Because the United States circumcises a majority of its male infants, circumcision is an American cultural value and is accepted as “normal.” (Cultural bias on this issue may be more obvious when considering the practice of female circumcision in Africa. Americans regard that practice the way Europeans, who do not cut genitals of male or females, regard American circumcision—with horror.) American circumcision advocates who are dissatisfied with the position of circumcision policy makers claim “anticircumcision bias,” but they support their claim only with their judgment that “substantial medical evidence” favors their view.¹ It is significant that circumcision advocates have never offered any rationale or research to explain why someone would have an “anticircumcision bias” and why, for example, some circumcised men, Jews, and doctors who performed routine circumcisions (and stopped) would adopt a position opposing circumcision that is not evidence-based.

Unlike “anticircumcision bias,” the bias in favor of circumcision has credible psychosocial explanations. These explanations include the following:

1. Ignoring evidence of harm and using medical claims to defend circumcision when that evidence is at best conflicting may be an unconscious way for some male physicians to avoid the emotional discomfort of questioning their own circumcision. A survey of randomly selected primary care physicians showed that circumcision was more often supported by doctors who were older, male, and circumcised.²

2. The possible use of psychological defense mechanisms by physicians to deny some of the evidence may also serve, in part, to protect their self-esteem, which could be adversely affected by the conscious recognition that circumcision may harm infants. Because protecting self-esteem sometimes takes priority over being accurate or correct, potentially threatening information may be reinterpreted or dismissed, sometimes unconsciously.^3,4

3. Other research has demonstrated that people will continue an endeavor once they have invested time and effort.⁵ Some circumcising doctors may be protecting their self-esteem in connection with hundreds or thousands of circumcisions they have performed throughout decades of practice.

A pro-circumcision bias may influence what questions are researched and what questions are ignored in American medical circumcision literature. Most American studies that assess the advisability of circumcision focus on the search for a presumed benefit. This is consistent with an American Academy of Pediatrics (AAP) Circumcision Policy Statement Task Force member’s statement that the committee was formed “to determine if there was scientific evidence to justify circumcision.”⁶ The answer is limited by the assumption in the statement of the problem. American circumcision studies invariably find a benefit, from treating epilepsy and mental disorders in the late 1800s to preventing sexually transmitted diseases today.⁷ Though such claims generally do not withstand scrutiny by policy committees, their continued publication over the years can lead to medical myths while raising questions about some researchers’ motives.

Not only is the issue of harm generally avoided as a research question, the studies seeking to claim benefits ignore even the mention of potential harm from a perfectly performed circumcision. This omission reflects the common American belief that the foreskin has no value.⁸

Findings that conflict with the current paradigm are difficult to get published because they are judged to be unacceptable.⁹ (Publication outside of the U.S. is more likely.) Authorities that do peer review are dependent on maintaining the existing belief system.^10,11 For example, studies on circumcision and urinary tract infection with better methodology and results that conflicted with those previously published in Pediatrics were rejected, though the previously published studies were flawed.¹² One researcher had a submission rejected on the cost-utility of circumcision. The reviewer for JAMA “denied the existence of 23 studies that I used . . . in spite of the fact that all of these studies were referenced in my paper.”¹² There are numerous other examples of bias in medical publishing associated with circumcision and the presence of anger and hostility in the reviews of submissions on circumcision.^12,13 (Reviewers do not have to identify themselves to authors, a questionable practice.¹⁴) Researcher John Taylor chose to submit his article on the anatomy of the foreskin to a British medical journal instead of an American journal. He judged that the likelihood of acceptance would be better with a British publication because the lack of routine circumcision in England accounts for a different cultural attitude toward it (personal communication, 1996).

Furthermore, medical researchers do not necessarily approach the literature “objectively.” They routinely cite studies that support current medical thinking and, as mentioned previously, ignore studies that conflict with that thinking.¹⁵ In addition, medical doctors prefer reports describing new treatments to those critical of current treatments.¹⁶

The commitment of American medical journal editors to accuracy on circumcision is subject to question. The following letter was sent by this office to Jerald Lucy, M.D., editor of Pediatrics, on May 13, 2003. MEDLINE is the primary database for medical literature. The article in question, cited in the AAP’s latest policy statement on circumcision (1999), was used to support the policy statement’s claim that the rate of circumcision complications is low.

