Circumcision study flaws

Circumcision study flaws are numerous. The medical literature relating to circumcision is influenced by the authors' religious and cultural views. Moreover, the circumcision status of male authors impacts their views.

Foreskinned doctors tend to write papers hostile to circumcision, while circumcised doctors tend to write papers in favor of circumcision. Consequently, the medical literature regarding male circumcision is highly polarized, argumentative, and biased. American doctors do research to find reasons to carry out non-therapeutic circumcision.

Review of the circumcision literature

Bossio et al. (2014) conducted a comprehensive review of the circumcision literature. They reported that most research was concentrated on finding a benefit for non-therapeutic circumcision and there were large gaps in the knowledge of the sexual health correlates of male circumcision, including:

• penile sensation
• sexual functioning
• effect on men's sexual partners and body image
• satisfaction with circumcision status
• factors that contribute to the decision to circumcise.

Bossio et al. made three recommendations:

1. That more rigorous and consistent methodology be used.
2. Empirically rigorous studies of the physiological effects of neonatal circumcision are needed.
3. Psychosocial factors, including sexual correlates of circumcision, should be studied.

To carry out the recommendations of the authors it would be necessary to violate the human rights of more boys who would be permanently injured by non-therapeutic circumcision and the loss of the multi-functional foreskin.

Statements from medical trade associations

Medical trade associations exist to protect and advance the professional, financial, business, and legal interests of their fellows (members). A few medical trade associations, whose members perform non-therapeutic circumcision, have issued statements regarding non-therapeutic circumcision of children. Circumcision policy statements frequently exclude discussions of sexual, psychological, human rights, ethical, and legal issues, and the anatomy and functions of the foreskin. Such statements usually have an inherent conflict of interest between the best interests of the fellows' financial well-being and the well-being of male children, so they tend to be biased in favor of protection of the physicians' financial incentive.

One should draw a distinction between non-US statements and US statements.

Australasia

Flag of Australia

The Royal Australasian College of Physicians (2010) released a 28-page updated position statement on non-therapeutic circumcision of boys in September 2010. This statement is deeply flawed and outmoded in 2020. It seems to be designed to protect the physicians' income from performing non-therapeutic circumcision. The statement accepts at face value the false, now disproved, claims that circumcision reduces the risk of HIV by 60 percent. The statement shows only limited understanding of the functions of the foreskin. While it recognizes the protective function, it does not recognize the immunological function or sexual function, and shows only limited understanding of the erogenous function. The RACP places parental preference above child human rights. Nevertheless, public hospitals in Australia have banned performance of non-therapeutic circumcisions and it is reported that only 4 percent of Australian boys currently are being circumcised. The RACP needs to update this backward-looking, outmoded statement.

• (September 2010). Circumcision of infant males , Royal Australasian College of Physicians. Retrieved 31 July 2020.

Canada

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The Canadian Paediatric Society (2015) issued a new statement regarding non-therapeutic circumcision of boys. This statement was prompted by the three seriously flawed HIV studies of adult males in Africa, that have now been disproved, and caused the retirement of the excellent previous 1996 statement.

This statement has very serious omissions that bias it in favor of circumcision. The description of the foreskin omits important information, including its innervation, its protective functions, its immunological functions, and its sexual functions. The statement claims "potential" benefits, which exist only in someone's imagination.

The CPS statement revives the claims made by circumcision promoter Thomas E. Wiswell's discredited studies from the 1980s in an apparent attempt to restart the UTI scare. It fails to mention that UTIS are easily treated with antibiotics. so circumcision is not required.

The conclusion states that circumcision may be beneficial "for some boys", but fails to state which boys the CPS thinks would benefit by circumcision.

The statement seems amateurish. It seems to have been drafted by a committee of people who had no special knowledge or understanding of the human foreskin, circumcision, or the literature. It seems divorced from the reality in Canada that the health insurance plans do not pay for non-therapeutic circumcision and most hospitals do not allow the performance of the non-therapeutic amputation.

It appears that the CPS was seeking to promote more circumcisions so its members can make more money.

• Sorokin ST, Finlay JC, Jeffries AL, et al. Newborn male circumcision. Paediatr Child Health. August 2015; 20(6): 311-20. PMID. PMC. DOI. Retrieved 31 July 2020.

The Canadian Urological Association (2018) issued a 24-page guideline on the care of the normal foreskin and neonatal non-therapeutic circumcision. The statement is very comprehensive and covers treatment of various diseases and deformities as well as discussing non-therapeutic circumcision of boys in Canada. Our comments are restricted to the discussion of non-therapeutic circumcision.

