Infant male circumcision: An evidence-based policy statement

Here we review the international evidence for benefits and risks of infant male circumcision (MC) and use this to develop an evidence-based policy statement for a developed nation setting, focusing on Australia. Evidence from good quality studies that include meta-analyses and randomized controlled trials showed that MC provides strong protection against: urinary tract infections and, in infancy, renal parenchymal disease;phimosis;paraphimosis;balanoposthitis;foreskin tearing;some heterosexually transmitted infections including HPV, HSV-2, trichomonas, HIV, and genital ulcer disease;thrush;inferior hygiene;penile cancer and possibly prostate cancer. In women, circumcision of the male partner protects against HPV, HSV-2, cervical cancer, bacterial vaginosis, and possibly Chlamydia. MC has no adverse effect on sexual function, sensitivity, penile sensation or satisfaction and may enhance the male sexual experience. Adverse effects are uncommon (<1%), and virtually all are minor and easily treated. For maximum benefits, safety, convenience and cost savings, MC should be performed in infancy and with local anesthesia. A risk-benefit analysis shows benefits exceed risks by a large margin. Over their lifetime up to half of uncircumcised males will suffer a medical condition as a result of retaining their foreskin. The ethics of infant MC and childhood vaccination are comparable. Our analysis finds MC is beneficial, safe and cost-effective, and should optimally be performed in infancy. In the interests of public health and individual wellbeing, adequate parental education, and steps to facilitate access and affordability should be encouraged in developed countries.

Critical Evaluation of a Survey Claiming “Long-Term Adverse Outcomes from Neonatal Circumcision”

We critically evaluate an online “Global survey of circumcision harm” that gauged beliefs of men who thought that their neonatal circumcision had harmed them. Sequential evaluation of the survey data and claims reveal numerous serious flaws that are at odds with strong scientific evidence. Moreover, the one-sided study design and “loaded” survey title meant the findings were not representative of the general population of circumcised males. None of the participants’ claimed physical problems were confirmed by a health practitioner. Belief in this seriously flawed survey has potential to cause psychological harm to vulnerable men influenced by anti-circumcision claims, and as such has serious detrimental implications for male sexual health. The survey appears driven less by empiricism and more by psychological forces, as we show in de-tail. The overwhelming body of high quality medical scientific evidence finds no adverse effect of male circumcision on sexual function and pleasure, but strong evidence for a wide array of lifetime benefits in protection against infections, dermatological problems, and genital cancers. Consistent with the United Nations Convention on the Rights of the Child, children are entitled to low risk procedures that are beneficial to their health. In conclusion, the survey and its uncritical presentation do a disservice to evidence-based medicine, sexual health, mental health, public health, human rights, and pediatric policy development. It should therefore be dismissed as unreliable.

Expertise and Ideology in Statistical Evaluation of Circumcision for Protection against HIV Infection

Aim: To critically evaluate data and arguments by Van Howe defending his stance opposing male circumcision (MC), in particular his meta-regression analyses evaluating the ability of MC to reduce HIV infection risk in heterosexual populations within and outside Africa. Methods: We performed metaregression analysis of log odds of HIV infection between uncircumcised and circumcised men using a single covariate (MC prevalence) in the meta-regression model involving the metareg package in STATA 13 for 103 populations worldwide and for populations within Africa. The meta-regression of log odds and MC prevalence was fitted to a line, as were empirical Bayes estimates resulting from post-estimation. Results: Our critical evaluation of Van Howe’s arguments attempting to undermine the scientific evidence in support of the benefits of MC in protection of men against HIV during heterosexual intercourse, as well as other infections and conditions, together with his use of statistics to support his beliefs, revealed serious flaws, obfuscation and missing data. We therefore performed our own meta-regression analysis using a trivariate model. Doing so revealed that for MC prevalences of 50%, 75% and 100% for general populations within Africa, odds ratios for HIV risk in uncircumcised vs. circumcised men were 1.35, 1.58 and 1.85, respectively. Our meta-regression analysis of data for all countries yielded similar findings. For a general population outside Africa with 100% MC prevalence, OR was 1.5. Van Howe failed to acknowledge that since MC prevalence in US whites (91%) and blacks (76%) exceeds 75% his results support MC having a protective effect in those population groups. Conclusions: The protective effect of MC against HIV infection during heterosexual intercourse applies to populations both within and outside Africa. The debate engineered by MC opponents, and led by Van Howe, now appears to have run its course. The scientific evidence has prevailed.

Male Circumcision Does Not Reduce Sexual Function, Sensitivity or Satisfaction

We disagree with Boyle’s recent article questioning our systematic review in Journal of Sexual Medicine in 2013 (Volume 10, pages 2644-2657). In particular, he disputed the quality ranking we assigned to 7 of the 36 articles that met our inclusion criteria. These had been ranked for quality by the Scottish Intercollegiate Guidelines Network (SIGN) grading system. We found that, “the highest-quality studies suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation or satisfaction.” This conclusion was supported by two randomized controlled trials, regarded as high-quality (1++) evidence and the majority of surveys and studies involving physiological measurements comparing uncircumcised and circumcised men. Here we explain why the 2 randomized controlled trials merit a 1++ ranking and why 4 reports that Boyle believes merit a higher ranking only meet the criteria set down for low quality (2?) evidence according to the SIGN system. We therefore stand by our conclusions. These are supported by a meta-analysis of sexual dysfunctions and by a recent detailed systematic review of the histological correlates of male sexual sensation.

Tye &Sardi’s Psychological, Psychosocial, and Psychosexual Aspects of Penile Circumcision*

Tye and Sardi recently reviewed the evidence purporting to implicate male circumcision, especially when performed early in infancy, in psychological problems in men. Here we provide a critical evaluation to determine the veracity of their evidence and claims. Missing from their review were critiques pointing out fundamental flaws in key studies. We argue that psychological stress in some men may be caused by anti-circumcision propaganda telling them that they are victims of “genital mutilation”, a term adopted from dissimilar female practices in particular ethnic groups. Sexual dissatisfaction results. We critically discuss claims about foreskin “gliding”, the eccentric foreskin-related sexual practice of “docking”, and the use of lubricant in masturbation. We further find that a study claiming to show numerous differences in socio-affective processing in men circumcised as neonates stem from statistically flawed and one-sided data that has been misinterpreted, and in fact shows the opposite of the hypothesis that psychological problems in some men can be attributed to the pain of their circumcision as newborns. Importantly, since the brain regions responsible for empathy, namely subcortical gray matter and white matter in frontal and parietal regions, were similar in neonatally circumcised and uncircumcised men, the null hypothesis remains null. In conclusion, we find no compelling evidence to support newborn circumcision pain being responsible for psychological problems in neonatally circumcised men. Men who come to believe that they are victims of their infant circumcision are in actual fact likely victims of false claims perpetrated by activist community groups with trenchant opposition to circumcision.