Recently, circumcision has resurfaced as a hot topic in the media. All last week, numerous articles with misleading titles were published by big name media outlets, promoting the latest “study,” which supposedly “confirms” the so-called “benefits” of circumcision.
Here are some of the titles:
“Infant circumcision is the healthiest choice, new study claims“
“Researcher says circumcision should be offered like childhood shots“
“Circumcision should be offered ‘like vaccines’ to parents of boys“
“Study determines circumcision comparable to vaccination” (Israel and Stuff)
“Call for circumcision gets a boost from experts“
“Circumcision rates declining in US infants, raising health risks later in life“
“Circumcision should be seen ‘in same light as childhood vaccination’: study“
“Circumcision benefits far outweigh the risks, finds study IN MAYO CLINIC PROCEEDINGS“ (elsevier connect)
“MAYO ON MILAH – Mayo clinic study confirms health benefits on circumcision” (The Jewish Press)
“New Journal argues circumcision should be mandatory“
“The benefits of circumcision outweigh the risks 100 to 1“
“To snip or not to snip – academic claims circumcision should be treated like vaccination“
But, is it true? Did the Mayo Clinic perform a new study on circumcision? And, was the study published legitimate?
To the casual observer, these headlines appear to say all they need to know. When they approach a conversation about circumcision, they will remember one of these headlines and quote it or paraphrase it without any real knowledge of what it means or what really happened. And this is exactly what some sectors want.
Now, let’s go step by step:
First off, the Mayo Clinic did not perform a study on circumcision.
The study being discussed is not new, original research, but a literature review of select articles.
The article was not written by unbiased researchers. The three authors have been known to promote circumcision for many years.
To call this article a “Mayo Clinic study” is misleading and manipulative. Independent authors submitted the article to the journal of Mayo Clinic, Mayo Clinic Proceedings. The Editorial Board procured peer reviewers, who then approved the article for publication. This is very different from having actual staff researchers or commissioned experts performing a study at the Clinic’s request. The article was not written at Mayo Clinic’s request or by Mayo Clinic personnel.
Related: Problems with Peer Review
Related: Is peer review broken?
This article (or literature review) was written by Australian retired professor and molecular biologist Brian Morris, and co-authored by Dr. Thomas Wiswell and psychologist Stefan A. Bailis, both of whom had already co-written other publications promoting infant circumcision with Brian Morris.
Some articles referred to Brian Morris as Dr. Morris. While the fact that Brian Morris has a PhD makes this reference technically correct, it is misleading because it makes it sound like he is a qualified medical physician, when he does not hold a medical degree of any kind. Brian Morris is not a physician or a medical doctor in any way, and the public should know that. He is a professor of molecular science, and does not hold a degree in urology, surgery, pediatrics or epidemiology.
In their last Policy Statement on circumcision (2012), the American Academy of Pediatrics tries desperately to push the soundbite that “The benefits of circumcision outweigh the risks.” Be that as it may, the AAP stops short of the recommendation that circumcision advocates like Brian Morris were hoping for. In this new review, Brian Morris takes a position far more extrem, going as far as comparing circumcision with vaccines; yet, the implied goal of both papers is to get Medicaid and insurance companies to re-establish coverage for neonatal circumcisions in those U.S. states where they no longer cover it.
This review makes claims that are manipulative and hard to prove, for example that the “benefits exceed risks by at least 100 to 1” and that “over their lifetime, half of uncircumcised males will require treatment for a medical condition associated with retention of the foreskin”.
Because awareness that circumcision of minors violates human rights has been moving from the “anti-circumcision lobby groups” (as Brian Morris refers to pro-genital integrity organizations on his website) to mainstream organizations such as the Royal Dutch Medical Association, the Parliamentary Assembly of Council of Europe, the International NGO Council on Violence against Children and many others, professor Morris now is trying to manipulate the language to suggest that “not circumcising a baby boy may be unethical because it diminishes his right to good health“, again a claim hard to substantiate.
Morris’ desired conclusion is that “as with vaccination, circumcision of newborn boys should be part of public health policies” particularly on “population subgroups with lower circumcision prevalence“.
