Wednesday, May 7, 2014

My objections to "Circumcision Rates in the United States: Rising or Falling? What Effect Might the New Affirmative Pediatric Policy Statement Have?" by Brian Morris, Thomas Wiswell and Stefan A. Bailis on Mayo Clinic Proceedings

When conclusions precede the process 

There are several problems with the abstract of "Circumcision Rates in the United States: Rising or Falling? What Effect Might the New Affirmative Pediatric Policy Statement Have?"(1) by Brian Morris, Thomas Wiswell and Stefan Bailis. The claims that benefits exceed the risks by 100 to 1, that 1 in 2 uncircumcised males will suffer from a condition over their lifetime, and that circumcision can be seen as a surgical vaccine, are not direct conclusions from this literature review; these are claims that Professor Morris has often repeated, most notably in the Australian TV Show Insight on October 2nd of 2012 (2).

The claim that not circumcising is unethical and diminishes the child's right to good health seems to be the authors' reaction to growing global awareness that non-therapeutic circumcision of minors violates the children's right to physical integrity (3), autonomy (4), may constitute bodily harm(5) and is a harmful practice against children (6).

The claim that there are no adverse effects on sexual function or pleasure is a conclusion from a previous meta-analysis by Professor Morris (7), where studies that present such adverse effects (8)(9)(10)(11) are rated low quality, and studies which deny such effects are rated high quality, including one (12) by Krieger, the co-author of that meta analysis. Said article is an attempt at denying the value of a normal part of the genitals in order to justify overriding consent and autonomy of male bodies. Circumcised children become circumcised adults, whether they like it or not.

Another important overlook is the minimization of the risks, which seems deliberate. For example, the rate of mortality cited by the authors is of 0.00001% which is equivalent to 1 in 10 million. The American Academy of Family Practitioners estimates one death in 500,000 (13), a number 20 times larger.

Twelve of the 80 references are co-authored by Professor Morris, including the Policy Statement of the Circumcision Foundation of Australia(14), a non-recognized organization created by Mr. Morris himself and a small number of Australasian physicians as an advocacy group with the purpose of promoting circumcision, and as a reaction to the more neutral 2009 policy statement presented by the Royal Australasian College of Physicians(15).

The objective of the current review appears to be to continue lobbying for insurance and Medicaid coverage for the procedure, a request previously voiced by Aaron Tobian (16), the American Academy of Pediatrics (17) and more recently doctor Saleem Islam in Florida (18).

The American medical establishment needs to abandon this late 19th and early 20th century social surgery, and come to terms with the ethical, human rights and medical paradigms of the 21st century.


1. Morris BJ, Bailis SA, Wiswell TE. Circumcision Rates in the United States: Rising or Falling? What Effect Might the New Affirmative Pediatric Policy Statement Have? Mayo Clin Proc. 2014 Mar 28. pii: S0025-6196(14)00036-6. doi: 10.1016/j.mayocp.2014.01.001

2. Insight: The First Cut. Episode aired 2012 Oct 2 on SBS.
   a) Claim that circumcision is a surgical vaccine at 27:08
   b) Claim that one in two uncircumcised males will suffer a condition during his lifetime at 28:15
   c) Claim that the benefits outweigh the risks by at least 100 to 1, at 34:05

3. Parliamentary Assembly of Council of Europe. Chidren's Right to Physical Integrity. REC 2023. 2013 Oct 01.

4. Royal Dutch Medical Association. Viewpoint on Non-therapeutic Circumcision of Male Minors. 2010 May 27.

5. Ruling by a regional court in Cologne, Germany, May of 2012. On 12 December 2012, following a series of hearings and consultations, the Bundestag adopted the proposed law explicitly permitting non-therapeutic circumcision to be performed under certain conditions; it is now §1631(d) in the German Civil Code.

6. Mulenga, Judith. Session 3: Legal Prohibition of all Harmful Practices against Children. International NGO Council on Violence against Children 2012.

7. Morris BJ, Krieger JN. Does male circumcision affect sexual function, sensitivity or satisfaction?ea systematic review. J Sex Med. 2013;10(11):2644-2657.

8. Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF,Wilcox N, Van Howe RS. Fine-touch pressure thresholds inthe adult penis. BJU Int 2007;99:864–9.

9. Frisch M, Lindholm M, Grønbeck M. Male circumcision and sexual function in men and women: A survey-based cross-sectional study in Denmark. Int J Epidemiol 2011;40:1367–81.

10. Kim D, Pang MG. The effect of male circumcision on sexuality. BJU Int 2007;99:1169–70.

11. Bronselaer GA, Schober JM, Meyer-Bahlburg HF, T’Sjoen G, Vlietinck R, Hoebeke PB. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int 2013;111: 820–7.

12 Krieger JN, Mehta SD, Bailey RC, Agot K, Ndinya-Achola JO, Parker C, Moses S. Adult male circumcision: Effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med 2008;5:2610–22.

13. American Academy of Family Physicians. "Circumcision: Position Paper on Neonatal Circumcision".  2007. 

14. Morris BJ, Wodak AD, Mindel A, et al. Infant male circumcision: an evidence-based policy statement. Open J Prevent Med. 2012; 2(1):79-82.

15. The Royal Australasian College of Physicians. Circumcision of Infant Males. September of 2010

16. Kacker S, Frick KD, Gaydos CA, Tobian AA. Costs and effectiveness of neonatal male circumcision. Arch Pediatr Adolesc Med. 2012;166(10):910-918.

17. American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics. 2012;130(3):e756-e785.

18. Gutwein LG1, Alvarez JF, Gutwein JL, Kays DW, Islam S. Allocation of healthcare dollars: analysis of nonneonatal circumcisions in Florida. Am Surg. 2013 Sep;79(9):865-9.

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