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Correspondent:

BRITISH MEDICAL JOURNAL


 
June 13, 2000

Sir:

I wish to raise questions in regard to an article by Robert Szabo and Roger V Short entitled 'How does male circumcision protect against HIV infection?' published in the June 10th issue.1

The authors support some of their assertions with selective referencing. For example, when they state that 'circumcision also protects against other sexually transmitted infections, such as syphilis and gonorrhoea', they are ignoring a substantial body of evidence to the contrary. Laumann et al., working at the University of Chicago, concluded on the basis of a nationally representative probability sample that 'circumcision provides no discernible prophylactic benefit and may in fact increase the likelihood of STD contraction'.2

Similarly, the authors have disregarded studies that found circumcision has an appreciable morbidity,3,4,5 and they have taken no account of a study that found a higher prevalence of HIV infection in a circumcised population.6

The result is that news media around the world have lent undue credence to questionable claims. The Globe and Mail, for instance, a daily newspaper published in Toronto and distributed across Canada, stated flatly on June 9th not only that circumcision affords protection against AIDS, but also that circumcised men contract sexually transmitted diseases at a 'markedly lower' rate than men who have not been circumcised.7

My questions are as follows:

  1. Is the peer review process not intended to weed out poorly grounded assertions that rely on selective citation?
     
  2. Did the British Medical Journal issue a news release in connection with the article in question? If so, would you be kind enough to send me a copy of it?
     
  3. For over a century, medical journals in the English-speaking world have been publishing grossly inaccurate information about circumcision with a view to promoting the practice. For example, a physician writing in the Journal of the American Medical Association in 1910 told readers that 'many women need circumcision'.8 In light of this appalling record, and in view of the immense social significance attached to male and female circumcision, is the British Medical Journal exercising due care to ensure its articles on circumcision rest on a solid scientific and ethical foundation?
     
  4. Does the editorial board of the British Medical Journal consider that removing specialized sexual tissue from the genitals of a healthy girl is a human rights violation?
     
  5. Does the editorial board of the British Medical Journal consider that removing specialized sexual tissue from the genitals of a healthy boy is a human rights violation? If not, please explain why.
The attitude of the medical profession toward circumcision is becoming a matter of increasing public concern. It has also prompted comment from leading ethicists. Some of the ethical problems associated with enlisting circumcision in the fight against AIDS were outlined in an article published on October 24, 1998 in the Gazette, a Montreal daily newspaper. The author was Dr Margaret A Somerville, a Fellow of the Royal Society and the founding director of the Centre for Medicine, Ethics and Law at McGill University. I enclose a copy of this article for your information.

I would appreciate a response at your earliest convenience. I look forward to your reply.

References:

 1  BMJ 2000;320:1592-1594.
 2  Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice. JAMA 1997;277:1052-1057.
 3  Kaplan GW. Complications of circumcision. Urol Clin N Amer 1983;10:543-549.
 4  Williams N, Kapila L. Complications of circumcision. Br J Surg 1993;80:1231-1236.
 5  Griffiths DM, Atwell JD,Freeman NV. A prospective survey of the indications and morbidity of circumcision in children. European Urology 1985;11:184-7.
 6  Grosskurth H et al. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS 1995;9:927-934.
 7  Picard A. Circumcision lowers risk of HIV: study. Globe and Mail, June 9, 2000, p. A2.
 8  Kistler SI. Rapid bloodless circumcision. JAMA 1910;54:1782; cited in Gollaher DL. Circumcision: A History of the World's Most Controversial Surgery (New York: Basic Books, 2000), p. 201, n. 28.

Sincerely,
 
[signed]
 
D ennis H arrison
 
cc: Dr Ian Bogle, Chairman, British Medical Association
 

30 June 2000

Dear Mr H arrison

Thank you for your letter of 13 June raising questions about the article by Szabo and Short in our issue of 10 June.

Firstly may I suggest that since you clearly disagree with the article that you send us a response to our website. I have enclosed instructions on how to do this and all letters posted on our website then become candidates for consideration for printing in the paper BMJ in our correspondence columns.

To answer some of the questions you raised, the article was peer reviewed. It wasn't a systematic review (and didn't claim to be) so it's probably inevitable that it was selective in its use of evidence; it was after all arguing a case. The press release is available on our website (go to 10 June issue and click on press releases at the end of the list of contents). I'm afraid I don't know what the editorial board thinks of circumcision; it's not a question that we've asked them, and it's not a question on which we have an editorial "view". We have however published a fair amount on circumcision, both male and female, and much of it has been very critical of the practice. Again if you go to our website (bmj.com) and perform a search using the word "circumcision" you will find 87 articles that we have published on the issue since 1994.

Yours sincerely,
 
[signed]
 
Jane Smith BA MSc

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