Unsurprisingly, the same authors, in cahoots with some of the promoters of circumcision in Africa, presented a paper called “a snip in time” two years ago, arguing that infancy is the best time to circumcise and that “by making MC (male circumcision) normative in a community, [...] the prospect of [psychological problems] would be largely eliminated“.
As usual, in this new article Morris references his own previous publications numerous times. Out of 80 references, he is author or co-author of at least 12 of them. On the contrary, the American Academy of Pediatrics in their 2012 Policy Statement did not quote a single publication by Brian Morris.
So this is the problem:
In the eyes of the casual observer (and reporter), the fact that this article is being published by Mayo Clinic Proceedings (a publication of the Mayo Clinic) is almost equivalent to saying that the Mayo Clinic performed an original study and/or agrees with it. While this is certainly not true, it is an easy assumption for people to make or believe.
Media headlines are used to manipulate the general opinion by using the more dramatic claims from the abstract to embed them in the collective consciousness. Most people will not read past the headlines, and will reach their conclusions based on this limited information.
Few reporters and authors dare to criticize peer reviewed publications. In this case, one notable exception is Wellington Professor, Dr. Kevin Pringle, who perfectly summarized: “Vaccination is a low-risk intervention to prevent a problem with significant adverse outcomes. Circumcision is an intervention with significant risks (ignored or minimised by the authors of this paper) to prevent problems that will not develop in the vast majority of males; most of which can be simply addressed if and when the need arises.”
For those wishing to seriously challenge Brian Morris’ new article, the following is a response from the Editor-in chief of the Mayo Clinic Proceedings journal:
April 4, 2014 at 2:46 am
The article, “Circumcision Rates in the United States: Rising or Falling? What Effect Might the New Affirmative Pediatric Policy Statement Have?” was authored by 3 experts in the subject matter. All 3 have previously authored numerous scientific articles on this topic, and their combined credentials are far more than adequate to allow them to authoritatively address the topic.
Once submitted to Mayo Clinic Proceedings, the aforementioned manuscript was rigorously peer reviewed by other experts in the field, revised, and later accepted for publication. The Journal’s Editorial Board oversaw this process. All of these are typical processes for the review and acceptance of a manuscript. As a result of these processes, the approved manuscript was deemed to provide solid scientific information and appropriate speculative synthesis on the subject matter.
Formal comments regarding this article and other materials published in Mayo Clinic Proceedings should be directed to the journal, in the form of a Letter to the Editor. That communication should be submitted through the journal’s manuscript management portal, http://mc.manuscriptcentral.com/mayoclinproc . There, those wishing to comment will find instructions on the allowable content and other guidelines for formulating a Letter to the Editor. The comments within the Letters must be restricted to the scientific matter under investigation, and will be evaluated by a peer-review process to determine their educational and clinical value to the general/internal medicine readership of the Proceedings. In general, only 15% to 20% of all submissions to the journal are eventually accepted for publication. Ad hominem attacks on the authors, the Journal, or its sponsoring institution, Mayo Clinic, will not be permitted in any published Letters. Further, any letters eventually accepted for publication will be accompanied by a published response from the authors.
William L. Lanier, MD
Mayo Clinic Proceedings
5 thoughts on “Did a Mayo clinic study confirm health benefits on circumcision? Or Brian Morris, and how to manipulate public opinion on circumcision using clever headlines”
This links to the Morris et al article.
I had never heard of the Mayo Clinic Proceedings until this brouhaha, but fossicking about its website convinced me that it is a serious medical journal. This article has many of the trappings of dead earnest medical science, so much so that I and the vast majority of social media intactivists are not qualified to read this article carefully and take it apart in print.
The first 4 pages of this article consist of a reworking of the American data on the RIC rate, and on the prevalence of circumcision in men between the ages of 14 and 59. This reworking is a grim high in technique and low in common sense. The prevalence data is based on (stratified?) random sample of about 6200 men. Circumcision status is when the men say it is. Historically, self-assessment of circ status by American men has been horribly error prone. In my view, there is no substitute for a clinical examination. Morris et al claim that the hospital discharge survey data seriously understate the RIC rate, and then make some assumptions, then “correct” the data. In Table 2, Morris et al claim that 40-50% of American RICs go unrecorded in the NHDS. I find that implausibly high. It will take time and effort for someone to figure out just what it is that Morris et al are doing that is dodgy. A curious contribution to this line of thinking is a short 2007 article by Jake Waskett, that sagacious paragon of medical statistics.
