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Tainted evidence Part 2

A critical analysis of Rebecca Dekker's "evidence based" circumcision article

Rebecca Dekker PhD RN, a nurse and founder of the Evidence Based Birth website, posted an article, "Evidence and Ethics on: Circumcision." [1] An FAQ states that the article provides "evidence-based information as clearly, completely, and objectively as possible... [W]e endeavored to leave our personal opinions out of this article on circumcision and highlight the voices of experts in the medical and bioethics literature." [2]

Guest contributor Melanie Lindwall Schaab MS RN wrote this comprehensive analysis. Schaab is a certified family nurse practitioner, a licensed midwife, and an admin for Circumcision Facts and Science, Dekker's statements are highlighted in blue, followed by Schaab's responses

Tainted evidence Part 1

Urinary Tract Infections (UTIs)

any research on the proposed benefits of circumcision that involves healthy newborns who were circumcised is observational.

She falsely states that all research on the effect of circumcision on the rate of UTIs is observational; therefore she dismisses all of it as not very informative. Actually to my knowledge there is one published RCT [41]

Because observational studies are not randomized, we cannot rule out that other factors may be at least partially responsible for the observed effects of circumcision. For example, preterm infants with low birth weight may be more likely to get a UTI and more likely to be intact (if they were considered too fragile for the circumcision surgery after birth), and this would show an increase in UTIs among intact infants (Van Howe, 2005).

She falsely implies (citing an anti-circumcision activist named Van Howe who is known for his dishonesty in research) that UTI results were biased by the inclusion of premature infants (who are more likely to have UTIs and also more likely to be uncircumcised). However, I would challenge her to provide just one study of circumcision vs. UTIs that included premature infants. There isn't one. (This is a weakness of circumcision research, since it cannot give us a risk-benefit ratio of elective circumcision in preemies for the prevention of UTIs.) So the results were not biased by the inclusion of premature infants.

In Table 1, where she lists the evidence on UTIs as Low quality and Weak, she should have labeled it as High quality and Strong because it includes an RCT and is not biased by the only issue she suggested (preemies). The table specifies RCTs on newborns who have not yet experienced the issue in question. In other words, she phrased it precisely to exclude the RCT from Turkey, because the youngest age was 3 months (not a newborn) and because they had already experienced a UTI. [37] In other words, she phrased it to eliminate any RCT on the subject, so that she could falsely label the evidence on UTIs as low quality and weak.

Ways to reduce risk of UTIs include breastfeeding, healthy bathroom habits, avoid constipation, healthy diet, avoid irritants, and minimizing antibiotic use.

In infancy, formula feeding appears to increase the incidence of UTI by 35%--i.e., formula-fed babies have 1.35x as many UTIs as exclusively breastfed babies [42]. However, uncircumcised infant boys have ten times more UTIs than do circumcised infant boys [43-47]. While I am a huge breastfeeding advocate, I'm not going to give a false impression of its effects in order to coerce or trick parents into doing what I think they should do.

The other preventive measures she recommends don't apply to infants, especially those younger than 6 months who are not yet eating solid foods. Since infancy is when UTIs are most common and most dangerous, that's an important distinction. Her recommendation to minimize antibiotics to prevent UTIs is ironic, since uncircumcised boys are more likely to need antibiotics.

About 111 circumcision would be needed to prevent a single (treatable) UTI in infancy.

Despite the evidence in the study clearly showing a significant benefit of circumcision, the authors reached an anti-circumcision conclusion. [48] As it is the third most recent meta-analysis on the subject, it's strange that she didn't use one of the two more recent meta-analyses. [49] The most recent meta-analysis (2013) reported that about 7% of uncircumcised boys will have a UTI by age 7. They calculated that the number of circumcisions needed to prevent one UTI across the lifespan (NNT) is about 4.6. (While they don't give a NNT for infancy, if 1.5% of uncircumcised boys will experience a UTI in infancy, the NNT for infancy is roughly 70.) They found that the lifetime risk of UTI is 32% for uncircumcised males and 9% for circumcised males. [50] (The female lifetime UTI risk is greater than 60%.) [51]

Phimosis and balanitis (inflammation)

[No] randomized [research] on healthy newborns not yet experiencing these medical problems [because] the research [regarding phimosis and balanitis] is on treatments for boys with physician-diagnosed phimosis.

Her statement is extremely specific to the effect that she rejects any research on the subject. The studies on the proportion of boys in each group who experience overall penile problems including phimosis and infections are not RCTs and don't assess boys who were "not yet experiencing these medical problems" - because nearly all newborns do have phimosis. It's the normal state of the newborn foreskin. So of course they were all affected before their circumcisions.

