Professor Brian Morris: relentless pro-circumcision activist

A man on a mission to rid the world of the male foreskin

Since the mid-1990s Brian Morris, at that time a respected professor of molecular biology at the University of Sydney, has been waging a one-man war against the foreskin, and more particularly a relentless campaign in favour of circumcising baby boys. He started with a website, then managed to persuade a university press to publish a little booklet, In Favour of Circumcision (1999), in which he rehashed a mass of largely nineteenth century medical wisdom, as well as informing us that Abraham circumcised himself in order to cure a “foreskin problem” and that uncircumcised men needed three showers a day to keep down the smell. The book did not find favour with health experts, however: reviewing it in Venereology, Professor Basil Donovan described Morris as “a man on a mission to rid the world of the male foreskin”, and some of the claims so misleading that the publishers ought to withdraw the book. It was, he concluded, “a serious disservice to parents”; since Morris was not suggesting that adult men ought to get themselves circumcised as a health precaution, it is obvious that parents were the target audience.

Undeterred, Professor Morris pressed on, hoping to influence the policy of the Royal Australasian College of Physicians, which had been anti-circumcision since the early 1970s. When this effort failed in 2002, 2004 and again 2010, and in response to his public disowning by the RACP,, he set up his own organisation, the Circumcision Academy of Australia, with a small group of like-minded academics and medical practitioners, some of whom derive their income from performing circumcision procedures, and who thus have a vested financial interest in emphasising its benefits. During this period Professor Morris became a prolific contributor to medical journals, trotting out one article after the other on the sins of the RACP and other anti-circumcision activists, and insisting that he and his friends were the only people observing the principles of evidence-based medicine, and thus the true source of medical wisdom. In fact, most of the articles (despite a varying cast of co-authors) were pretty much the same, largely repeating the familiar litany of the benefits of circumcision that he had first set out in his booklet.

Where all this frantic industry has led him can now be seen in a couple of articles that attempt to quantify the benefits of circumcision, and the results have been dramatic.

Foreskin health risk doubles in 2 years

A couple of years ago Brian Morris drew a certain amount of attention to himself with the claim that the benefits of circumcision outweighed the risks by 100 to 1. At the time child health authorities ridiculed the claim as scientifically baseless, exaggerated, implausible, absurd, frankly preposterous and just crazy. His additional suggestion that circumcision was just like vaccination and should be compulsory was described as the dumbest idea ever. Undeterred by these harsh words, our fearless anti-foreskin warrior has now published a further article in which he claims that the benefits of circumcision outweigh the risks by 200 to 1, and that 50 per cent of all uncircumcised men will experience medical problems as a direct result of their regrettable genital anatomy.

This means that the danger to health posed by the foreskin has doubled in only 2 years, and should imply that boys and men all over the world (but especially in Europe, Britain and Australia) should be swarming into hospital emergency departments with crippling foreskin-related diseases. If the risk continues to soar at this rate, it will not be long before uncircumcised men are dropping like flies in the street. The fact that none of this is happening, however, does lend a certain air of unreality to Professor Morris’s alarmism, and perhaps explains the fact that, while his earlier (2014) claim met with ridicule and refutation, his latest anathema against the foreskin has left health authorities dumbfounded and speechless with amazement.

The 100 to 1 claim was made in a respectable journal as an aside to an article that was really a speculation on the possible effects of the American Academy of Pediatrics 2012 circumcision policy on United States circumcision incidence. It is noteworthy that Professor Morris’s 200 to 1 claim appears in the very obscure Chinese-based World Journal of Clinical Pediatrics. Despite its grandiose title, this is a recently established, low-ranking organ that was included in Beale’s list of predatory open access publishers. It had, in fact, already been the target of a speeding ticket from Retraction Watch for dodgy publication practices – in this case, failure to ensure objective peer review. Still, one can’t blame Morris for that: if you are going to make claims as outlandish as those made by him and his coterie at the Circumcision Academy of Australia it is not surprising that you have to scrape the bottom of the barrel.

The war of words

Professor Morris seems to think that the war against the foreskin will be won by the weight of artillery and the number of shells that each side can fire – rather like the donkey generals of the First World War. If he can cite more articles in favour of circumcision than critics can cite articles against, the case for circumcision will be proved. Hence the bloated reference lists at the end of his numerous repetitive articles.

But this is to overlook two vital factors: the quality of the articles and the burden of proof. It is one thing to cite dozens of papers, but if they turn out to be no more than letters to the editor, opinion pieces, viewpoints and literature reviews, and if they are published in obscure or low-ranking journals, they carry far less weight than if they are reports of real studies (i.e. of actual data), meta-analyses and other relevant literature. In the case of Morris’s most recent effort in the World Journal of Clinical Pediatrics, no fewer than 27 of the 160 references are to papers by Morris himself or close associates; at this rate it will not be long before he can prepare a “systematic review” consisting solely of his own work. Papers published in high-ranking journals carry more weight than those published in obscure or low-ranking journals, such as the World Journal of Clinical Pediatrics – a title cited in Beale’s list of predatory open access publishers, and already under criticism for failure to ensure objective peer review. Morris himself has stated that the only papers that need be taken seriously are “good research studies published in reputable journals” [1]. On that basis, there would seem to be no reason to pay any attention to his two most recent articles, neither of which is a “good research study”, and both of which are published in an obscure journal with no reputation at all.