“The following abstract is copied from the MEDLINE online database.

Pediatrics 1976 Dec;58(6):824-7

According to the article, the 0.2% figure is not correct. It represents only “really significant” (p. 827) complications. The correct incidence of complications reported in this article is 2% (p. 825).

I suggest that you submit the correct information to MEDLINE so that this abstract will be consistent with the results of the article. Please let me know your response to this matter and any response you receive from a MEDLINE administrator.

Thanks for your time and consideration.”

No response was received. A followup letter was sent on September 15, 2003. Again no response was received. A third letter was sent to the AAP Executive Director Joe Sanders, Jr., M.D., requesting assistance and a response. No response was received. The error is still uncorrected. Apparently, the AAP does not have a high priority on correcting known errors to their circumcision literature that continue to be repeated in recent literature citations.

The AAP Committee on Bioethics report states, "Pediatric health care providers … have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses… .[T]he pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent." For these reasons, some physicians and nurses refuse to circumcise for ethical reasons. Yet the AAP Circumcision Policy Statement concluded that it is "legitimate" to circumcise if the parent requests it for nonmedical reasons. These two reports of the AAP are in conflict. This office wrote to Kathryn Moseley, M.D., a member of the AAP Committee on Bioethics, on October 7, 2002 and requested comment on this conflict (see text of letter). No response was received.

NOTES

1. Schoen E, Wiswell T, Moses S. New policy on circumcision: Cause for concern. Pediatrics 2000; 105: 620-623.

2. Stein M, Marx M, Taggert S, Bass R. Routine neonatal circumcision: The gap between contemporary policy and practice. Journal of Family Practice 1982; 15: 47-53.

3. Raynor J, McFarlin D. Motivation and the self-system. In: Sorrentino R, Higgins E, eds. Handbook of Motivation and Cognition: Foundations of Social Behavior. Guilford, New York, 1986.

4. Steele C, Liu T. Dissonance processes as self-affirmation. Journal of Personality and Social Psychology 1983; 45: 5-19.

5. Arkes H, Blumer C. The psychology of sunk cost. Organizational Behavior and Human Decision Processes 1985; 35: 124.

6. Shoemaker C. Deposition: Flatt v. Kantak 2002. Available from URL http://www.boystoo.com/legal/shoemakerdepo.htm#Craig%20Shoemakers%20Depositions.

7. Gollaher D. Circumcision: A history of the World's Most Controversial Surgery. Basic Books, New York, 2000.

8. Kelalis D, King L, Belman A. Clinical Pediatric Urology. Harcourt Brace Jovanovich, Philadelphia, 1992.

9. Kuhn T. The Structure of Scientific Revolutions, 3rd edn. University of Chicago Press, Chicago, 1996.

10. Horrobin D. The philosophical basis of peer review and the suppression of innovation. Journal of the American Medical Association 1990; 263: 1438-1441.

11. Stehbens W. Basic philosophy and concepts underlying scientific peer review. Medical Hypotheses 1999; 52: 31-36.

12. Van Howe R. Peer-review bias regarding circumcision in American medical publishing. In: Denniston G, Hodges F, Milos M, eds. Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice. Kluwer Academic/Plenum Publishers, New York, 1999; 357-378.

13. Fleiss P. Peer-review bias regarding circumcision in American medical publishing. In: Denniston G, Hodges F, Milos M, eds. Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice. Kluwer Academic/Plenum Publishers, New York, 1999; 379-402.

14. Godlee F. Making reviewers visible: Openness, accountability, and credit. Journal of the American Medical Association 2002; 287: 2762-2765.

15. Kessner D. Diffusion of new medical information. American Journal of Public Health 1981; 71: 367-368.

16. Payer L. Medicine and Culture: Varieties of Treatment in the United States, England, West Germany, and France. Henry Holt and Company, New York, 1988.

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