Claims that circumcision increases alexithymia and erectile dysfunction are unfounded: a critique of bollinger and van Howe's "Alexithymia and circumcision trauma: a preliminary investigation".
Article Type: Letter to the editor
Subject: Circumcision (Complications and side effects)
Alexithymia (Risk factors)
Impotence (Risk factors)
Authors: Morris, Brian J.
Waskett, Jake H.
Pub Date: 06/22/2012
Publication: Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 Men's Studies Press ISSN: 1532-6306
Issue: Date: Summer, 2012 Source Volume: 11 Source Issue: 2
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 305192594
Full Text: In the July 2011 issue of International Journal of Men's Health, Bollinger and Van Howe present results from "preliminary investigation" involving the Toronto 20-Item Alexthimia Scale (TAS-20) of the relationship between circumcision and alexithymia (stated on the recruitment website as "having no words for feelings") (Bollinger & Van Howe, 2011). They conclude that "Alexithymia in this population of adult men is statistically significant for having experienced circumcision trauma and for erectile dysfunction drug use" (p. 184).

The main problem with this small-scale survey is that the 236 circumcised men and 64 uncircumcised men were self-selected, which can lead to a well-recognised source of bias (Rothman & Greenland, 2005). Furthermore, the authors seem to have made no attempt to minimize such potential bias. Indeed, men were recruited through advertisements on two Internet sites: menstuff.org and themenscenter.com (now mensightmagazine.com), both of which appear to take a strong anti-circumcision stance (see: http://mensightmagazine.com/ bookstore.htm#CIRCUMCISION and http://www.menstuff.org/issues/byissue/circumcision.html). The title of a recruitment advertisement for the survey--"Male Circumcision Trauma Survey"--is itself "loaded," especially as trauma in infancy associated with circumcision, in the absence of local anaesthesia, nor with any other minor trauma, is not recognized clinically as being responsible for any psychological or sexual problem later in life. Moreover, the survey dated 2006 and attributed to Bollinger, an "Independent Men's Issues Researcher" (see: http://mensightmagazine.com/Articles/Bollinger,%20Dan/traumasurvey.htm), is on a website that proclaims supposed psychological harm that circumcision causes males, and which includes a document entitled "Resolution for Genital Integrity," with a link to Bollinger's anti-circumcision organisation, the International Coalition for Genital Integrity (http://www.icgi.org). Psychiatric problems have been found in men unhappy about having been circumcised (Mohl, Adams, Grier, & Sheley, 1981). One, body dysmorphic disorder, has been linked to alexithymia (Fenwick & Sullivan, 2011).

It therefore seems reasonable to expect that the modality of recruitment employed would have resulted in a study population containing a disproportionate number of men with anti-circumcision views. Unless one is willing to assume that circumcised men with sexual or psychological problems are equally likely to hold anti-circumcision views as other men, this source of bias should be obvious. Any scholar should therefore be concerned about the influence of anti-circumcision propaganda on the survey results and the unrepresentative nature of the respondents. Thus, on top of the well-known ability of self-selection being prone to introduce biases, in the case of the present survey the authors seem to have actively encouraged such bias. In fairness to the authors, they do acknowledge the limitations of their self-selection process, and further recognize that recruitment websites might themselves bias the sample. In our opinion, however, these biases were downplayed and inadequately explored.

All of the subjects completed a questionnaire to determine their alexithymia (ALEX) score, yet nowhere do the authors state that alexithymia is defined as a TAS-20 score of > 61. Their Figure 1 provides distribution curves for ALEX scores for circumcised and uncircumcised men, but neither the number of men who had "Low," "Moderate," and "High" ALEX scores, nor the proportion of each, is provided anywhere in their paper. Curiously, the legend to this Figure states that "A larger proportion of circumcised men had higher Low, Moderate, and High ALEX scores than uncircumcised men as shown by these smoothed distribution curves." Such an assertion is unmathematical. By using a "cut and weigh" technique to determine the area under each curve, we calculated that 30 percent (71/236) of the circumcised men had a "High ALEX" score (shown as > 61) compared with 15 percent (23/64) of the uncircumcised men. For the type of questionnaire used, an n value of 23 is too low to provide confidence that the conclusion reached is reliable. Moreover, if a "High ALEX" score was being used as a definition of alexithymia-- as it should--then the proportion of men in the survey with alexithymia greatly exceeds the general population prevalence of alexithymia, which for healthy people has been reported as less than 10 percent (Franz et al., 2008; Jimerson, Wolfe, Franko, Covino, & Sifneos, 1994; Mattila, Salminen, Nummi, & Joukamaa, 2006). This deviation from the norm further supports our assertion that the survey population was unrepresentative.