Morris et al say that circumcision prevalence decline from 83% in 2000 to 77% in 2010. They assert, but do not argue, that this can be entirely explained by a high Latino birthrate, and a low RIC rate among Latino families. For example, Morris et al do not show a graph of the overall American birth rate, and of the fraction of American births that are Latino.
To us intactivists, the adult incidence of circumcision is not very interesting.
It interests Morris et al, because in their thinking, the lower the incidence, the greater the risk of STDs and the lower the “benefits” of circumcision. We intactivists see the incidence rate as driven by choices made last century, in ignorance of the adverse consequences of RIC. Much more interesting to us is the RIC rate, which is very relevant to ongoing intactivist activity.
Table 4 lists all of the studies Morris et al invoked to make their claim that the benefits of RIC outweigh the risks. Notice how they downplay and dismiss the risks, and rate highly most studies claiming benefits. The risks do not include too much skin removed, and sexual difficulties in adult life. Read carefully footnote (c) in this table, which claims that most of these studies were conducted in the USA. How many were conducted using subjects not living in urban slums? This study is silent about the possibility that socioeconomic factors may have a major impact on the claimed benefits of RIC. I invite European professors of medicine to comment on each of the studies cited in Table 4, and to assess whether the measured risks reported in those studies are consistent with their European clinical experience.
The claim that the benefits of RIC exceeds the risks 100 to 1, is made at the top of page 6. Morris does not explain how all the studies in Table 4 were aggregated so as to make this claim. Had I been the reviewer, I would have made them remove this claim.
The section of the paper just before the Conclusion includes an extensive discussion of Morris’s view of how RIC poses no problem for medical ethics, simply because he asserts that RIC is beneficial for the child. He also cites Morris and Krieger (2013) as “proving” that RIC has no adverse effects on adult sexuality. Morris has asserted this over and over of late. An expert on human sexuality and biomedical statistics needs to publish a thorough critique of Morris & Krieger. For starters, Morris & Krieger have a simplistic and reductionist view of the subtleties and complexities of human sexuality.
Morris et al want Medicaid funding of RIC restored, so that underclass mothers are not out of pocket for the circumcisions of their newborn sons. Morris et al concede, as did the AAP in 2012, that parents have the final say, and may make their decision using criteria other than those of narrow medical science. This is a backhanded acknowledgement of intactivism. We are called “anti science” and “not evidence based,” but are allowed to have our way.
It is not evident to me that Morris et al carefully distinguish RIC incidence at birth, from circumcision prevalence among 14-59s. They claim, however, that the invidence data understate incidence by 40-50%. This claim is based on algebra justified in a technical appendix that is not part of their published paper.
The Mayo Clinic, as a corporate entity, does not take a position re the merits of any article published in the Proceedings. The Mayo Clinic has to do this in order to avoid being sued in case people are hurt or die because of a procedure advocated in a Proceedings article.
Brian Morris is the corresponding author, and hence is the person ultimately responsible for writing this paper and defending its claims.
Thank you Roger for your thoughtful and detailed analysis.
“qualified to read this article carefully and take it apart in print.”
May I dare say, there is no need to read it.
