On 2017 Dec 13, Daniel Mønsted Shabanzadeh commented:

Response to Frisch and Earp’s comments on Systematic Review

Daniel Mønsted Shabanzadeh^1,2,3 Signe Düring⁴ Cai Frimodt-Møller⁵

¹ Digestive Disease Center, Bispebjerg Hospital ² Research Centre for Prevention and Health, Capital Region of Denmark ³ Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen ⁴ Mental Health Services of the Capital Region Region of Denmark ⁵ Department of Urology, CFR Hospitals, Denmark

This response was posted on the Danish Medical Journal's website July 2016: http://ugeskriftet.dk/files/response_to_frisch_and_earp_dmj.pdf

Dear Morten Frisch and Brian Earp

We thank you both for the comments(1) on our systematic review(2).

We respectfully disagree that the conductance of systematic reviews is unjustified. We can only emphasize the importance of identifying all available literature for clarity, before drawing conclusions on a delimited objective, such as, whether the exposure of circumcision has an impact on outcomes of perceived sexual function in adult males. The systematic process was performed according to the PRISMA statement and our conclusion reflected the lack of research in specific domains. We therefore, do not feel the need to justify the methodology any further.

You have problematized that we did not include a Canadian study of sexual partners to circumcised males, however, this was not part of our research objective. To answer the objective of the impact of circumcision on sexual partners perceived sexual function would require yet another systematic review process.

Circumcision is performed on both clinical indications such as penile or prepuce pathology and for nonclinical purposes such as cultural practice or with the aim of HIV-prevention. As we have demonstrated in the paper, many studies fail to distinguish these two populations which is major limitation from a clinical perspective, and one should therefore not draw conclusions about either from such studies. Frisch and Earp suggest that a number of other factors besides this clinical perspective may contribute to the outcome of perceived sexual function in males and we do agree. We have risen the issue of heterogeneity and limitations of the available literature in the discussion.

Our conclusion clearly states the results of the highest quality of available evidence and the lack of high quality studies on consequences of medically indicated circumcision and age at circumcision in order to fully answer our study objectives, and we have specifically stated that a majority of the studies does not take sexual orientation into perspective. We have suggested specific study designs on how to fill the gaps in evidence for future research.

We would like to extend to you both, and all other interested parties, an invitation to collaborate in the future. We can all agree that the field calls for further research, and would be happy to join forces, with contributions from both clinical, epidemiological and physiological angles.

References

(1) Frisch M, Earp B. Problems in the qualitative synthesis paper on sexual outcomes following nonmedical male circumcision by Shabanzadeh et al http://ugeskriftet.dk/files/201607001_commentary_frisch_earp_on_paper_by_shabanzadeh_et_al_dmj_1.pdf

(2) Shabanzadeh DM, During S, Frimodt-Moller C. Male circumcision does not result in inferior perceived male sexual function - a systematic review. Danish medical journal. 2016;63(7)

On 2017 Dec 06, Morten Frisch commented:

Problems in the qualitative synthesis paper on sexual outcomes following non-medical male circumcision by Shabanzadeh et al

by Frisch M^1,2 & Earp BD³

¹ Statens Serum Institut, Copenhagen, Denmark ² Aalborg University, Aalborg, Denmark ³ Hastings Center Bioethics Research Institute, USA

The comment below was published on the Danish Medical Journal's (Ugeskrift for Læger's) website on July 1, 2016: http://ugeskriftet.dk/files/2016-07-01_commentary_frisch_earp_on_paper_by_shabanzadeh_et_al_dmj_1.pdf

_____________________________________________________________________________________________________________

Shabanzadeh et al (1) claim in their title that “Male circumcision does not result in inferior perceived male sexual function.” Yet such a categorical conclusion does not follow from the data and analysis presented in the paper itself. As the authors state, there was “considerable clinical heterogeneity in circumcision indications and procedures, study designs, quality and reporting of results” in the studies they reviewed, which precluded an objective, quantitative assessment. Inadequate follow-up periods of only 1-2 years in the prospective studies imply that their results cannot be generalized beyond that range. In addition, “Risks of observer and selective reporting bias were present in the included studies … only half of the studies included validated questionnaires and some studies reported only parts of questionnaires.”