Her rating of the evidence on phimosis is disingenuous at best. For example, she rates the evidence on topical steroids for treatment of pathological phimosis--in which case, the boy is already experiencing pathological phimosis*--as moderate to high quality. However, she requires the research on circumcision to involve only boys who have NOT already experienced phimosis. Since nearly all boys experience phimosis from birth and since studies of circumcision (or anything else) for *treatment of pathological phimosis involve boys who obviously already have pathological phimosis, this means she (a) phrased the question in such a way that all research on circumcision and phimosis would be excluded and (b) is using different standards for research on circumcision and research on alternatives to circumcision.

She rates the research that was not about circumcised vs. uncircumcised boys on these issues and therefore cites very uninformative and outdated studies. For example, she cites a 1999 study by Dr. Rickwood for the incidence of pathological phimosis in uncircumcised boys, which she puts at 0.6%. However, research has shown that the incidence of pathological phimosis, mostly due to a skin disease called lichen sclerosus (LS) or balanitis xerotica obliterans (BXO), is increasing [52], and so more recent research is necessary to draw an incidence estimate. In fact, another article by the same author she had cited, Dr. Rickwood, published only 3 years later reported the incidence at about 1.5% [53]. Another important point is that the incidence of LS/BXO peaks in males aged in their 30s, which means it's very short-sighted to only look at the incidence in children, and it affects 35-55% of uncircumcised diabetic males [54]. Since about 20% of males will develop diabetes, that means 7-11% of uncircumcised males will develop LS/BXO due to diabetes. This does not include the proportion who will develop LS/BXO in adulthood due to other causes.

It's also important to note that she understates the issue when she implies that the only form of phimosis that may require treatment is caused by LS/BXO. A 2016 study from Denmark (a country very hostile to circumcision) reported that 5.5% of boys required treatment for phimosis. [55]

Her section on balanitis is also very confusing. She cites one study here and one study there (in 1997 and 1999) which confirms her opinion, but does not cite higher quality evidence such as a systematic literature review or meta-analysis. I found two such recent articles which reported that circumcised males experienced a nearly 70% reduction in balanitis [54] and another which did not provide a meta-analysis but reported similar incidences in circumcised and uncircumcised males [56].

The risk of phimosis as a complication following circumcision is also about 1%, which occurs when the scar tissue covers the glans.

It's unclear where she got this idea; that figure contradicts other research on the subject. Such a problem would require re-circumcision, which is only done in about 0.2% of newborn circumcisions (usually for cosmetic reasons). [57] Correctional procedures up to age 18 were performed on 0.3% of circumcised boys. [36] The studies show that phimosis affects 6% of uncircumcised boys and less than 0.2% of circumcised boys - not her figures of 0.6% of uncircumcised boys and 1% of circumcised boys.

Human immunodeficiency virus (HIV)

I've already addressed her HIV arguments, so I'll skip that part of the table.

Human papillomous virus (HPV)

Condoms, HPV vaccine, abstinence, or mutual monogamy with an uninfected partner [are] non-invasive methods of prevention or treatment. Consistent condom use does reduce the risk of HPV. [58] However, as I discussed earlier, many men don't use condoms even when extensively and repeatedly educated about the importance of condoms and given plenty of free condoms. If men did use condoms consistently as we've been advising for decades, we wouldn't have the STD epidemic that we do. The most recent meta-analysis indicates that a vaccine does not prevent HPV infection in males. (It does in females.) In fact, the meta-analysis found a non-significant increased incidence of HPV infection in vaccinated males. [59] Abstinence is great for young people, but realistically most people eventually have sex. Monogamy requires that the individual depend on his partner to practice safe sex. So why not circumcision? Basically, of all the options to reduce HPV risk, circumcision is the best option. It actually works (unlike the vaccine for males). It does not make unrealistic expectations of the male (like condoms and abstinence). It does not rely on the faithfulness of his sexual partner (like monogamy). Because the evidence in favor of the HPV preventive effect comes from high-quality observational research and one of the highest-quality types of study, very large RCTs, the evidence is High quality and Strong, not moderate quality and weak. The most recent meta-analyses all report more than 40% reduced incidence of HPV in circumcised males. [60] [61] [62] [63]

Herpes Simplex Virus (Herpes)

Abstinence or mutual monogamy with an uninfected partner [are] non-invasive methods of prevention or treatment; consistent condom use provides the same (low) level of protection as circumcision.