1832 Dr. Claude François Lallemand: nocturnal seminal emissions.
1845 Dr. Edward H. Dixon: masturbation.
1855 Dr. Johnathon Hutchinson: syphilis.
1865 Dr. Nathaniel Heckford: epilepsy.
1870 Dr. Lewis A. Sayre: epilepsy, spinal paralysis.
1871 Dr. M.J. Moses: masturbation.
1873 Dr. Joseph Bell: bed wetting.
1875 Dr. Lewis A. Sayre: curvature of the spine, paralysis of the bladder, clubfoot.
1879 Dr. H.H. Kane: nocturnal emissions and abdominal neuralgia.
1881 Dr. Maximillian Landesburg: eye problems; masturbation.
1886 Dr. William G. Eggleston: crossed eyes.
1888 Dr. John Harvey Kellogg: masturbation.
1890 Dr. William D. Gentry: blindness, deafness and dumbness.
1891 Dr. Johnathan Hutchinson: masturbation.
1894 Dr. P.C. Remondino: blacks raping whites.
1894 Dr. H.L. Rosenberry: urinary and rectal incontinence.
1895 Dr. Charles E. Fisher: nerve tension, derangement of the digestive organs, restlessness, irritability, chorea, convulsions, paralysis.
1900 Dr. Johnathan Hutchinson: the pleasure of sex; sexual immorality.
1901 Dr. Ernest G. Mark: masturbation.
1902 Dr. Roswell Park: epilepsy.
1912 Lydston G. Frank: sexual irritability, evil sexual habits such as masturbation.
1914 Abraham L. Wolbarst: nervous phenomena, convulsions and epilepsy, masturbation, nocturnal pollutions. “It is therefore not at all improbable that in many infants who die in convulsions the real cause of death is a long or tight prepuce.”
1914 Dr. Abraham L. Wolbarst: tuberculosis.
1915 L. W. Wuesthoff: passion, rape, separation and divorce, unhappy marriage.
1915 Dr. Benjamin E. Dawson: “many neuroses” (female circumcision).
1918 Dr. Belle Eskridge: masturbation (female circumciqsion).
1920 I. Solomons: hernia.
1926 Dr. Abraham L. Wolbarst: penile cancer.
1930 Dr. Norton Henry Bare: epilepsy.
1935 Dr. R.W. Cockshut: sex.
1941 Alan F. Guttmacher: Masturbation
1941 Dr. Allan F. Guttmacher: “male sexual sensitivity”
1942 Dr. Abraham Ravich: prostate cancer.
1949 Dr. Eugene H. Hand: venereal disease, cancer of the tongue.
1951 Dr. Abraham Ravich: cervical cancer.
1953 Dr. R.L. Miller and Dr. D.C. Snyder: masturbation; “immunity to nearly all physical and mental illness.”
1954 Dr. Ernest L. Wydner: cervical cancer.
1958 Dr. C.F. McDonald: “the same reasons that apply for the circumcision of males are generally valid when considered for the female.”
1959 Dr. W.G. Rathmann; among the many benefits of female circumcision is that it will make the clitoris easier for the husband to find.
1969 Dr. Morris Fishbein: nervousness, masturbation.
1971 Dr. Abraham Ravich: bladder cancer, rectum cancer.
1985 Dr. Thomas E. Wiswell: urinary tract infections.
1986 Dr. Aaron J. Fink:s AIDS.
1988 Dr. Aaron J. Fink: neonatal group B streptococcal disease.
1991 Dr. Aaron J. Fink: sand.
2005 Dr. R.Y. Stallings finds that HIV rates are significantly lower in circumcised women.
2007 Dr. R.C. Bailey ends his study early with the conclusion touting circumcision as a ‘vaccine’ that prevents HIV infection.
Circumcision is the answer for whatever people are afraid of, and gullible enough to believe. Foreskin is not a birth defect. Most people, when given a choice, do not cut off healthy body-parts, sans-anesthesia.
I will now comment on the Abstract to the recent article by Morris et al (2014) in the Mayo Clinic Proceedings. I am very curious as to who refereed this.
“The objective of this review was to assess the trend in the US male circumcision rate and the impact that the affirmative 2012 American Academy of Pediatrics policy statement might have on neonatal circumcision practice.”
ME. That statement is more ‘affirmative’ in Morris’s opinion than it is in fact.
“We searched PubMed for the term circumcision to retrieve relevant articles.”
ME. This proves that what Morris et al wrote was not a “study” or original “research”, but a literature review.
“This review was prompted by a recent report by the Centers for Disease Control and Prevention that found a slight increase, from 79% to 81%, in the prevalence of circumcision in males aged 14 to 59 years during the past decade.”