There is also a troubling heteronormativity to the authors’ headline claim. As they state: “Most studies focused on the heterosexual practice of intravaginal intercourse and did not take into account other important heterosexual or homosexual practices that comprise male sexual function.” Such practices include, inter alia, styles of masturbation that involve manipulation of the foreskin itself, as well as “docking” among men who have sex with men (MSM), both of which are rendered impossible by circumcision (2). Related to this, a recent Canadian study, not included in the paper by Shabanzadeh et al, found “a large preference toward intact partners for anal intercourse, fellatio, and manual stimulation of his partner’s genitals,” in a small but demographically diverse sample of MSM (3). Against such a backdrop, the authors’ characterization of their paper as “a systematic review” showing a definitive lack of adverse effects of circumcision on perceived male sexual function is unjustified. As Yavchitz et al argue, putting such a conclusive ‘spin’ on findings that are in truth more mixed or equivocal “could bias readers' interpretation of [the] results” (4). Thus, while the literature search performed by Shabanzadeh et al may well have been carried out in a systematic manner, their ‘qualitative synthesis without metaanalysis’ leaves the distinct impression of a partial (in both senses of the word)assessment.

The authors mention that the rationale for undertaking their analysis was “the debate on non-medical male circumcision [that has been] gaining momentum during the past few years”. But the public controversy surrounding male circumcision has to do with the performance of surgery on underage boys, specifically, in the absence of medical necessity. By contrast, therapeutic circumcisions that cannot be deferred until an age of individual consent are broadly perceived to be ethically uncontroversial, as are voluntary circumcisions performed for whatever reason on adult men, who are free to make such decisions about their own genitals (5). Consequently, studies dealing with either therapeutic or adult circumcisions are irrelevant to the ongoing controversy and should have been excluded by the authors in light of their own aims; such exclusion would have left only a handful of relevant investigations out of the 38 included studies.

As one of us has noted elsewhere: “the [sexual] effects of adult circumcision, whatever they are, cannot be simply mapped on to neonates” or young children (2). This is because studies assessing sexual outcome variables in adults typically do not account for socially desirable responding (6); they concern men who, by definition, actively desire to undergo the surgery to achieve a perceived benefit, and are therefore likely to be psychologically motivated to regard the result as an improvement overall; and such studies are typically hampered by limited follow-up (as noted above), rarely if ever extending into older age, when sexual problems begin to increase markedly (7). In infant or early childhood circumcision, by contrast, “the unprotected head of the penis has to rub against clothing (etc.) for over a decade before sexual debut. In this latter case … the affected individual has no point of comparison by which to assess his sexual sensation or satisfaction - his foreskin was removed before he could acquire the relevant frame of reference - and thus he will be unable to record any differences” (2).

The sexual consequences of circumcision are likely to vary from person to person. All-encompassing statements, such as that forming the title of the paper by Shabanzadeh et al, do not reflect this lived reality. Individual differences in sexual outcome variables will be shaped by numerous factors, such as the unique penile anatomy of each male, the type of circumcision and the timing of the procedure, the motivation behind it, the cultural context, whether it was undertaken voluntarily (or otherwise), the man’s subjective feelings about having been circumcised, his underlying psychological profile, and so on (8, 9). Collapsing across all of these factors to draw general conclusions can only serve to obscure such crucial variance (10).

Therefore, the choice of the authors to include any study looking at sexual outcomes after circumcision, whether in boys or adult males, whether in healthy individuals or in patients with a foreskin problem, whether in Africa or in Western settings, and whether with a follow-up period of decades or only a few months to years is problematic. Such a cacophony of 38 studies, dominated by findings on short-term sexual consequences of voluntary, adult male circumcision has limited relevance, if any, to the authors’ stated research question: how non-therapeutic circumcision in boys affects the sex lives of the adult men they will one day become.

References

(1) Shabanzadeh DM, Düring S, Frimodt-Møller C. Male circumcision does not result in inferior perceived male sexual function – a systematic review. Danish Medical Journal 2016; 63: A5245 (http://www.danmedj.dk/portal/page/portal/danmedj.dk/dmj_forside/PAST_ISSUE/2016/D MJ201607/A5245).

