94.3 square centimetres, which is a very generous foreskin, even assuming
both inner and outer surfaces are being counted. None of this mattered for
the purposes of the original study, but Fleiss' extrapolation is absurd
and, without a control, worthless.
Copying another of Fleiss's errors, Lang complains about,
"desensitisation of the glans ... due to successive layers of
keratinisation from constant exposure and abrasion". As before this is not
backed up by peer-reviewed science. Like the oft-repeated 20000 figure, it
is an urban myth. What scant evidence there is indicates no difference
between circumcised and uncircumcised members4.
Continuing with his theme of copying uncritically from Fleiss, Lang
lectures about drying of the glans and interruption of "the normal
circulation of blood". Without wishing to sound facetious one may retort,
"So what?" In the absence of evidence that these things matter, they are
irrelevant, although it could be argued that drying creates an environment
less conducive to pathogens.
The doctrine of the gliding motion is next. Circumcision immobilises
the remaining skin and thereby "destroys the mechanism by which the glans
is normally stimulated", Lang parrots Fleiss. It may be countered that
circumcision enhances the actual mechanism by which the glans is
stimulated - direct contact with the vaginal wall. Many men do find their
foreskins gliding back and forth during coitus, but others have short
foreskins that retract behind the glans upon erection. Where is the
research indicating how many men experience gliding, what they (and their
partners) think about it, and whether the greater contact with the vaginal
wall experienced by a bare glans compensates for its loss? What would a
condom do to it?
Finally breaking from echoing Fleiss, Lang begins copying
unquestioningly from Cold & Taylor5. Meatal stenosis, we are told,
occurs in "in 5-10% of circumcised males" citing these two circumcision
opponents, but theirs' is a secondary source, which in turn cites five
others. The first is an author (Van Howe) whose later more detailed study
on this topic was discredited6. Three others were studies of children
circumcised because of foreskin pathology, which may be associated with
meatal stenosis. The remaining study found an 8 % incidence but had no
control.
Some recent studies find dramatically lower figures. 0.55 % and 0.9
% in Iran7,8 and 0.01 % for English boys9. Another Iranian study found 6.6
%, but none at all when petroleum jelly was applied for 6 months post-
op10. Meatal stenosis has long been regarded as subjective and tricky to
define and diagnose consistently, with differences of opinion even as to
its significance11.
"The prepuce is primary, erogenous tissue necessary for normal sexual
function. The complex interaction between the protopathic sensitivity of
the corpuscular receptor-deficient glans penis and the corpuscular
receptor rich ridged band of the male prepuce is required for normal
copulatory behavior" Lang cuts and pastes from Cold & Taylor. But
others dismiss this as unproven speculation12. Although the sample size
was small, when men were asked to rank the different parts of their penis
with respect to sexual sensation, the glans was first, the prepuce last13.
Sexual sensation is mediated by genital corpuscles, which are absent from
the prepuce14.
In the recent African HIV prevention trials, thousands of men were
circumcised and compared to controls. These studies included sexual
function. In the Ugandan trial, 98 - 99 % of both the intervention and the
control groups reported satisfaction with their sexual function after two
years15. In the Kenyan trial, 64 % of men found that sensitivity improved
after circumcision, and 54.5 % reported greater ease of achieving
orgasm16. The most recent meta-analysis on the subject found that
circumcision has no adverse effect on male sexual function17. Circumcision
opponents greatly overstate the alleged erogenous merits of the foreskin.
Lang switches to a study by two other prominent, anti-circumcision
figures, Bollinger & Van Howe18 to claim that "circumcised men are 4.5
times more likely to use an erectile dysfunction drug than intact men."
Unfortunately, Lang ignores the subsequent criticism of this study19. Its
self-selected sample was recruited through advertisements on two websites
with strongly anti-circumcision content. It is hard to imagine a more
effective way of ensuring a biased sample, short of advertising
specifically for circumcision opponents. Indeed the loaded title of the
advertisement, "Male circumcision trauma survey" comes close to doing
exactly that. In their reply, Bollinger & Van Howe concede the
potential for bias, and that their results are "unconfirmed"20.
When Lang gets to his next point, "18% of adult American men (of whom
approximately three-fourths are circumcised) have erectile dysfunction" he
finally cites a credible source21. But it is a source that linked erectile
dysfunction to cardiovascular problems, diabetes, lack of exercise and
age, not to circumcision. The aforementioned meta-analysis found no
association between circumcision and erectile dysfunction17.
Lang concludes his section on the alleged harm of circumcision with
an extraordinary combination of speculation and barrel-scraping. The USA,
he tells us, "accounts for 46% of Viagra sales" and, whilst conceding that
this "could be explained by any number of factors unrelated to
circumcision", speculates that this is due to truncation of the perineal
nerve.
In the absence of any credible evidence that circumcision causes
erectile dysfunction, speculations about the perineal nerve are moot. And
the popularity of Viagra, which can be a recreational drug, in the
wealthiest country on earth, with a high consumption of all manner of
pharmaceuticals, can indeed be explained without recourse to baseless fear
-mongering about circumcision.