I addressed abstinence and monogamy above. The most recent systematic review found that condoms are ineffective against herpes. "Using condoms during more than 25% of sex acts was associated with a 92% reduction in the risk of women acquiring HSV-2 but was not associated with a protective effect among men." [64] By contrast, circumcision reduces herpes risk by roughly 30%. [65] Because that data includes RCTs, it is "high quality" and "strong" evidence, not "moderate quality" and "weak." Circumcision is also effective at treating herpes according to research from India, a country which has an anti-circumcision bias. They found that herpes outbreaks were 21 to 25 times higher before circumcision and in men who remained uncircumcised than in men after circumcision. Circumcised men also enjoyed longer disease-free periods between outbreaks. [66]

For reasons unclear, she does not provide information on several STIs and STDs, including genital ulcerative disease, chancroid, lymphogranuloma venereum, granuloma inguinale, chlamydia, gonorrhea, trichomonas, hepatitis B, mycoplasma genitalium, genital warts, non-gonococcal urethritis, scabies, and pubic lice. Besides phimosis she also does not address structural problems with the penis, such as paraphimosis, frenulum breve, buried penis, chordee, pearly penile papules, penile lymphedema, and penile mondor's disease. [67]

Penile Cancer

Most penile cancer is linked to HPV. Researchers today believe that HPV and lichen sclerosus (LS) are the most important risk factors for penile cancer. I already addressed HPV above. She indirectly refers to LS when she says to "treat phimosis that persists into adulthood". LS causes phimosis and there is no increased risk of penile cancer in uncircumcised men without phimosis compared to circumcised men, but there is up to 37 times higher risk of penile cancer in uncircumcised men with phimosis, indicating the strong effect of LS on penile cancer. [68] [69] In fact, the incidence of HPV is also much higher in men with phimosis than in men without phimosis. For example, a 2016 Brazilian (anti-circumcision) study found that HPV affected 47% of phimotic men vs. 16% of non-phimotic uncircumcised men, and that 50% of the HPV samples from phimotic men were high-risk (i.e., cancer-causing) HPV compared to only 1 man without phimosis [70].

The link specifically to LS, not just phimosis, has also been studied; it's now undeniable that LS is a primary, if not the primary, cause of penile cancer. Researchers have not yet found any way to prevent LS aside from circumcision. Treatment typically involves steroids and circumcision or steroids alone, but to my knowledge, there is no research showing that either treatment prevents penile cancer.

According to the AAFP, 300,000 circumcisions would need to be done to prevent one case of penile cancer.

Actually it's closer to 600-900 circumcisions since 1 in 600-800 men not circumcised in infancy will be affected by penile cancer compared to 1 in 50,000-12,000,000 men circumcised in infancy. According to a study that I cited earlier, 1.9 circumcision complications would occur for every 1 case of penile cancer prevented. [50] And since penile cancer is far more serious than the average circumcision complication, that means the benefits outweigh the risks on this one issue alone.

The reason that no RCT has assessed circumcision for the prevention of penile cancer is obvious. Since infant circumcision protects against penile cancer, but circumcision later in life does not, one would have to randomly assign thousands of infants to be circumcised or to remain uncircumcised (again, there's the issue of getting parents to agree to it) and then track them for more than 90 years each. (The average age of penile cancer in a circumcised man is about 88, while the average age in an uncircumcised man is several decades younger) The fact that we don't have an RCT on a subject that is not practical to study via RCT should not count as evidence against this point. It's a similar reason why RCTs were conducted on adult men to study the effect of circumcision on HIV: because if they did infants, they'd have to track them for several decades.

It's puzzling that she doesn't mention prostate cancer, the most common cancer to affect men. In the most recent meta-analysis I could find, researchers found that circumcision reduces prostate cancer by 10% and aggressive prostate cancer by 16%. (Among men with prostate cancer, circumcised men are less likely to have a serious case.) [71]

What are the potential health risks from circumcision?

Complications that can occur during and soon after circumcision

The true rate of complications after newborn circumcision is not known. Part of the reason for this is that researchers are focused on finding the potential benefits from circumcision (e.g., protection from HIV), not the potential harms.

Actually the reason why there's so much research on HIV is because it's a terrible scourge. It is the primary cause of infectious disease deaths in the world, and it spreads rapidly. Most of the early studies on circumcision and HIV were actually studies of everything versus HIV, and coincidentally discovered an association with circumcision. (They first discovered that religious and cultural groups that circumcise had lower rates of HIV than groups that did not circumcise, whereupon they started specifically seeking out circumcision information.) If you look at research on the benefits of, say, PrEP or ART against HIV, you will see a similar pattern with far more studies on efficacy than on safety. Exactly the same pattern occurs with studies on vaccines. For example, year after year, the Cochrane Collaboration has reported that hundreds of studies have assessed the efficacy of the flu vaccine, but none (literally 0) have assessed whether the flu vaccine can trigger the development of pneumonia, in spite of case studies suggesting that effect. That doesn't mean researchers are wholly unconcerned with the safety of PrEP or ART or anything else. It simply means we need to know with absolute certainty whether the intervention in question even works because if it doesn't work, then safety is irrelevant, whereas some risk is always acceptable if the benefits are greater. (Think of it this way: if you had to prove safety first beyond a shadow of a doubt before researching efficacy, no chemo drug would ever be approved.)

