Non-therapeutic infant male circumcision. evidence, ethics and international law perspective
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* Alamin Berhanu

*To the Editor*

I have read Dr. Alkhenizan and Dr. Elabd systematic review on circumcision1 in its entirety and with great interest. A narrative overview to gather evidence from previous secondary literature into an accessible and usable document is useful to aid healthcare practitioner2 and I wish there will be more literature in an overview format to aid healthcare practitioners. The benefits as you have identified in the work are numerous including; a decrease in infection, cancer, and so forth, and the legal and ethical aspects are well presented. Oftentimes, we unconsciously associate circumcision with cultural norms and practices only and as healthcare practitioner we fail to read about it in medical literature. Indeed, it is an ancient and medieval period cultural practice that withstood the rigor of medical evidence into modern age. This is an opportune time to read a full article on circumcision and I am glad that this article has a lot to share regarding benefits, ethics, and legal ramification at a time when there are attempts to ban circumcision in some regions of a continental Europe. Legislators in continental Europe3 are advocating a policy against circumcision based on a cultural bias toward the others and emotive comprehension of the issue rather than medical evidence. This work is a timely anti-dote to emphasize the perennial goodness of infant circumcision and the need to reassert the wisdom of the practice.

Two comments: one is a noticeable absence of duplicate articles despite using 3 different databases (PubMed, EMBASE, and Cochrane) in your search strategy. PubMed would include in their database articles that are found in EMBASE or Cochrane, as such duplicate article is a natural byproduct of using multiple databases. My second comments is that I have not seen a tabulation of retrieved articles that are included in your review to complement your narrative. The tabulation would serve dual purpose to provide a quick summary of the narrative and for a comparative study purposes when performing similar study. A tabulation even as an addendum to the correspondence or follow up would be complementary to the main article.

Two Questions: Some authors have adopted a contrarian opinion as to the merits of circumcision claiming it even as last standing dead dogma.4 Among physician who has persistently asserted such view is Dr. Van Howe5 and has produced numerous articles related to circumcision to further his beliefs and views. Among his claims are that circumcision is unethical and unlawful and that there are no reduction of human papilloma virus among circumcised individuals6 as opposed to your review which showed a 43 % reduction.1 In light of your current review, what are the merits or claims of the above contrarian view? Is there any validity to such a claim? Has his meta-analysis been incorporated in your review to adequately assess and compare with the other works? My second question relates to legal and ethical ramification of performing circumcision in Islam. You have stated an interesting information that as per majority muslim scholars, circumcision is mandatory in Islam. I have to admit my ignorance that I used to think as a Muslim that circumcision is a must for all Muslims. My follow up question therefore is what are the opinion of the minority in Islam? Are there any region with Muslim population that practice contrary to the majority opinion? In general, what is the source of legal injunction for circumcision in Islam?

***Reply from the Author***

We would like to thank Dr. Berhanu for his interest in our paper and his comments. We agree on the importance of covering important medico-legal and ethical controversies in the field of medicine using a systematic review methodology. We did not have issues with duplicate publications because we limited our search to systematic reviews of the literature, which significantly limited the possibility of having duplicate publications. The aim of our publication was not to comment on the opinion of individual researchers, but to review the ethical and legal aspects of infant male circumcision in addition to reviewing the evidence of the benefits and harms of this procedure. The paper of Van Howe 6 you referred to is an outdated paper, which did not mount to be a systematic review as it is a single author publication which did not include several relevant publications in the field and it was based on a the analysis of only 3 studies. We based our findings on a large systematic review including 21 studies including more than 14000 participants.1 Based on this large systematic review, circumcision was associated with 43% reduction of human papilloma virus infection.7 Finally, all Muslim scholars agree that male circumcision is permissible; however, majority of Muslim scholars have the opinion that male circumcision is mandatory, details regarding this is available in formal Islamic Fiqh (jurisprudence) books.8

***Abdullah Alkhenizan***

*Department of Family Medicine Riyadh, Kingdom of Saudi Arabia*

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## References

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8.  Islam Questions and Answers (2002) Circumcision: how it is done and the rulings on it, Available at: [https://islamqa.info/en/9412](https://islamqa.info/en/9412).