(2) Earp BD. Sex and circumcision. American Journal of Bioethics 2015; 15: 43-5.

(3) Bossio JA, Pukall CF, Bartley K. You either have it or you don't: the impact of male circumcision status on sexual partners. Can J Hum Sex 2015; 24: 104-19.

(4) Yavchitz A, Boutron I, Bafeta A, Marroun I, Charles P, Mantz J, Ravaud P. Misrepresentation of randomized controlled trials in press releases and news coverage: a cohort study. PLoS Med 2012; 9, e1001308.

(5) Darby R. Targeting patients who cannot object? Re-examining the case for nontherapeutic infant circumcision. SAGE Open 2016; 6: 2158244016649219.

(6) Earp BD. The need to control for socially desirable responding in studies on the sexual effects of male circumcision. PLoS ONE 2015; 10: 1-12.

(7) Earp BD. Infant circumcision and adult penile sensitivity: implications for sexual experience. Trends in Urology & Men’s Health 2016; in press.

(8) Goldman R. The psychological impact of circumcision. BJU International 1999; 83: 93-102.

(9) Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. Journal of Health Psychology 2002; 7: 329-343.

(10) Johnsdotter S. Discourses on sexual pleasure after genital modifications: the fallacy of genital determinism (a response to J. Steven Svoboda). Global Discourse 2013; 3: 256-265.

On 2017 Dec 06, Morten Frisch commented:

Problems in the qualitative synthesis paper on sexual outcomes following non-medical male circumcision by Shabanzadeh et al

by Frisch M^1,2 & Earp BD³

¹ Statens Serum Institut, Copenhagen, Denmark ² Aalborg University, Aalborg, Denmark ³ Hastings Center Bioethics Research Institute, USA

The comment below was published on the Danish Medical Journal's (Ugeskrift for Læger's) website on July 1, 2016: http://ugeskriftet.dk/files/2016-07-01_commentary_frisch_earp_on_paper_by_shabanzadeh_et_al_dmj_1.pdf

_____________________________________________________________________________________________________________

Shabanzadeh et al (1) claim in their title that “Male circumcision does not result in inferior perceived male sexual function.” Yet such a categorical conclusion does not follow from the data and analysis presented in the paper itself. As the authors state, there was “considerable clinical heterogeneity in circumcision indications and procedures, study designs, quality and reporting of results” in the studies they reviewed, which precluded an objective, quantitative assessment. Inadequate follow-up periods of only 1-2 years in the prospective studies imply that their results cannot be generalized beyond that range. In addition, “Risks of observer and selective reporting bias were present in the included studies … only half of the studies included validated questionnaires and some studies reported only parts of questionnaires.”

There is also a troubling heteronormativity to the authors’ headline claim. As they state: “Most studies focused on the heterosexual practice of intravaginal intercourse and did not take into account other important heterosexual or homosexual practices that comprise male sexual function.” Such practices include, inter alia, styles of masturbation that involve manipulation of the foreskin itself, as well as “docking” among men who have sex with men (MSM), both of which are rendered impossible by circumcision (2). Related to this, a recent Canadian study, not included in the paper by Shabanzadeh et al, found “a large preference toward intact partners for anal intercourse, fellatio, and manual stimulation of his partner’s genitals,” in a small but demographically diverse sample of MSM (3). Against such a backdrop, the authors’ characterization of their paper as “a systematic review” showing a definitive lack of adverse effects of circumcision on perceived male sexual function is unjustified. As Yavchitz et al argue, putting such a conclusive ‘spin’ on findings that are in truth more mixed or equivocal “could bias readers' interpretation of [the] results” (4). Thus, while the literature search performed by Shabanzadeh et al may well have been carried out in a systematic manner, their ‘qualitative synthesis without metaanalysis’ leaves the distinct impression of a partial (in both senses of the word)assessment.