Peer review, or endorsement by mates?

The quality of the peer review process is also an important factor to consider when judging the credibility of any paper or article. In fact, an earlier paper by Morris in the same journal was the target of a complaint to Retraction Watch because the sole peer reviewer was an associate and frequent collaborator with Morris. The editor agreed to retract the paper, and when this did not happen resigned. In the case of his most recent “systematic review”, the sole reviewer has been named as Webster Mavhu and his comments to the author made public; there is not much to them:

COMMENTS TO AUTHORS: This a well-conducted and well-written systematic review of the current scientific evidence of the protection afforded by early infant male circumcision against infections and other adverse medical conditions. I have only a few minor comments: Suggest changing USA to Us throughout. p3 Core tip - insert 'of'. Our systematic review of... p8 Last paragraph, 2nd sentence - '...increased in... (not is). p10 Give a brief explanation of UTI and phimosis (as you do with paraphimosis) p10 References [33-46] and [47] - format different from the rest. pages 11,12 and Table 1, give full form of approx. p16 i.e., 6% - missing a point after e.

Mr Mavhu, a health official from Zimbabwe, turns out to be an ardent believer in the efficacy and acceptability of non-therapeutic circumcision of minors, and is professionally involved in the “roll-out” of the African circumcision programs – hardly the sort of authority to give an objective and impartial assessment of Morris’s arguments.

Burden of proof

There is also the question of where the burden of proof lies. Since the foreskin is normal human anatomy (indeed, common to all mammals, male and female) it is not up to the circumsceptics to prove that circumcision is harmful, but up to the circumcision advocates to prove that it is so dangerous to health that it must be removed from as many boys as possible before it can do too much damage. In an article a few years ago Professor Morris claimed that the benefit/risk ratio was 100 to 1; in his most recent paper the ratio has increased to 200 to 1. According to him, in only a couple of years the danger of the foreskin to health has doubled. This news may come as a surprise to the 75 per cent of men worldwide who seem to be coping quite satisfactorily despite such a malevolent anatomical disadvantage and it would appear to be contradicted by “a good research study” (i.e. one using actual patient data) showing that 95 per cent of boys never experience any foreskin problems, and that only a tiny minority of these require circumcision to correct it.

In relation to the burden of proof, the situation is analogous to a court of law where the foreskin is charged with the offence of being a menace to individual and public health – a situation where the accused is innocent until proved guilty. The prosecution can bring in as many witnesses as it likes, but as in a court of law the defence does not have to prove anything. It does not even have to produce witnesses of its own or require the foreskin to make any statement in its own defence. The outcome of the case depends on the credibility, consistency and force of the evidence presented by the prosecution, as judged by the jury, the members of which must assess its validity and relevance. Are the claims plausible? Could the prosecution witnesses be mistaken? Have they misinterpreted what they think they saw? Do they agree? Could they be motivated by personal malice or ideology? How credible are these authorities? How consistent are they? Has the case for a guilty verdict been made beyond reasonable doubt?

In this situation it would not matter if there was not a single article n a medical or other journal contesting the claims of the circumcision advocates (though in fact there are a great many) – the prosecution would still have to prove its case to an impartial jury. In fact, the medical literature is as contested and inconclusive as it is vast; as when witnesses give contradictory accounts of “what happened,” it is thus difficult to draw firm conclusions. But if firm conclusions cannot be drawn the verdict arrived at must be “Not Guilty” (or as the Scots say, Not Proven), and the foreskin discharged. The real question is not whether it might have been guilty, but why a normal feature of human sexual anatomy should have to justify its existence to the likes of Professor Morris.

Non-therapeutic circumcision like elephant repellent

Recommending circumcision as a prophylactic of childhood diseases is reminiscent of the old joke about the fairground snake oil salesman flogging elephant repellent. Confronted by sceptical customers who point out that there are no elephants around, he has the compelling reply, “Proof of how effective it is!” The point is, that even if the repellent were effective, you do not need it in regions where elephants are not normally encountered, nor if elephants are not really very dangerous and can be scared away by saying “Shoo!”

The key question, therefore, is not whether circumcision might have health benefits, or even if the benefits outweigh the risks, but whether the net benefits (i.e. after taking all harms into account) are great enough to justify performing the operation on children who cannot give informed consent. In making this assessment it is not enough to dredge through the vast accumulation of medical literature to find studies supporting some degree of risk reduction; nor is it enough when considering the cons to consider merely the risk of surgical complications, as the American Academy of Pediatrics and the Centers for Disease Control have done. The calculation required is far more complex.