Bollinger and Van Howe go to some lengths to connect alexithymia to "circumcision trauma" in infancy. This claim is not, however, supported by their finding that "Age at time of circumcision was not significant (t = 1.44, p = 0.1499 [sic!])". Their statement that "age at time of circumcision was not a factor, suggesting that early traumas with these participants were as likely to lead to alexithymia as the same trauma later in life" is more likely to reflect the biased nature of the study population than any effect unique to circumcision in infancy. They also state that "Circumcision pain itself did not seem to effect [sic!] acquiring alexithymia."

One of the references they cite actually states there is "strong empirical support for alexithymia being a stable personality trait rather than just a consequence of psychological distress" (Taylor, Bagby, & Parker, 1997), contradicting their argument.

Bollinger & Van Howe also draw on inter-country comparisons in an attempt to support their argument about alexithymia. However, there is an enormous array of variables that would influence such considerations, making inter-country comparisons strongly prone to confounding. Moreover, a recent, very large survey of 19,850 pre-school children from 24 societies (Rescorla et al., 2011) that examined a comprehensive range of emotional problems, found differences in severity of these between countries, but none would appear related to infant circumcision practice or the prevalence of circumcised males in each country. The same can be said for findings in a similar survey of children aged 6-16 from 31 countries (Rescorla et al., 2007).

The negative findings by the authors are instructive. The survey attempted to find an association with post-traumatic stress disorder (See http://web.archive.org/web/ 20070329051708/http://www.babyboy.info/tmc/survey.htm), but no findings were reported in their paper. Bollinger and Van Howe did, however, report that there was no difference in erectile dysfunction (ED) between circumcised and uncircumcised men (see their Table 3, especially the results from multivariate analysis). An association of circumcision with ED drug usage was, however, noted. One might ask what could explain equal susceptibility to ED but greater use of ED medication by circumcised men in the survey? One consideration might be socioeconomic status and thus the ability to afford drugs. It has been found consistently that circumcision is associated with upper socioeconomic indices (Laumann, Maal, & Zuckerman, 1997; Richters, Smith, de Visser, Grulich, & Rissel, 2006; Xu, Markowitz, Sternberg, & Aral, 2007). National differences may also play a role: 78 percent of participants (and, it seems likely, more circumcised men) were from the USA, where usage of pharmaceuticals per capita is relatively high.

Bollinger & Van Howe claim, without evidence, that higher ALEX scores in men than in women can be attributed to "circumcision trauma." They cite a study by Parker, Bagby, Taylor, Endler, and Schmitz (1993) that they claim shows higher alexithymia in American men. However, that study found higher alexithymia in men in each of the German, Canadian and American college students surveyed (Parker et al.). Higher alexithymia in males has also been observed in Finland and other countries where circumcision is uncommon (Mattila et al., 2006). Parker et al. considered higher alexithymia among men was as expected, given that emotional processing involves lateralized cerebral functions, whereas women display a lesser degree of hemispheric specialization, and are better than men at communicating information about feelings and health problems. Both men and women in the American sample had higher alexithymia scores than obtained for men and women in the Canadian and German sample. Parker et al. attributed such between-country differences irrespective of sex to be a result of cultural differences and the older age of the German sample. Interestingly, a study in London (where circumcision is relatively common) found female undergraduates, particularly science students, had higher alexithymia scores than males (Mason, Tyson, Jones. & Potts, 2005).

CONCLUSION

We suggest that the recruitment methods used by Bollinger and Van Howe would strongly bias their survey towards anti-circumcision respondents. We posit that circumcised men with psychological issues are going to be more likely to become anti-circumcision activists than those who are well-adjusted, since the latter have no need to blame their circumcision for anything. Difficulty with erections is a common problem in men. We predict that vulnerable men with such difficulties may well be influenced by statements on anti-circumcision websites and blame their childhood circumcision for their sexual problems. We conclude that the present "preliminary investigation" falls welt short of providing any support for an association between circumcision and alexithymia, ED or any other item in the questionnaire.