The authors mention that the rationale for undertaking their analysis was “the debate on non-medical male circumcision [that has been] gaining momentum during the past few years”. But the public controversy surrounding male circumcision has to do with the performance of surgery on underage boys, specifically, in the absence of medical necessity. By contrast, therapeutic circumcisions that cannot be deferred until an age of individual consent are broadly perceived to be ethically uncontroversial, as are voluntary circumcisions performed for whatever reason on adult men, who are free to make such decisions about their own genitals (5). Consequently, studies dealing with either therapeutic or adult circumcisions are irrelevant to the ongoing controversy and should have been excluded by the authors in light of their own aims; such exclusion would have left only a handful of relevant investigations out of the 38 included studies.

As one of us has noted elsewhere: “the [sexual] effects of adult circumcision, whatever they are, cannot be simply mapped on to neonates” or young children (2). This is because studies assessing sexual outcome variables in adults typically do not account for socially desirable responding (6); they concern men who, by definition, actively desire to undergo the surgery to achieve a perceived benefit, and are therefore likely to be psychologically motivated to regard the result as an improvement overall; and such studies are typically hampered by limited follow-up (as noted above), rarely if ever extending into older age, when sexual problems begin to increase markedly (7). In infant or early childhood circumcision, by contrast, “the unprotected head of the penis has to rub against clothing (etc.) for over a decade before sexual debut. In this latter case … the affected individual has no point of comparison by which to assess his sexual sensation or satisfaction - his foreskin was removed before he could acquire the relevant frame of reference - and thus he will be unable to record any differences” (2).

The sexual consequences of circumcision are likely to vary from person to person. All-encompassing statements, such as that forming the title of the paper by Shabanzadeh et al, do not reflect this lived reality. Individual differences in sexual outcome variables will be shaped by numerous factors, such as the unique penile anatomy of each male, the type of circumcision and the timing of the procedure, the motivation behind it, the cultural context, whether it was undertaken voluntarily (or otherwise), the man’s subjective feelings about having been circumcised, his underlying psychological profile, and so on (8, 9). Collapsing across all of these factors to draw general conclusions can only serve to obscure such crucial variance (10).

Therefore, the choice of the authors to include any study looking at sexual outcomes after circumcision, whether in boys or adult males, whether in healthy individuals or in patients with a foreskin problem, whether in Africa or in Western settings, and whether with a follow-up period of decades or only a few months to years is problematic. Such a cacophony of 38 studies, dominated by findings on short-term sexual consequences of voluntary, adult male circumcision has limited relevance, if any, to the authors’ stated research question: how non-therapeutic circumcision in boys affects the sex lives of the adult men they will one day become.

References

(1) Shabanzadeh DM, Düring S, Frimodt-Møller C. Male circumcision does not result in inferior perceived male sexual function – a systematic review. Danish Medical Journal 2016; 63: A5245 (http://www.danmedj.dk/portal/page/portal/danmedj.dk/dmj_forside/PAST_ISSUE/2016/D MJ201607/A5245).

(2) Earp BD. Sex and circumcision. American Journal of Bioethics 2015; 15: 43-5.

(3) Bossio JA, Pukall CF, Bartley K. You either have it or you don't: the impact of male circumcision status on sexual partners. Can J Hum Sex 2015; 24: 104-19.

(4) Yavchitz A, Boutron I, Bafeta A, Marroun I, Charles P, Mantz J, Ravaud P. Misrepresentation of randomized controlled trials in press releases and news coverage: a cohort study. PLoS Med 2012; 9, e1001308.

(5) Darby R. Targeting patients who cannot object? Re-examining the case for nontherapeutic infant circumcision. SAGE Open 2016; 6: 2158244016649219.

(6) Earp BD. The need to control for socially desirable responding in studies on the sexual effects of male circumcision. PLoS ONE 2015; 10: 1-12.

(7) Earp BD. Infant circumcision and adult penile sensitivity: implications for sexual experience. Trends in Urology & Men’s Health 2016; in press.

(8) Goldman R. The psychological impact of circumcision. BJU International 1999; 83: 93-102.

(9) Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. Journal of Health Psychology 2002; 7: 329-343.

(10) Johnsdotter S. Discourses on sexual pleasure after genital modifications: the fallacy of genital determinism (a response to J. Steven Svoboda). Global Discourse 2013; 3: 256-265.