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.

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.