In fact, we recently discovered that use of PrEP (pre-exposure prophylaxis, a drug you can take before or a couple days after having sex that reduces your likelihood of catching HIV from that person) reduces the use of condoms--i.e., when PrEP is available, people feel less pressure to use condoms. However, we had already discovered that, whatever the risks, PrEP is effective. Since we already knew it is net effective, the fact that it results in reduced use of condoms was irrelevant to the decision of whether to use it. Research after that discovery focuses on how to reduce the risk that people will stop using condoms after PrEP becomes available in their community (i.e., EFFICACY of intervention to improve condom use), rather than conducting yet more studies on the degree to which people stop using condoms (i.e., SAFETY of PrEP). So the effect remains that there are more studies on efficacy than on safety.

Another reason there are more studies on efficacy of circumcision than on safety is that you can't always study both at the same time like you can with things like vaccines or other drugs. At the same time that you give a drug--say, ART (anti-retroviral therapy against HIV)--you can assess whether they had any side effects (safety) AND whether the viral counts decreased (efficacy). However, with circumcision, you can usually only assess the efficacy and only sometimes the efficacy and the safety. For example, most U.S. males are circumcised in infancy, so you couldn't simultaneously assess their risk of STDs, penile or prostate cancer, penile structural problems, skin diseases, etc., all of which generally occur after infancy. And while you can easily ask a group of circumcised and uncircumcised men about various issues and test them for various problems (e.g., a blood test for HIV), you can't easily recruit several physicians or hospitals that perform circumcisions and get permission to comb through their confidentiality-protected medical records. Nevertheless, there have been many studies on the complications and risks of circumcision. I've collected more studies on that topic than on circumcision's effects on penile cancer. It's true that there are limitations to the studies on circumcision complications. For example, Wiswell's infamous study of over 100,000 circumcised boys and almost 36,000 uncircumcised boys to compare circumcision complications vs. UTIs in the two groups tracked the boys for a full month after the circumcisions, which is longer than most vaccine studies (which usually track for a week). Others have tracked rates of complications over more than a year after circumcision, such as Simforoosh et al (2010), which tracked for 15 months. Still others have tracked even longer, such as the El Bcheraoui study that tracked up to age 18. The feasibility of studying long-term effects longitudinally (that track the same people over time), be it vaccines or circumcision or any other issue, is largely affected by the expense and by the likelihood that parents will bring their child to all of the follow-up exams over several years (assuming, for example, that they don't move to a new area or choose a new pediatrician for whatever reason). Even anti-circumcision activist Van Howe could not produce a longitudinal study on his patients. He produced a snapshot of how many kids in each group had X problem or Y problem at various ages, which is what most studies on either efficacy or safety do.

She accurately states that most studies find that the serious complication rate is at or close to 0%, but then she cites studies from third world countries for safety. Earlier, she argued that African studies on HIV could not be extrapolated to other countries. Yet here she contradicts herself without giving the same caveat that she did earlier: studies of safety in third world countries with limited access to low-quality medical care cannot necessarily be extrapolated to developed nations with ready access to high-quality medical care.

[The El Bcheraoui] study has been criticized for assessing certain complications over too short of a follow-up window and relying on a type of database thought to underestimate the rate of complications (Frisch and Earp, 2018). As we will discuss, potential complications such as a narrowing of the urethral meatus (opening) can take many years for doctors and parents to detect.

The study [36] went up to 18 years; so I'm not sure how far she wanted it to go! The study did assess meatal stenosis; rates of urethral stricture were 0.007% uncircumcised vs. 0.008% circumcised, with the difference not statistically significant. Maybe she doesn't understand that urethral stricture and urethral meatal stenosis are the same thing. (If that's the case and she's a PhD nurse, then one wonders what she does know about circumcision and male genital organs.)

New research from the United Kingdom (U.K.) proposes that newborn circumcision might increase risk of SIDS, or Sudden Infant Death Syndrome, once called crib death (Elhaik, 2018).

Although she had discussed criticisms of pro-circumcision studies, she failed to discuss any of the criticisms of the SIDS study. [72] For example, one critical point that completely defeats the entire study and makes it entirely null is that the author based newborn circumcision rates on the proportion of Jews and Muslims in the country in question. But Muslims typically circumcise between ages 5 and 13 - not during infancy. So he found an association between death in uncircumcised infants and parents who plan to circumcise them several years later - not an association between SIDS and circumcision. [73] Other researchers have found no association between male to female infant mortality ratio in countries with high and low newborn circumcision rates. Israel, with perhaps the highest newborn circumcision rate, has one of the lowest infant mortality rates; while Norway, with practically a 0% newborn circumcision rate, has one of the highest infant mortality rates. [74] [75] [76]

Recent Case Reports

She very, very oddly discusses a bunch of case reports of super rare and super scary things. I can produce case reports of super rare and super scary things, too, but it's odd because earlier she said that she was going to provide best research. Case studies are literally the lowest quality form of research.

Complications with newborn circumcision versus older male circumcision

She goes back and forth between medical and ethical arguments when she discusses complications in newborn vs. older male circumcision. For example...