Done properly, circumcision does not damage sexual function. But
misleading claims put about by its opponents do damage the self-esteem of
circumcised males by needlessly making them feel they are damaged, and are
missing an important part of their anatomy. And they distress parents by
deceiving them into believing they have harmed their sons. This is
certainly an effective way to draw angry and motivated new recruits into
the anti-circumcision movement, and into "surveys" on "circumcision
trauma", but it is misleading and unethical.
Whether or not to circumcise should be decided on quality peer-
reviewed evidence that withstands scrutiny. Not urban myths, untested
speculations, and discredited "surveys" on biased samples by biased
authors. But that is all Lang offers us. It is ironic that the title of
Lang's opinion piece should state that "the anatomical details matter" and
he then proceeds to get them wrong, or to exaggerate their importance. His
details do not matter. The facts do, and they do not support the anti-
circumcision crusaders' claims about impairment of sexual function.
References.
1. Lang, D.P. "Circumcision, sexual dysfunction and the child's best
interests: why the anatomical details matter". J Med Ethics, 2013;39:429-
31.
2. Fleiss, P. The case against circumcision. Mothering: the Magazine
of Natural Family Living. 1997;Winter:36-45.
3. Bazett, H.C., McGlone, B., Williams, R.G., Lufkin, H.M., Depth,
Distribution and Probable Identification in the Prepuce of Sensory End-
Organs Concerned in Sensations of Temperature and Touch; Thermometric
Conductivity. Archives of Neurology and Psychiatry, 1932;27:489-517.
4. Szabo, R., Short,R.V., How does male circumcision protect against
HIV infection? BMJ, 2000;320:1592-4.
6. Schoen, E.J. Letter to the editor. Clin Ped., 2007;46(1):86.
7. Simforoosh, N., Tabibi, A., Khalili, S.A.R., Soltani, M.H.,
Afjehi, A., Aalami, F., Bodoohi, H. Neonatal circumcision reduces the
incidence of asymptomatic urinary tract infection: a large prospective
study with long-term follow up using Plastibell. J Ped Urol., 2012;8:320-
3.
8. Yegane, R-A., Salehi, N-A., Koshdel, J-A. Late complications of
circumcision in Iran. Pediatr Surg Int., 2006;22:442-5.
9. Cathcart, P., Nuttall, M., Meulen, J., Emberton, M., Kenny, S.E.
Trends in paediatric circumcision and its complications in England between
1997 and 2003. Brit J Surg. 2006;93:885-90.
10. Bazmamoun, H., Ghorbanpour, M., Mousavi-Bahar, S.H., Lubrication
of circumcision site for prevention of meatal stenosis in children younger
than 2 years old. Urol J., 2008;5(4):233-6.
12. Alanis, M.C., Lucidi, R.S., Neonatal circumcision: A review of
the world's oldest and most controversial operation. Obstet Gynecol Surv.,
2004;59(5):379-95.
13. Schober, J.M., Meyer-Bahlburg, H.F., Dolezal,C. Self-ratings of
genital anatomy, sexual sensitivity and function in men using the 'Self-
assessment of genital anatomy and sexual function, Male' questionnaire.
BJU Int., 2009;103:1096-1103.
14. Rhodin, J.A.G. Histology. 1974. Oxford University Press, London.
15. Kigozi, G., Watya, S., Polis, C.B., Buwembo, D., Kiggundu, V.,
Wawer, M.J., Serwadda, D., Nalugoda, F., N., Bacon, M.C., Ssempijja, V.,
Makumbi, F., Gray, R.H., The effect of male circumcision on sexual
satisfaction and function, results from a randomized trial of male
circumcision for human immunodeficiency virus prevention, Rakia, Uganda.
BJU Int., 2008;101:65-70.
16. Krieger, J.N., Mehta S.D., Bailey R.C., Agot, K., Ndinya-Achola,
J.O., Parker, C., Moses, S. Adult male circumcision: Effects on sexual
function and sexual satisfaction in Kisumu, Kenya. J Sex Med., 2008;5:2610
-22.
17. Tian, Y., Liu, W., Wang, J.Z., Wazir, R., Yue, X. & Wang,K.J.
Effects of circumcision on male sexual functions: a systematic review and
meta-analysis. Asian J Androl., 2013; in press.
18. Bollinger, D., Van Howe, R.S. Alexythmia and circumcision trauma:
a preliminary investigation. Int J Men's Health, 2011;10:184-95.
19. Morris, B.J., Waskett, J.H., Claims that circumcision increases
alexithymia and erectile dysfunction are unfounded: a critique of
Bollinger and Van Howe's "Alexithymia and circumcision trauma: a
preliminary investigation". Int J Men's Health. 2012;11:177-81.
20. Bollinger, D., Van Howe, R.S. Preliminary results are
preliminary, not "unfounded": reply to Morris and Waskett. Int J Men's
Health. 2012;11:181-4.
21. Selvin, E., Burnett, A.L., Platz, E.A. Prevalence and risk
factors for erectile dysfunction in the US. Amer J Med., 2007;120:151-7.
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By Stephen Moreton Ph.D.
Whilst it is right and proper that the circumcision issue be debated, it is disturbing that many of those who oppose circumcision rely heavily upon selective literature citations, untested speculations about foreskin function, fear-mongering aimed at making circumcised males feel they have been sexually damaged, and denialism about the proven benefits of the procedure, while ignoring pub...
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