DOI: 10.3149/jmh.1102.177.

REFERENCES

Bollinger, D., & Van Howe, R.S. (2011 ). Alexithemia and circumcision trauma: A preliminary investigation. International Journal of Men's Health, 10, 184-195.

Fenwick, A.S., & Sullivan, K.A. (2011 ). Potential link between body dysmorphic disorder symptoms and alexithymia in an eating-disordered treatment-seeking sample. Psychiatry, Research, 189. 299-304.

Franz, M., Popp, K., Schaefer, R.. Sitte, W., Schneider, C., Hardt, J., et al. (2008). Alexithymia in the German general population. Social Psychiatry Psychiatric Epidemiology, 43, 54-62.

Jimerson. D.C., Wolfe, B.E., Franko, D.L., Covino, N.A., & Sifneos, P.E. (1994) Alexithymia ratings in bulimia nervosa: Clinical correlates. Psychosomatic Medicine, 56, 90-93.

Laumann, E.O., Maal, C.M., & Zuckerman, E.W. (1997). Circumcision in the United States. Prevalence, prophyactic effects, and sexual practice. Journal of the American Medical Association, 277, 1052-1057.

Mason, O., Tyson, M., Jones, C., & Potts, S. (2005). Alexithymia: Its prevalence and correlates in a British undergraduate sample. Psychology and Psychotherapy, 78(Pt. 1), 113-125.

Mattila, A.K., Salminen, J.K., Nummi, T., & Joukamaa, M. (2006). Age is strongly associated with alexithynfia in the general population. Journal of Psychosomatic Research, 61,629-635.

Mohl, P.C., Adams, R., Grief, D.M., & Sheley, K.A. (1981). Prepuce restoration seekers: Psychiatric aspects. Archives of Sexual Behavior, 10, 383-393.

Parker, J.D.A., Bagby, R.M., Taylor, G.J., Endler, N.S., & Schmitz, P. (1993). Factorial validity of the 20-item Toronto Alexithymia Scale. European Journal of Personality, 7, 221-232.

Rescorla, L.A., Achenbach, T.M, Ivanova, M.Y., Dumenci, L., Almqvist, F., Bilenberg, N., et al. (2007). Behavioral and emotional problems reported by parents of children ages 6 to 16 in 31 societies. Journal of Emotional and Behavioral Disorders, 15, 130-142.

Rescorla, L.A., Achenbach, T.M., Ivanova, M.Y., Harder, V.S., Otten, L., Bilenberg, N., et al. (2011). International comparisons of behavioral and emotional problems in preschool children: Parents' reports from 24 societies. Journal of Clinical Child & Adolescent Psychology, 40, 456-467.

Richters, J., Smith, A.M., de Visser, R .O., Grulich, A.E., & Rissel, C.E. (2006). Circumcision in Australia: Prevalence and effects on sexual health. International Journal of STD & AIDS, 17, 547-554.

Rothman, K.J., & Greenland. S. (2005) Basic concepts. In W. Ahrens & I. Pigeot (Eds.), Handbook of epidemiology (pp. 43-88). Berlin: Springer.

Taylor, G.J., Bagby, R.M., & Parker, J.D.A. (1997). Disorders of affect regulation: Alexithymia in medical and psychiatric illness. Cambridge, U K: Cambridge University Press.

Xu, F., Markowitz, L.E., Sternberg, M.R.. & Aral, S.O. (2007). Prevalence of circumcision and herpes simplex vires type 2 infection in men in the United States: The National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sexually Transmitted Diseases, 34,479484.

BRIAN J. MORRIS, PH.D. * and JAKE H. WASKETT **

* School of Medical Sciences, University of Sydney, Australia.

** Circumcision Independent Reference and Commentary Service, Radcliffe, Manchester. UK.

Correspondence concerning this letter should be sent to Brian J. Morris, School of Medical Sciences and Bosch Institute, University of Sydney, Sydney NSW 2006, Australia. Email: brian.morris@sydney.edu.au
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