Researchers who advocate for routine newborn circumcision ... say, “A desirable feature of infant male circumcision is the surgical ease of performing a circumcision on an immobile newborn … facilitating the use of local anesthesia.” However, those opposed to infant circumcision argue that the infant’s immobility (due to being strapped into a restraining device, and being unable to defend itself) actually makes infant circumcision less desirable than circumcision on someone who can provide consent for the procedure.

In other words, this medical statement related to minimizing the risk of complications is accurate; since she can't argue against it, she's changing the subject.

Again, she compares developed nations to third world nations. She cites one study that collected 16 studies from around the world and compares it to other studies from both first world and third world, in order to make the argument that there isn't a huge difference in complication rates among age groups. However, she ignored a more recent, larger, single-country developed nation study she had already cited earlier: the El Bcheraoui study. This study included over 2 million boys, 55.9% of whom were circumcised, and complications were recorded up to age 18. They found the complication rates were 0.4% for ages 0-1 year, 9.06% for ages 1-9 years, and 5.31% for ages 10+. In other words, the complication rate was 22.7x higher for ages 1-9 and 13.3x higher for ages 10+. [36]

Since nearly 10% of boys get circumcised between 1 yr and 18 yrs and since the complication rate then is 10 to 20 times higher, boys are less likely to experience a circumcision complication if circumcised in infancy than if not circumcised in infancy. In other words, she had to engage in some pretty impressive cherry-picking and mixing observational studies from third world and first world in order to give a false impression when she could more easily and more accurately have gotten the truth from a single, massive, high quality observational study from a developed nation.

Pain with circumcision

The surgical removal of the nerve-laden male prepuce is an invasive, painful procedure and requires pain treatment. Researchers have described that when there is inadequate pain treatment during circumcision, newborns can experience stress chemicals in the body, increased heart rate and breathing rate, decreased oxygen, skin turning red or blue, vomiting, increased crying, gagging/choking, and withdrawing (becoming less responsive to parents) (Brady-Fryer et al. 2004).

She expends a lot of energy talking about pain, probably because this is an emotional topic. No parent wants her baby to experience unnecessary pain. The truth is that numbing injections are extremely effective at nearly eliminating pain. On average, babies experience almost no pain, but do still have some discomfort. There is no evidence that pain from circumcision causes long-term behavioral changes. She very vaguely hints at this fact when she states, "researchers theorized that painful events... may have long-lasting consequences on the child's behavior." But she does not provide any evidence to this effect even though the study she cited was from more than twenty years ago.

It's possible that pain after circumcision could interfere with early breastfeeding. However, at this time, there is no strong evidence linking modern routine circumcisions to problems with breastfeeding.

A more accurate statement would be, "there is strong evidence that circumcision does not affect breastfeeding success." [77]

Ronald Goldman, Ph.D., is a critic of newborn circumcision and well-known psychological researcher in this field. He believes circumcision trauma in early life can lead to long-term psychological effects.

Several studies from countries where circumcision is common have found circumcised men are psychologically better off. Nunberg reported that circumcision seemed to have positive effects on mental health. [78] Ozturk and Şahin found that Turkish boys felt better emotionally when they were circumcised. [79] [80] Aydogmus found that circumcised men had improved body image and reduced social anxiety. [81] A couple of studies found that circumcised sons of intactivist parents and circumcised intactivist men were psychologically worse off. Bossio found that circumcised men who believed that circumcision is good were psychologically better off than circumcised men who believed that circumcision is bad; and that uncircumcised men who thought the foreskin was great were on equal psychological standing as circumcised men who thought circumcision is good. [82] In short, the culture or micro-culture in which you live and your personal beliefs about circumcision or the foreskin has an effect on your psyche while the circumcision itself does not. [83]

Meatal Stenosis

Circumcision is considered the most important cause of meatal stenosis; this condition rarely (if ever) occurs among intact males.

I mentioned above that the largest study on the subject found the meatal stenosis rates to be 0.007% and 0.008%, not significantly different. [36] Two other studies conducted by intactivists (one by Frisch of 810,000 boys [84] and one by Van Howe of 1,100 boys [85]) found no significant difference in meatal stenosis rates between circumcised and uncircumcised males.

So basically her whole section on meatal stenosis is irrelevant because even intactivists can't produce sufficient research to conclude that circumcised boys have a higher meatal stenosis rate. If it is higher in circumcised boys, the difference is so tiny that it is still irrelevant. [86]

Loss of sexual function and sensitivity

It's funny that she labels the next section "Loss of sexual function and sensitivity", rather than "Effects on sexual function and sensitivity." Her expectation is a foregone conclusion. Of about 65 studies and 4 systematic literature reviews and meta-analyses on the subject, the result is clear that circumcision does not harm - and in some cases may very slightly benefit - sexual sensation and function. [87]

That concludes her discussion of the medical effects of circumcision. She never discussed the effects of male circumcision on female sexual partners, including: reduced incidence of bacterial vaginosis; reduced risk of syphilis, HPV, herpes, trichomonas, genital ulcerative disease, and cervical cancer; and ​possible reduced risk of HIV and chlamydia. I know parents who were motivated at least in part by the effects on female sexual partners, especially those who are affected or know someone who is affected by something that circumcision of the male partner could have prevented.