While the discussion of the medical evidence is very good, the authors were unaware of the methodological and statistical errors in the three African RCTs, so they gave the RCTs excessive and undeserved weight. Although the authors recognized the loss of sensation caused by circumcision, they seemed to lack understanding of the full range of sexual injury caused by circumcision. The authors relied on studies of sexual function from Africa which were written by the same group that promotes circumcision in Africa. The authors of those studies were conflicted, so the studies cannot be believed.

They apparently had no knowledge of the psychological impact as that is not discussed at all.

The authors show no understanding that an infant is a person with human rights, that non-therapeutic circumcision violate those rights, or that the practice may be unethical or unlawful under the right to security of the person granted by Article Seven of the Canadian Charter of Rights and Freedoms.

While the authors properly conclude that non-therapeutic circumcision of children is "not justifed", they fail to recognize the full extent of the inherent harm and injury.

• Dave S, Afshar K, Braga L, Anderson P. Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (full version). Can Urol Assoc J. February 2018; 12(2): E76-99. PMID. PMC. DOI.

Netherlands

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The Royal Dutch Medical Association {KNMG) published a statement regarding the non-therapeutic circumcision of male minors in 2010. The Netherlands is a nation where human rights are respected, so it should be no surprise that the statement emphasizes the protection of the human rights of male minors and the reduction in the number of non-therapeutic circumcisions of children as much as possible. It finds no medical purpose for child non-therapeutic circumcision.

• Kruseman, Arie (27 May 2010). Non-therapeutic circumcision of male minors , www.knmg.nl, Royal Dutch Medical Association. Retrieved 31 July 2020.

UK

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The British Medical Association 28-page statement (2019) focuses on legal and ethical advice to its fellows to help keep them out of trouble in a legal and regulatory environment that is increasingly unfriendly to practitioners of non-therapeutic male circumcision. It has little to say about the medical aspects of non-therapeutic circumcision. To its credit it cites the Human Rights Act 1998 and calls for practitioners to respect the child's rights under that act.

• (2019). Non-therapeutic male circumcision (NTMC) of children – practical guidance for doctors , www.bma.org.uk, British Medical Association.

USA

All AAP policy statements expire after five years unless reaffirmed. This policy received overwhelming critical comment, so it was not reaffirmed. It expired on 31 August 2017, however the AAP did not officially announce the expiration until November 2022. Currently, the AAP does not have a circumcision policy and has not had one since 2017.

Flag of the United States of America (USA)

The United States are unique because the American medical industry has been promoting the practice of non-therapeutic circumcision since the late 19th Century. As a result of the centuries-old promotion almost all American males were circumcised soon after birth from the 1930s through the 1980s. As a result, many Americans have never seen a human foreskin and most are profoundly ignorant of its anatomy, functions, and care.

With such an environment the medical industry has been able to develop its circumcision business into a colossus that exceeds an estimated $3 billion per year. Non-therapeutic circumcision of boys has become the proverbial Goose That Lays Golden Eggs, so there is intense interest in keeping the Goose alive. Third-party payment is frequently available in the United States.

Several state Medicaid programs stopped paying for non-therapeutic circumcision in the early in the 21st Century. It is believed that this caused alarm in the circumcision industry. Shortly after The Lancet published two reports on randomized controlled trials (RCTs) from sub-Saharan Africa, it was announced in 2007 that the American Academy of Pediatrics (AAP) would take the lead, in association with the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians {AAFP}, these being the three trade associations (stakeholders) whose members perform most of the non-therapeutic circumcisions, in developing a new circumcision policy for America.

The new policy was finally published in an unusual two-part article in the September 2012 issue of Pediatrics. It immediately received an unrelenting and on-going storm of adverse critical comment:

• Chapin, Georganne (31 August 2012). My Letter to the American Academy of Pediatrics, https://intactamerica.wordpress.com, Intact America. Retrieved 3 August 2020.
  Quote: How can you approve a report that extols the benefits of removing the foreskin, a normal body part, without one single word devoted to the function of that body part, or why it’s there in the first place?

• Hill, George: Commentary on American Academy of Pediatrics 2012 Circumcision Policy Statement , Doctors Opposing Circumcision (D.O.C.). (April 2013). Retrieved 3 August 2020.

