Circumcision booklet slammed by sexual health expert

"A serious disservice to parents"

BOOK REVIEW

Brian Morris, In favour of circumcision. University of New South Wales Press, 1999 (Paperback, 104 pp, $16.95)

Reviewed by Basil Donovan
Director, Sydney Sexual Health Centre

Professor Morris is a man on a mission to rid the world of the male foreskin. His book is targeted squarely at new parents, but he states that "doctors, nurses, midwives and other health professionals will also benefit". While the author says that the information in the book is intended "to give a balanced overview of the medical and other literature on the topic", even the most naïve reader can see  that, like all of its predecessors (both for and against circumcision), it is a very unbalanced book.

The author is an eminent molecular geneticist, but not a clinician, though a layperson could be forgiven for failing to discern the latter fact from the author's biographical details. He gives himself away with his first clinical anecdote, received via email correspondence to the author's pro-circumcision website:

A clinician would have advised this distressed father that we don't forcibly retract two-year-old foreskins. The lay readers of this book should also have been told this, but they were not. Moreover, balanitis is rarely so painful – this child should be directed to an emergency department to have more sinister pathology excluded. Indeed, a number of the author's email correspondents seemed to have more serious problems above the belt than below it.

But the author is not easily distracted from his mission. Immediately after his brisk preface about the value of the scientific method, he preys on parental fears with his (unreferenced) claims that the presence of a foreskin "serves as an impediment to sexual intercourse" and that "circumcision facilitates procreation". Perhaps he hopes that members of the target audience with shorter attention spans who fail to read any further will at least have been imprinted with these little gems. Job done.

I will spare you the details, but thereafter the author discusses at length issues such as urinary tract infections in babies, zipper injuries, HIV and STD transmission, circumcision procedures ("pain is something that is experienced from time to time by babies"), phimosis leading to urinary retention and (ultimately) stroke and heart attack, penile cancer, prostate cancer, cervical cancer, aesthetics, sexual function, and even the difficulty hospital orderlies have inserting a urinary catheter into uncircumcised men. The list goes on, and the agenda remains clear. Needless to say, no mention is made of the total absence of randomised trials – after all, if so many parents are equivocal about circumcision that there is a market for books like this, recruitment for such trials would seem quite achievable. The ubiquitous issue of socio-economic confounders (the presence [or absence] of a foreskin is typically an economic, ethnic or religious marker) is brushed aside, less drastic surgical interventions for men with phimosis are conveniently never mentioned, and the morbidity statistics are presented in their grimmest possible light.

The author seems unaware that most balanitis is caused by Candida [a kind of fungus, commonly present on the skin], with only minor roles played by Streptococci and anaerobes, so the treatment of balanitis contributes nothing to global antibiotic resistance.

Opponents of circumcision are variously dismissed in the book as being anti-Semitic, under the influence of hippies, convicted felons, on the lunatic fringe, members of a politically correct lobby to feminise men, or (at best) selective in the surveying of the evidence. Hmm ... Given this climate, it is no wonder that the medical colleges choose to sit on the fence.

It appears that beauty is in the eye of the holder as well as of the beholder. In one of the book's numerous low points, the author reminds us that the character Elaine in the comedy series Seinfeld exclaimed that an uncircumcised penis "looks like an alien". The scientist, not content with anecdote, has stooped to the level of outright fiction. The slender data presented  that supports an aesthetic preference for circumcised penises came from cultures where most men are circumcised. One can only speculate what the preference would have been if similar studies were presented from cultures where most men were uncircumcised – or perhaps even from cultures where they are subincised. [a]

Not surprisingly, the book concludes with a list of "points for and against" circumcision which provides 11 points in favour and one point against (that circumcision is a minor surgical procedure that carries with it small surgical risks). Readers of this journal may be particularly interested in the sixth summary point:

Let's address the second sentence first, remembering that the author has already told us to deplore those who are  selective in their use of the evidence. Of the many studies that have looked at circumcision status and HIV risk, only one been approached an eight-fold risk for the uncircumcised, and they were members of an ethnic minority in Kenya. The bulk of the studies clustered around a relative risk of 1.37. Typically, the uncircumcised men were from ethnic minorities, and thus the association with HIV infection had a good chance of being confounded [b]. Indeed, when having a foreskin signalled membership of the ethnic majority, its presence ceased to be a risk factor for HIV infection. [1] It is possible  that the author of this meta-analysis may also have had an element of selectiveness in his use of the literature, but at least he subjected himself to the peer-review process. The ball's in your court, Professor Morris.

