title: Does Male Circumcision Protect against Sexually Transmitted Infections? Arguments and Meta-Analyses to the Contrary Fail to Withstand Scrutiny.
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.
authors.affiliation: School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Morris
authors.affiliation: Department of Global Health, Academic Medical Centre and Amsterdam Institute for Global Health and Development, University of Amsterdam, 1100DE, Amsterdam, The Netherlands ; Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.
authors.forename: Catherine A
authors.initials: CA
authors.lastname: Hankins
authors.affiliation: Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA.
authors.forename: Aaron A R
authors.initials: AA
authors.lastname: Tobian
authors.affiliation: Section of Urology University of Washington School of Medicine and VA Puget Sound Health Care System, Seattle, WA 98108, USA.
authors.forename: John N
authors.initials: JN
authors.lastname: Krieger
authors.affiliation: Division of Infectious Diseases and Program in Global Health, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA 90095, USA.
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Klausner