• Frisch M, Aigran Y, Barauskas V, et al. Cultural bias in the AAP’s 2012 Technical Report and Policy Statement on male circumcision. Pediatrics. 1 April 2013; 131(4): 796-800. PMID. DOI. Retrieved 3 August 2020.
  Quote: Cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious. The conclusions of the AAP Technical Report and Policy Statement are far from those reached by physicians in most other Western countries.

• Earp, Brian (27 May 2013). The AAP report on circumcision: bad science + bad ethics = bad medicine , www.academia.edu, University of Oxford. Retrieved 3 August 2020.
  Quote: Some readers will be unaware that the AAP is not a dispassionate scientific research body, but rather a trade association for pediatricians. Those among its members and stakeholders who perform NTCs stand to profit from the procedure, to the collective annual tune of $1.25 billion according to one (albeit not impartial) estimate. Given the yawning potential for a financial conflict of interest, then, there needs to be a very strong, independent medical case for circumcision; and the AAP had better be able to show that it is both the safest and most cost effective means of promoting infant health. Both of these propositions fail,however, as I will continue to show in what follows.

• Svoboda JS, Van Howe RS. Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision. J Med Ethics. 2013; 39(7) PMID. DOI. Retrieved 2 August 2020.

• Van Howe, Robert S.: Statement by statement analysis of the 2012 report from the American Academy of Pediatrics Task Force on Circumcision: when national organizations are guided by personal agendas II , Academia. Retrieved 3 August 2020.

• Darby R. Risks, benefits, complications and harms: neglected factors in the current debate on non-therapeutic circumcision. Kennedy Institute of Ethics Journal. March 2015; 25(1): 1-34. PMID. DOI. Retrieved 3 August 2020.

The AAP has a long-standing policy that its published policies and statements expire after five years unless re-affirmed. The AAP has not re-affirmed the statements below so they expired on 31 August 2017. The AAP now has no official position on non-therapeutic circumcision of boys.

• Blank S, Brady M, Buerk E, Carlo W, Diekema D, Freedman A, Maxwell L, Wegner S. Circumcision Policy Statement. Pediatrics. 1 September 2012; 130(3): 585-6. PMID. DOI. Retrieved 2 August 2020.
• Task Force on Circumcision. Male Circumcision. Pediatrics. 1 September 2012; 130(3): e756-85. PMID. DOI. Retrieved 2 August 2020.

The American College of Obstetricians and Gynecologists (ACOG) endorsed the 2012 AAP statement even before it had been published. It promptly put its own statement on its website citing the now expired AAP statement and subtly promoting non-therapeutic male circumcision to expectant mothers. It still cites the AAP statement although that statement expired in 2017.

• Newborn Male Circumcision. Retrieved 3 August 2020.

The American Academy of Family Physicians continues to promote non-therapeutic male circumcision. The AAFP report is based on the now discredited 2012 AAP statement. It touts prevention of urinary tract infection (UTI), but fails to advise that UTI is easily treatable with antibiotics if it should occur. The AAFP gives no information on the multiple functions and value of the foreskin. It fails to state that circumcision of the newborn is a medically-unnecessary, non-therapeutic amputation of a valuable body part that leaves a life-long injury and impairment of function.

• Neonatal Circumcision. Retrieved 3 August 2020.

Doctors Opposing Circumcision (D.O.C.) is a non-profit, educational organization. It does not earn money from performing non-therapeutic circumcision and is not biased by financial incentive. DOC rejects all of the self-serving statements from the medical trade associations and endorses a statement by the non-profit International Coalition for Genital Integrity (ICGI).

• Bollinger, Dan / John W. Travis / Ken W. Peterson / George Hill: Position Paper on Neonatal Circumcision and Genital Integrity , International Coalition for Genital Integrity. (28 September 2007). Retrieved 3 August 2020.
  Quote: Benefits to the infant boy from possessing an intact penis include: protection of the patient’s legal right to bodily integrity, conservation of the protective foreskin, avoidance of postsurgical complications, avoidance of persistent pain and trauma, shielding of the urethra from feces and E. coli, improved protection from Staphylococcus aureus infection in the newborn nursery (especially the increasingly present methicillin-resistant type), ease of breastfeeding initiation, with the multiple health and developmental benefits it provides, and provision of normal moisture and emollients to the mucosa of the glans penis and inner foreskin. Intact infants do not require care of a circumcision wound in the perinatal period, and do not have heightened pain responses. Financial benefits include earlier post-birth hospital discharge and a reduction of healthcare costs.

See also

• Financial incentive
• Position statements on infant circumcision
• Trauma