ME. How would the CDC know this, without ordering a large random sample of men to down trousers? Given that men 60 and over are excluded from this statistic, I am downright skeptical of this rise.
“There were racial and ethnic disparities, with prevalence rising to 91% in white, 76% in black, and 44% in Hispanic males.”
ME. I strongly doubt that the 91% figure for whites, given the large immigration into the USA in recent decades, and given the fact that boys born in the 1990s were counted.
“Because data on neonatal circumcision are equivocal, we undertook a critical analysis of hospital discharge data.”
ME. What does “equivocal” mean in this context?
Did Morris et al conduct a critical analysis of their incidence data just discussed above?
“After correction for underreporting, we found that the percentage had declined from 83% in the 1960s to 77% by 2010.”
ME. Or does their “correction” result in an overstatement?? To my eye, It looks like Morris et al are inferring that 21% of boys born in 2010 were circumcised in doctors’ offices as outpatients. It is a hard fact that nobody, including HHS, counts circumcisions not done in maternity wards.
“A risk-benefit analysis of conditions that neonatal circumcision protects against revealed that benefits exceed risks by at least 100 to 1″
ME. The long run risks for adult sexual pleasure and function are unknown. Unknown risks cannot be compared to benefits, real or alleged. I am confident that what Morris has done, or is citing, is a “risk-benefit analysis” in name only. This is the first time I have encountered the term, BTW. The conventional term is “cost-benefit analysis”.
“…and that over their lifetime, half of uncircumcised males will require treatment for a medical condition associated with retention of the foreskin.”
ME. Over a lifetime, everyone will come down with several dozen common colds. Is this a reason to cut off the nose? Just how serious are these foreskin caused conditions? Does what Morris write here resonate with American urologists? With European and Japanese ones?
“Other analyses show that neonatal male circumcision is cost-effective for disease prevention.”
ME. Tobian (2012) is incompetent. And how many of these cost benefit analyses are based on data and findings from the North Atlantic, as opposed to East Africa?
“The benefits of circumcision begin in the neonatal period by protection against infections that can damage the pediatric kidney.”
ME. Then millions of women must be suffering from kidneys damaged by the UTIs their genitalia condemned them to suffer while they were infants and toddlers.
“Given the substantial risk of adverse conditions and disease, some argue that failure to circumcise a baby boy may be unethical because it diminishes his right to good health.”
ME. What is unethical is Morris’s refusal to engage with pediatric and urological evidence from First World countries other than the USA, and to refuse to entertain the possibility that circumcision can detract from sex.
The UK and New Zealand gave up RIC during the second half of last century. Time series data from those countries would be revealing, if in fact the foreskin is unhealthy. Ditto for Australia and Canada, where RIC rates have declined by a lot. Finally, people should not have good health forced on them by authoritarian parenting or medical practice. Medical care should require informed consent, especially when the proposed treatment can adversely affect adult sexual pleasure and function.
“There is no long-term adverse effect of neonatal circumcision on sexual function or pleasure.”
ME. Wrong. Pleasure cannot be measured. There are no studies of the correlation between RIC and adult sexual dysfunction. One cannot find what one cannot or will not look for.
“The affirmative 2012 American Academy of Pediatrics policy supports parental education about, access to, and insurance and Medicaid coverage for elective infant circumcision.”
ME. It’s all about access to private insurance and the public purse, is it not?
“As with vaccination, circumcision of newborn boys should be part of public health policies.”
ME. I do not agree that vaccination should be compulsory. If RIC were a sound public health measure, a comparison of data from the 3 western nations that circumcise (Korea, Israel and USA) with the other western nations would be very revealing. That comparison has yet to be carried out. It is a fact that STDs are less common in Japan and Europe than in the USA.
“Campaigns should prioritize population subgroups with lower circumcision prevalence and a higher burden of diseases that can be ameliorated by circumcision.”
ME. In other words, hospital staff should twist the arms of underclass mothers, with the resulting RICs paid for by Medicaid. I am confident that very privately, Morris, Wiswell et al concede that RIC is a lost cause among the educated middle class, because of evolving parenting and sexual mores. For nobody believes that white middle class penises are penises that are very much at risk.