But what about the first sentence? What message does it send to the father of the baby boy whose physical integrity is under consideration? Let's hope the father has the wisdom to substitute either the word "condom" or the word "restraint" – depending on your philosophy – for the word circumcision. I would consider this sentence alone to be so dangerous that it provides sufficient grounds for the publishers to withdraw the book.

I have no strong feelings about the medical indications for male circumcision either way. It is a culturally entrenched practice with mainly murky evidence to inform the debate. This sort of document adds to the murk and amounts to a serious disservice to parents.

Basil Donovan is Director of the Sydney Sexual Health Centre and Clinical Professor in the School of Public Health and Community Medicine, University of Sydney.

Reference

1. Van Howe RS. Circumcision and HIV infection: A review of the literature and meta-analysis. International Journal of STDs and AIDS, Vol. 10, 1999, pp. 8-16

Source:  Venereology, Vol. 12, 1999, pp. 68-9

Response by Brian Morris

In his review of my book Dr Donovan would seem intent on misrepresenting the evidence I present in favour of circumcision. While I appreciate that the howls from both sides in this debate have caused the colleges, as he says, to maintain a stance of sitting on the fence, it seems clear that, contrary to his statement in the last paragraph of his review, that Dr Donovan does have "strong feelings about the medical indications for male circumcision". This is most evident in the single reference he choose to cite (by Van Howe) [1] to refute my review of the large number of studies that have been performed that show higher HIV incidence in uncircumcised men, even after adjusting for potential confounding factors. Dr Donovan surely must be aware that the same journal as Van Howe published his "meta-analysis" an article appeared resoundingly debunking the latter as "highly unsound methodology" leading to erroneous conclusions. [2] When an accepted approach was used an odds ratio of 3.0 (95 per cent CI 2.6-3.4) was obtained, so that "the evidence that lack of male circumcision increases the risk for HIV infection appears compelling, contrary to the contention of Van Howe's paper". Thus Dr Donovan's "the ball is in your court, Professor Morris" comment has been very well dealt with by Moses et al already. Dr Donovan takes my statement out of context, and contrary to what he says, I do advocate use of condoms (although perhaps he might like to comment on the relative ease of fitting one of these to a circumcised as opposed to an uncircumcised penis!?) [c]

Basil knows me well enough to appreciate that I am an easy gong kind of person, not "a man with a mission". After all, my book started with a joke (which was modified by the publisher from little Johnny telling how he learnt at school that day that Sir Francis Drake had circumcised the world with a 60 foot cutter). As well as several chapters that summarise all of the medical research data published in peer reviewed international journals, the book also attempts to deal with more general aspects. Thus to broaden the scope of the book I also included a chapter on reproducing the personal accounts from men. These include the diversity of views "out there" concerning the circumcision issue. The fact that these were clearly not my words gets misconstrued in Dr Donovan's book review. I might add that most of the people with psychological problems who emailed me were clearly members or supporters of anti-circumcision groups. To all who emailed me seeking help I always emailed back telling them to see a medical practitioner as soon as possible, so I don't understand why Dr Donovan makes an issue about how he would have responded to "A concerned father" in an email account he reproduces from my book.

I have been very grateful to Dr Donovan for his help to me in the supply of samples for my research years ago on validating molecular methods for HPV detection in cervical screening. While we may share a chat over a beer and I may laugh at his ringbarking comments, if he rolls a cigarette I might have to leave the room. Yes, medical researchers and clinicians are united in their thinking about many issues, but there are some matters where consensus has never, and may never be, reached. If my book clears the air a bit then I would be happy. Indeed, the intention of my book, as should be apparent to the reader, and as stated, is to inform – especially on this issue, which has been the subject of an enormous amount of misinformation, hysteria and distortion by anti-circumcision campaigners. I feel it is my duty as an academic to present an up-to-date review and believe it does help push aside the murk, thereby helping parents and health professionals. The reader is free to consult the 170 references I cite for a fuller account. I point out that after properly studying the issues it is up to the reader to come to their own decision. I too would welcome further studies and would gladly present these in the similar balanced manner as I have done in my book.