Discussion of the evidence in light of ethics and human rights

Given her inaccurate account of the medical effects of circumcision, the discussion on ethics has a foregone conclusion. She misinterprets bodily integrity and informed consent. She implies that the procedure causes too much pain. How does one determine that? I define it by medical facts: circumcised boys are less likely to suffer complications overall, so a temporary slight pain is not too much compared to infection prevention.

She falsely states the risks may outweigh the benefits. She falsely implies that the absence of the foreskin poses risk to the glans and meatus. She falsely implies that circumcision causes sexual dysfunction or loss of sexual sensation. She falsely states that "there are less invasive and more effective preventions and treatments available for many conditions it addresses" (which I discussed in greater detail above, giving, for example, research showing the HPV vaccine doesn't work for boys). She compares circumcision to FGM as if there is no difference between male and female genitals.(Does she also promote mammograms and pap tests in men and prostate exams in women?)

View that routine male circumcision is not ethical It's ironic that she reports that the country with the most papers against circumcision is the United States, which she earlier argued is culturally biased in favor of circumcision.

Practice Guidelines

She mentions an open letter from anti-circumcision activists to the AAP, [88] but she fails to mention the open letter from pro circumcision researchers to the RACP about its neutral position statement. [89] While arguing that American position statements are biased by a pro circumcision American culture, she fails to realize that the same might be said of position statements from countries biased against circumcision. It's interesting to read U.S. professional statements on male circumcision and [FGM] side by side to see how organizations view these as distinctly different practices."

That's because they are distinctly different practices. She selectively reports what international medical associations say about circumcision. For example, she mentions that the Canadian Paediatric Society (CPS) [90] and the Royal Australasian College of Physicians (RACP) [91] do not recommend routine circumcision, but she does not mention that the American Academy of Pediatrics (AAP) says exactly the same thing. [92] This omission gives the false impression that the AAP is on the opposite side of the issue as the CPS and RACP. All three organizations acknowledge the benefits and the risks, and all three support the parents' right to decide whether to circumcise their infant sons.

Andrew Freedman ... explains his view that parents choose circumcision for a wide variety of non-medical reasons (e.g., religion, culture, cosmetic preferences, family tradition) and that physicians have no authority to judge these nonmedical reasons (Freedman, 2016). He says “protecting this option was not an idle concern at a time when there are serious efforts in both the United States and Europe to ban the procedure outright.” So it appears that the AAP task force was at least partially motivated by a desire to keep circumcision available as a parental choice.

She implies that the AAP didn't actually produce a risk-benefit analysis, but rather that the AAP fraudulently produced a result to protect religious liberties. By cherry-picking Dr. Freedman's article, she gives the misleading impression that the AAP was primarily influenced in their risk-benefit analysis by a desire to protect circumcision for religious and cultural reasons. The two preceding sentences, which she failed to include, give a far different picture: "The ethical standard used was 'the best interest of the child,' and in this setting the well-informed parent was felt to be the best proxy to pass this judgment." [93] [94]

The Royal Dutch Medical Association (KNMG) in the Netherlands has one of the strongest statements opposing circumcision.

She doesn't dismiss the KNMG position against circumcision [95] as a result of cultural bias - as she had done with the AAP's policy statement in support of parental choice.

In Germany in 2012, a regional judge in Cologne ruled that circumcision is already illegal under German law... The judgment drew harsh criticism from Jewish and Muslim communities.

The ruling was denounced by the Roman Catholic Archbishop, the German Evangelical Church, and other Chistian groups - as well as several medical organizations. The German parliament swiftly passed legislation to nullify the decision.

A citizen’s ballot initiative to ban the non-therapeutic circumcision of minors in the city of San Francisco received enough signatures to appear on the ballot but pressure from pro-circumcision forces resulted in a local judge removing the initiative from the ballot.

Actually, the measure was removed because it violated California law. Regulation of medical procedures belongs to the state and is outside the purview of a city. [96]


In this article the author’s anti-circumcision bias strongly affects what she writes. The result is a biased, inaccurate, and non-evidence-based opinion piece. Throughout, her choice of words, the topics she includes, and the claims she makes betray her bias.