First you must consider the frequency, severity, transmissibility and curability of the diseases etc to which circumcision is claimed to provide protection. Then (2) you must make a comprehensive study of the physical harms, including impact on sexual experience, surgical complications and other adverse outcomes, not merely in the immediate post-operative period, but long-term, until sexual maturity. Then (3) you must factor in the sexual, aesthetic, and personal value of the foreskin to the individual and the psychological impact of removing it. Next (4) you must assess the ethical harms and damage to human rights arising from operating without informed consent. Finally (5), you must find some widely acceptable formula for weighting all these disparate factors to produce a final judgement.

Using a flame-thrower to swat a blowfly

No circumcision advocate, and certainly not Professor Morris, for all their diligent labours, have ever come close to performing such an exercise. They have rather confined themselves to selective literature reviews, picking out studies that show, or appear to show, the foreskin increasing the risk of this or that disease, while ignoring or disparaging critiques of these, as well as dismissing studies that reach different conclusions. Despite his impressive productivity, Professor Morris’s own papers tend to repetition – a familiar litany of the benefits of circumcision, along with assurances that it carries a minimal risk of complications and makes no difference to sexual experience. They also ignore the frequency, severity, transmissibility and curability of the diseases etc to which circumcision is claimed to provide protection; in fact, most of them are rare, mild in effect, non-transmissible or of low virulence, and readily curable with antibiotics or other medications. Using circumcision to prevent or cure trivial penis problems such as inflammation (balanitis); or urinary tract or venereal infections that can be cured with antibiotics or prevented by behavioural strategies is like using a flame-thrower to swat a housefly.

Nowhere in his extensive list of publications does Professor Morris tell us what material weighting he would give to the 5 factors listed above, most of which he simply ignores. How, then, can he arrive at the triumphant conclusion that the benefits of circumcision outweigh the risks by a factor of 200 to 1? One feels that the figure must have been plucked out of the air, having about as much scientific validity as phlogiston.

Range of opinions on circumcision – but Morris and coterie at extreme edge

Professor Morris would like us to believe that there are basically two positions on circumcision: the pro-circumcision position, represented by himself, the American Academy of Pediatrics, the United States Centers for Disease Control and many other responsible health authorities; and the anti-circumcision position, represented by a few misguided medical ethics wonks and some ratbag community activists.

In fact, there are at least 6 major positions on circumcision, which may be summarised as follows:

1. Professor Morris and his coterie at the Circumcision Academy of Australia and the Early Infant Circumcision Advocacy Group who believe that parents should be strongly encouraged or compelled to get their baby boys circumcised.

2. The American Academy of Pediatrics and the US Centers for Disease Control, which do not recommend circumcision, but consider that the benefits of circumcision exceed the risk of surgical complications (though not by much).

3. Paediatric authorities such as the Royal Australasian College of Physicians and the Canada Paediatric Society which consider that the risks and harms of circumcision outweigh the benefits and that circumcision is neither warranted nor desirable, and certainly not necessary.

4. Medical authorities such as the Royal Dutch Medical Association, others in Europe and (marginally) the British Medical Association who consider that circumcision is both physically harmful and ethically unacceptable, and therefore that doctors and public health institutions should actively discourage the practice. A number of independent researchers, epidemiologists and paediatricians are also included in this group.

5. Legal authorities such as the Tasmania Law Reform Institute, the Cologne Court of Appeal and numerous legal, bioethical and human rights scholars who consider that non-therapeutic circumcision of minors violates accepted principles of bioethics and human rights, and should be treated in much the same way as female genital mutilation – that is partially prohibited or at least strictly regulated.

6. Community organisations and individuals who regard circumcision as genital mutilation and consider that it should be legally prohibited, and perpetrators prosecuted.

As you can see, there is an extensive spectrum of opinion on circumcision from right to left, from compulsory at one end to legal prohibition outright at the other. It is also evident that by far the greater weight of opinion on a world scale is against circumcision, and that Professor Morris and friends are at the extremist end of the scale. The AAP must tremble at the thought of being defended by such fanatical allies – though in truth it is strange that no other supporters are speaking up in their favour, and that its own position is very much at variance from those of all other child health authorities.

Does Professor Morris really matter?

For all his industry and zeal, however, Professor Morris cannot claim many victories. His efforts to influence the RACP have failed; his attempt to get the Australian and New Zealand Public Health Association to adopt a resolution in favour of circumcision got nowhere; the AAP has not recommended circumcision; the Canada Pediatric Society came out against circumcision; circumcision incidence in the United States and Australia continues to decline; legal, bioethical and human rights authoritie increasingly question the practice. The increasing desperation of the circumcision lobby is shown in the escalating stridency and implausibility of its claims (200 to 1: really!), and its marginalisation by reliance on low-status, low-credibility publications. They really might as well pack up their gomcos and plastibels and devote their considerable energy to something more useful and productive than destroying foreskins.

1. “Circumcision facts trump anti-circ fiction”, Australian Skeptic 27 (4) Summer 2007. See also reply by Robert Darby, showing that Professor Morris’s respect for evidence is not all that it might be, and that he has trouble giving correct citations to sources.