The Australian College of Paediatrics similarly reviewed the evidence and dropped its opposition to circumcision several years ago. [d] In the interests of  sexual health, perhaps Dr Donovan should acknowledge that consensus of studies now affirm that there is a case in favour of circumcision.

References

1.  Van Howe RS. Circumcision and HIV infection: A review of the literature and meta-analysis. International Journal of STDs and AIDS, Vol. 10, 1999, pp. 8-16

2.  Moses S. Nagelkerkle NJD. Blanchard JF. Analysis of scientific literature on male circumcision and risk of HIV infection. International Journal of STDs and AIDS, Vol. 10, 1999, pp. 626-8

Source:  Venereology, Vol. 12, 1999, p. 154

Response by Basil Donovan

Perhaps it's timely to out my own views on the relationship between the foreskin and sexual health. Professor Morris may be surprised to learn that I had long suspected that the presence of an intact foreskin might increase the risk of men acquiring certain STDs. I base this starting point on an analogy with the well-documented greater efficiency of transmission of many STDs from men to women rather than from women to men. The sub-preputial space on an uncircumcised man would seem to me to present a larger and more hospitable target foreskin some pathogens, as does the vagina. Indeed, I find that I am able to help many uncircumcised men with chronic balanitis by drawing that analogy and getting them to wash out that space no more than once a day, plus minimising exposure to substances that are not friendly to the vagina, such as soap and antiseptics. [e]

Armed with this hunch, rather than set up a website I chose to do some research. Australia is a good place to do such research because there is a roughly even population split for the intervention (circumcision) and in most cases it is not a maker of ethnicity, wealth, education or religion. Unexpectedly, our research findings were uniformly negative. [1] Circumcision did not protect against STDs in our clinic population, though we did not look at HIV because it is rare in heterosexual men in Sydney. We were careful to point out that the spectrum of STDs and access to facilities for genital hygiene – that's code for running water – differed between Sydney and most parts of Africa. This was even implied by the title of the article. Nevertheless, this honest bit of research, honestly reported, earned us the dubious title of "anti-circumcision campaigners". You may have noticed that that this area of human inquiry is riddled with name calling and other attempts at discrediting the messenger.

I remain of the reversible opinion that, in certain settings, being uncircumcised is a risk factor for some STDs. But, to me, the question isn't whether or not; the key questions are "how much?" and "where?". No, Professor Morris, it is not legitimate to extrapolate blandly from east Africa to urban Australia. Nor can data on the relative safety of the surgical process derived from hospitals in industrialised countries be applied to situations where surgical skills and levels of infection control cannot be guaranteed. Could it be that in the countries where circumcision is safest it is least indicated? Answers to these questions are needed before the intervention can even be seriously considered.

Questions that would then arise would include the acceptability and feasibility of mass circumcision. The ensuing public outcry would overwhelm and affect other important issues, such as vaccination. Equally importantly, limited resources would be diverted from more wide-ranging interventions, such as improving access to clean water, which could partly obviate the need for circumcision anyway. If I campaign against anything, I campaign against extremism and over-simplification of the issues.

I selected the review by Van Howe [2] because Morris had chosen directly to attack him in his book. Among Morris's criticisms was that Van Howe's website was biased and that he avoided the peer review process. At least Van Howe can no longer be accused of the latter. Moses et al's letter [3] in response to Van Howe estimated an odds ratio of 3, derived from prospective studies in Africa. This falls far short of the 8-fold protection against HIV claimed by Morris in his book intended for Australian parents.