She routinely misunderstands or misrepresents important bio-ethical principles. She contradicts herself on ethical principles and when discussing bias according to country of origin. She selectively cites obscure anti-circumcision activist articles while failing to mention opposing viewpoints. She cites rare negative consequences of circumcision, but she cites only some of the most common foreskin complications. She uses medically inaccurate language to prompt an emotional response. She gives unrealistic suggestions as alternatives to circumcision, and she misrepresents her own sources or takes them out of context. She (1) routinely rejects the highest quality evidence where it contradicts her opinion; (2) offers poor quality evidence in favor of her own opinion; (3) makes vague statements that give a false impression in favor of her opinion; and (4) fails to offer any critiques whatsoever of the articles in favor of her opinion. In conclusion, her anti-circumcision bias made both the content and the conclusion sadly predictable. Her article reads as if it were written for an intactivist website. It fails to meet the evidence-based standards set by her prior articles on other subjects. Rebecca Dekker let her bias get in the way of professionalism, evidence, and accuracy.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *


Dr. Amy Tutuer - The Skeptical Ob - has harshly criticized Dekker for "deliberately misleading" posts that "are not based on scientific evidence", and for contradicting medical experts on topics in which she lacks medical qualifications and expertise.

[1] Rebecca Dekker PhD, RN and Anna Bertone, MPH; "Evidence and Ethics on: Circumcision"; Evidence Based Birth; July 19, 2019

[2] Ibid - "Frequently Asked Questions"

[36] Charbel El Bcheraoui, PhD et al; "Rates of Adverse Events Associated with Male Circumcision in U.S. Medical Settings, 2001–2010"; JAMA Pediatrics; July 2014

[41] A Nayir; "Circumcision for the prevention of significant bacteriuria in boys"; Pediatric Nephrology; April 2002

[42] Omotomilola M.Ajetunmobi MSc et al; "Breastfeeding is Associated with Reduced Childhood Hospitalization: Evidence from a Scottish Birth Cohort (1997-2009)"; Journal of Pediatrics; March 2015

[43] D Amato, J Garduño-Espinosa; "Circumcision in the newborn child and risk of urinary tract infection during the first year of life. A meta-analysis"; Boletin medico del Hospital Infantil de Mexico; October 1992 [44] TE Wiswell, WE Hachey; "Urinary tract infections and the uncircumcised state: an update"; Clinical Pediatrics; March 1993 [45] D. Singh-Grewal et al; "Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies"; Acute paediatrics; 2005 [46] N Shaikh; "Prevalence of urinary tract infection in childhood: a meta-analysis"; Pediatric Infectious Disease Journal; April 2008 [47] Brian J. Morris and Thomas E Wiswell; "Circumcision and Lifetime Risk of Urinary Tract Infection: A Systematic Review and Meta-Analysis"; Journal of Urology; June 2013

[48] D Singh-Grewal et al; "Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies"; Archives of disease in childhood; 2005

[49] The most recent meta-analysis is Brian J. Morris and Thomas E. Wiswell; "Circumcision and Lifetime Risk of Urinary Tract Infection:A Systematic Review and Meta-Analysis"; Journal of Urology; June 2013

[50] A 200 study found that 6 UTIs would be prevented for every circumcision complication. Dimitri A. Christakis et al; "A Trade-off Analysis of Routine Newborn Circumcision"; Pediatrics; January 2000

[51] "What is a Urinary Tract Infection (UTI) in Adults?"; Urology Care Foundation; Article Updated: April 2019

[52] Soledad Delis et al; "Balanitis xerotica obliterans in children and adolescents: a literature review and clinical series"; 2014. NOTE: The abstract rates the incidence of LS/BXO as "35% among circumcised children," but it should say "35% among uncircumcised boys with phimosis," - as confirmed via an email from one of the authors.

[53] A.M.K. Rickwood; "Medical indications for circumcision"; BJU International; 1999

[54] Brian J. Morris et al; "A 'snip' in time: what is the best age to circumcise?"; BMC Pediatrics; February 2012

[55] Ida Sneppen and Jørgen Thorup; "Foreskin Morbidity in Uncircumcised Males"; Pediatrics; May 2016

[56] Ibrahim Atilla Aridoğan et al; "Superficial fungal infections of the male genitalia: a review"; Critical Reviews in Microbiology; 2011

[57] J. Ben Chaim; "Complications of circumcision in Israel: a one year multicenter survey"; Israel Medical Association Journal; June 2005

[58] Eileen F. Dunne et al; "Prevalence of HPV infection among men: A systematic review of the literature"; Journal of Infectious Diseases; October 15, 2006

[59] Daniel C. Beachler et al; "Natural Acquired Immunity Against Subsequent Genital Human Papillomavirus Infection: A Systematic Review and Meta-analysis"; Journal of Disinfectious Diseases; December 21, 2015

[60] F Xavier Bosch et al; "Male circumcision, human papillomavirus and cervical cancer: from evidence to intervention"; Journal of Family Planning and Reproductive Health Care; January 2009 [61] Natasha Larke et al; "Male Circumcision and Human Papillomavirus Infection in Men: A Systematic Review and MetaAnalysis"; Journal of Infectious Diseases; November 2011

[62] Ginesa Albero, MPH et al; "Male Circumcision and Genital Human Papillomavirus: A Systematic Review and Meta-Analysis"; Sexually Transmitted Diseases; November 2012

