Tuesday, February 17, 2015
Professor Robert van Howe was requested, in his capacity as a pediatrician with an expertise in male circumcision, to peer-review the US Centers for Disease Control and Prevention's (CDC) draft recommendations following their 'Consultation on Public Health Issues Regarding Male Circumcision in the United States for the Prevention of HIV Infection and Other Health Consequences'. The full peer-review is available on the Academia.edu site, with some comments and a brief extract on the Circumcision Information website.
One might think, from the constant bombardment of articles in praise of circumcision, that there was a fair body of thought in favor, and a comparable body of thought against the practice. However, the majority of countries in the world do not practice routine male circumcision for 'medical' purposes, and only a minority do so for religious and/or cultural reasons. Enthusiasm for the operation for 'medical' reasons emanates almost entirely from the US.
Van Howe's critique is not technically difficult, and many of the arguments against male circumcision would be widely accepted, perhaps even by those who have little familiarity with the subject. But the list of criticizms of the CDC's draft runs to over 100 pages, with the bibliography of literature supporting the case against the operation running into another 100 pages.
The CDC draft is found to lack scientific and scholarly rigor, neglecting important and relevant findings, but using reviews and other lower quality material instead. Research was carried out carelessly and reported badly. Grasp of basic epidemiology among those who wrote the draft is also low. Van Howe suggests that these apparent flaws may have been part of a deliberate attempt to bias the subsequent recommendations.
In addition to highly selective analysis of medical evidence, ignoring any that might not support what seem like CDC's prior belief in the virtues of male circumcision, the authors continue a long tradition among proponents of the operation of failing to discuss any kind of causal mechanism by which it might 'prevent' HIV or various sexually transmitted infections (STI).
While US professional medical associations resolutely stand by their long held regard for circumcision, equivalent associations elsewhere continue to express their opposition to it. The CDC's draft neglects to mention any of this substantial opposition by experts. Yet the intention of the CDC's recommendations are that they will form the basis of advice and information to be given by medical professionals to members of the public about the operation.
Van Howe's recommendation is that this draft be scrapped and the process be started again, from scratch. He also advises that they " review the entire medical literature, thoroughly scrutinize the studies in the literature, and properly apply basic epidemiological principles. When they have done so, they need to consult with experts from around the world to make sure their findings are not culturally biased. They also need to focus on the United States, not Africa."
But what's this about Africa? Van Howe finds that much of the 'evidence' for the claimed benefits of circumcision in 'reducing' transmission of HIV and other STIs comes from studies carried out in African countries, despite being used to support their arguments that it should be routine in the US. These often-cited studies carried out in Africa are themselves highly questionable, were carried out by people who were already convinced that circumcision 'reduced' HIV transmission, and have spent many years (and many millions of research dollars) trying to push their agenda in African countries (with varying levels of success).
The US is by no means the lowest HIV prevalence country in the world. In fact, it has the highest prevalence among wealthy countries, despite spending a lot more per head on health than some others. The largest HIV positive population in the western world can be found in the US, even though there are probably more men there who were circumcised for 'medical' reasons than in any other country.
Van Howe's article may come closer to listing every major argument against male circumcision as a 'medical' intervention against HIV and STIs than any other; it certainly provides counter-arguments against the sort that the CDC draft seems to be filled, flimsy, half baked maunderings and puerile innuendo, apparently the best that many years of study by a whole team of researchers can muster. Even if you can't read the entire peer-review it will be a good source of information, with a very comprehensive bibliography.
The CDC must be a very powerful part of American democracy if they can spend so much effort and money lying to the public about male circumcision. The operation has been entirely discredited as an intervention for reducing HIV and STI transmission, even in African countries that have far more serious HIV epidemics than the one in the US. But it's difficult to imagine why this lie is supported by so many US professionals, academics, institutions and money.
Posted by Simon at 3:44 PM