I'm pleased to hear that Morris has become a condom advocate, because he wasn't in his book. Since he has not retracted his claim that circumcision is the most effective HIV prevention strategy available to most men, by inference ahead of condoms, I have to persist in condemning the book as dangerous.

In response to his question about circumcision status and success with using condoms, I only have preliminary data to report. In one study [4] we found no tendency for uncircumcised men to indicate physical discomfort with condoms when compared with circumcised men. In another study [5], condoms slipped off circumcised penises more often. I call these findings preliminary because they await confirmation, and the second finding was unexpected. But these studies were omitted – along with many others – when Morris attempted to "summarise all [emphasis mine] of the medical research data published in peer reviewed international journals" in his book. Though, in Morris's defence, he did cite Reference 1. Similarly, his selection of clinical anecdotes could hardly claim to represent the "diversity of views out there", when not a single happily intact male got a voice. But never mind, Van Howe and his ilk are on the case. It's a pity that two wrongs don't make a right.

Morris and I seem to be like spirits in urging further higher quality research on this topic. Heat of debate is no substitute for sound data in its proper context.

References

1.  Donovan B, Bassett I., Bodsworth NJ. Male circumcision and common sexually transmissible diseases in a developed nation setting. Genitourinary Medicine, Vol. 70, 1994, pp. 317-20

2.  Van Howe RS. Circumcision and HIV infection: A review of the literature and meta-analysis. International Journal of STDs and AIDS, Vol. 10, 1999, pp. 8-16

3.  Moses S. Nagelkerkle NJD. Blanchard JF. Analysis of scientific literature on male circumcision and risk of HIV infection. International Journal of STDs and AIDS, Vol. 10, 1999, pp. 626-8

4.  Richters J., Gerofi J., Donovan B. Are condoms the right size(s)?  A method for measurement of the erect penis. Venereology, Vol. 8, 1995, pp. 77-81

5.  Richters J., Gerofi J., Donovan B. Why do condoms break or slip off in use? International Journal of STDs and AIDS, Vol. 6, 1995, pp. 11-18

Source:  Venereology, Vol. 12, 1999, p. 155

Editorial notes

a.  The practice of slitting the underside of the penis (originally with a sharp stone), so as to open the urethra, as performed as an initiation rite among a few Aboriginal peoples in the central Australian desert. There is an interesting (if gruesome) paper on this by Jon Willis, covering the effect of the penis surgery undergone by Pitjantjatjara men in the course of their tribal initiations. This involves  circumcision followed later by subincision, and then regular reopening of the wounds in all-male bonding rites, where blood must flow. The author shows that the combination of these surgeries cripples the penis so effectively that the men have very little interest in or capacity for sex, and suggests that the only place where it would feel remotely comfortable if touched is inside a very soft and well-lubricated vagina; anywhere else, touch on the penis would be too painful.

Jon Willis, "Heteronormativity and the deflection of male same-sex attraction among the Pitjantjatjara people of Australia's Western Desert", Culture Health and Sexuality, Vol. 5, 2003, pp. 137–151

b.  That is, holding the foreskin responsible for differences in sexual behaviour or contacts produced by the person's membership of a particular ethnic, religious or other social group, where that adherence determines the kinds of sexual behaviour engaged in or the range of his sexual contacts. The authoritative Cochrane Review, concluding that circumcision could not be recommended as an effective AIDS strategy in Africa, noted that confounding was a serious problem with nearly all the studies which claimed to find an association between lack of circumcision and greater susceptibility to HIV infection.

c.  One wonders as to the extent and sources of Professor Morris's experience on this point.

d.  Blatant misrepresentation, contradicting Morris's earlier comment that the colleges were sitting on the fence. Although the paediatricians' 1996 statement was weaker than that of 1983, it maintained their opposition to routine circumcision, a stance that was more strongly affirmed in 2002.

Current policy statement (2002, reaffirmed 2004)

Previous policy statements

Statements by other medical authorities

e.  "Balanitis" (any inflammation of the glans) is more likely to be caused by excessive washing and irritation from soap than by its natural covering.

Further information

Not to be confused with the more serious (but very rare) lichen sclerosis, or Balanitis xerotica obliterans (BXO)