Abstract
We critically evaluate a recent article by Van Howe involving 12 meta-analyses that concludes, contrary to current evidence, that male circumcision increases the risk of various common sexually transmitted infections (STIs). Our detailed scrutiny reveals that these meta-analyses (1) failed to include results of all relevant studies, especially data from randomized controlled trials, (2) introduced bias through use of inappropriate control groups, (3) altered original data, in the case of human papillomavirus (HPV), by questionable adjustments for “sampling bias,” (4) failed to control for confounders through use of crude odds ratios, and (5) used unnecessarily complicated methods without adequate explanation, so impeding replication by others. Interventions that can reduce the prevalence of STIs are important to international health. Of major concern is the global epidemic of oncogenic types of HPV that contribute to the burden of genital cancers. Meta-analyses, when well conducted, can better inform public health policy and medical practice, but when seriously flawed can have detrimental consequences. Our critical evaluation leads us to reject the findings and conclusions of Van Howe on multiple grounds. Our timely analysis thus reaffirms the medical evidence supporting male circumcision as a desirable intervention for STI prevention.
Highlights
Male circumcision has long been considered to have a protective effect against acquisition of various sexually transmitted infections (STIs) [1,2,3,4,5]
Considering the problems outlined above, we suggest that if Van Howe’s 2013 meta-analysis had included all of the important data it might have led to a conclusion other than, “While there is a trend toward higher incidence and prevalence of Herpes simplex virus (HSV) in intact men, the finding is persistently not statistically significant despite a number of adjustments.”
After necessary, detailed scrutiny, we find that Van Howe’s arguments and data attempting to discredit the ability of male circumcision to protect against various STIs lack scientific rigour and lead to conclusions that cannot be justified scientifically
Summary
Male circumcision has long been considered to have a protective effect against acquisition of various sexually transmitted infections (STIs) [1,2,3,4,5] This benefit is one of many that have led to recent affirmative evidence-based policy statements by medical bodies in support of the procedure [6, 7]. The issue of male circumcision for protection against STIs is one of the potential benefits that opponents dispute, sometimes with the support of data Their arguments have been fully enunciated in a recent 42-page article that included a series of 12 meta-analyses [10]. Van Howe, claimed that his analyses show that male circumcision increases STI risk. His marathon study examined STIs other than human immunodeficiency virus (HIV), Trichomonas vaginalis, and Mycoplasma genitalium
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