[63] Brian J. Morris et al; "Early infant male circumcision: Systematic review, risk-benefit analysis, and progress in policy"; World Journal of Clinical Pediatrics; February 8, 2017

[64] King K. Holmes et al; "Effectiveness of condoms in preventing sexually transmitted infections"; Bulletin of the World Health Organization; June 2004

[65] "Male Circumcision Reduces Sexually Transmitted Infections/Diseases (STIs/STDs)"; Circumcision Facts and Science; July 30, 2019

[66] Vandna Jerath MD, Vikram K Mahajan MD; "Does circumcision influence recurrences in herpes genitalis?"; Indian Journal of Dermatology, Venereology and Leprology; November-December 2009

[67] "Male Circumcision Reduces Penile Structural ProblemsXII. Conclusion & Executive Summary"; Circumcision Facts and Science; May 21, 2019

[68] Natasha L. Larke et al; "Male circumcision and penile cancer: a systematic review and meta-analysis"; Cancer Causes Control; August 22, 2011 [69] Janet R Daling et al; "Penile cancer: Importance of circumcision, human papillomavirus and smoking in in situ and invasive disease"; International Journal of Cancer; April 11, 2005 [70] Larissa A.Afonso et al; "High Risk Human Papillomavirus Infection of the Foreskin in Asymptomatic Men and Patients with Phimosis":; Journal of Urology, June 1, 2016

[71] Yu-Dan Li et al; "The Association of Circumcision and Prostate Cancer: A Meta-Analysis"; Asian Pacific Journal of Cancer Prevention; 2016

[72] Eran Elkhaid; "Neonatal circumcision and prematurity are associated with sudden infant death syndrome (SIDS)"; Journal of Clinical and Translational Research; January 9, 2019

[73] Andrew Gross; "Does circumcision cause SIDS? A point-by-point response to Eran Elhaik’s study"; Circumcision Choice; August 30, 2018

[74] Jake Waskett; "Fatally flawed: Bollinger's circumcision death calculations"; Circumcision News; May 8, 2010

[75] Stephen Moreton PhD; "A fallacy for every occasion"; Circ Facts; January 2017

[76] Brian J Morris et al; "A critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries"; AIDS Care; March 28, 2012

[77] "Intactivist Lie of the Week: Circumcision Harms Breastfeeding"; Circumcision Facts and Science; November 15, 2016

[78] Herman Nunberg; "Circumcision and the problems of bisexuality"; Revista de Psicoanal; Jan-Mar 1952

[79] Orhan M Ozturk; "Ritual circumcision and castration anxiety: Psychiatry; February 1973

[80] F Şahin et al; "Attitudes and practices regarding circumcision in Turkey"; Child Care Health and Development; July 2003

[81] Yasin Aydogmus MD et al; "Psychological and sexual effects of circumcision in adult males"; May 2016

[82] Jennifer Bossio et al; "Examining Sexual Correlates of Newborn Circumcision in Adult Men"; Queens University; September 2015

[83] Andrew Gross; "Does circumcision cause psychological damage?" Circumcision Choice; February 7, 2019

[84] Morten Frisch, Jacob Simenson; "Cultural background, non-therapeutic circumcision and the risk of meatal stenosis and other urethral stricture disease: Two nationwide register-based cohort studies in Denmark 1977–2013"; The Surgeon; April 2018

[85] Robert S. Van Howe MD; "Incidence of Meatal Stenosis following Neonatal Circumcision in a Primary Setting"; Clinical Pediatrics; January-February 2006

[86] See also Brian Morris; "Does Circumcision Increase Meatal Stenosis Risk? – a Systematic Review and Meta-Analysis"; Urology; August 2017

[87] "Conclusions and Executive Summary"; Circumcision Facts and Science; May 16, 2017

[88] Morten Frisch et al; "Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision"; Pediatrics; April 2013

[89] B.J. Morris et al; "The 2010 Royal Australasian College of Physicians' policy statement ‘Circumcision of infant males’ is not evidence based"; Internal Medicine Journal; July 18, 2012

[90] "Position Statement: "Newborn male circumcision"; Canadian Paediatric Society;

[91] "Circumcision of Infant Males"; Royal Australasian College of Physicians; September 2010

[92] Susan Blank et al; "Circumcision Policy Statement: Task Force on Circumcision" Pediatrics; September 2012

[93] Andrew L. Freedman; "The Circumcision Debate: Beyond Benefits and Risks"; Pediatrics; May 2016

[94] See also "Intact America Part 2: They're unreliable because they lie"; Circumcision Choice; October 8, 2018

[95] "Non-therapeutic circumcision of male minors"; Royal Dutch Medical Association (KNMG); May 27, 2010

[96] Mikaela Conley; "Proposed Circumcision Ban Struck From San Francisco Ballot"; ABC News; July 28, 2011

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