Circumcision or Mutilation? A critical appraisal of a study that finds PTSD among circumcised Filipino boys

A boy gets circumcised during a surgical mission in Palawan, Philippines (Gideon Lasco, 2014)

A critical appraisal of the study entitled “Ritual and Medical Circumcision among Filipino boys: Evidence of Post-traumatic Stress Disorder” by Samuel Ramos and Gregory Boyle

By Gideon Lasco, MD 

To all Filipino males out there: Would you entertain the thought that as a child, you were “mutilated” and “criminally assaulted” through the procedure of circumcision? An Australian study says just that.

In a paper entitled “Ritual and Medical Circumcision among Filipino boys: Evidence of Post-traumatic Stress Disorder” published in 2000, authors Samuel Ramos and Gregory Boyle studied circumcision among boys aged 11-16 in Batangas, a province in Southern Luzon, Philippines. According to their findings, a majority of the boys had post-traumatic stress disorder after circumcision, and uses the findings to support the general statement that circumcision is a form of physical violence.

How valid is their paper? Can circumcision, which is accepted by over a billion people, be in reality a form of mutilation? This piece is an exercise that critical explores the connection between the “anthropological reality” presented by the authors and the “emic reality” as experienced by myself, who belong to the culture that is the subject of the paper.

This piece uses the qualitative critical appraisal questionnaire by the Critical Skills Appraisal Programme network (http://www.casp-uk.net/).

1 Was there a clear statement of the aims of the research? 
The authors state that they aim to investigate the psychological consequences of “partial penile amputation”. The authors then connect the relevance of this study in building the case that the Filipino practice of male circumcision is “in reality, criminal assault. Evidence of post-traumatic stress disorder (PTSD) would be used as the parameter by which psychological consequence (i.e. harm) would be measured.

2. Is a qualitative methodology appropriate? 
To their credit, the authors employed qualitative methods, which comprise the first half of the paper. Thereafter, an interview is sent out. For such a sensitive, multi-factorial topic such as circumcision, qualitative methods are truly appropriate to make sense of the practice, whether or not in conjunction with a quantitative paper.

3. Was the research design appropriate to address the aims of the research? 
The research design calls for the measurement of post-traumatic stress disorder (PTSD) among children who underwent circumcision; an outcome showing PTSD is then used as a justification in labeling circumcision as “violence”. They used the DSM-IV criteria (a listing of psychiatric conditions) to define PTSD.

There are serious flaws in the research design. In the first place, the very premise of the study is the diagnosis of PTSD according to the DSM-V criteria. How valid is the DSM criteria, especially when doing cultural research? To show how dynamic and arbitrary this criteria is, homosexuality was once part of DSM-II, and today there is growing criticism of DSM particularly with its cross-cultural applicability (Kleinman, 1987; Faraone and others, 2003, Hinton and Fernandez, 2011). Circumcision definitely presents with pain but there is a need for a much deeper analysis before someone becomes qualified to say that it is “violence”.

PTSD is defined in the DSM-V as a condition that "may develop after a person is exposed to one or more traumatic events, such as sexual assault, warfare, serious injury, or threats of imminent death" (APA, 2013), and thus it is highly questionable for circumcision to be included in this category, given that while it presents with "pain", it is a very tolerable kind of pain that is indeed likened as "kagat lang ng langgam" (just like the bite of an ant). In circumcision missions I have attended, it is the boys themselves who volunteer to be circumcised, and there is no sign of emotional trauma on their part after the procedure.Whether or not the boys in questions actually had (or have) PTSD can be subject to further technical questions in many levels.

Finally, the short-time frame given to the study limits its reliability. There are culturally-sanctioned forms of short-term pain and suffering which would find vindication in the future.

4. Were the data collected in a way that addressed the research issue? 
If research issue is “prevalence of PTSD among Filipino boys who undergo circumcision”, the sample is limited and cannot represent the population in question. Moreover, if the research issue is expanded to deal with issues of “harm” and even “criminal assault”, then measurement of PTSD alone gives the researchers with very limited, weak data.

5. Has the relationship between researcher and participants been adequately considered? 
The bias of the researchers on the practice in question is glaring throughout the paper, evidenced by their semantics. For instance, the use of “mutilation” is preferred in this paper, which itself indicates a value-judgment. In effect, the researchers have already stated their preference for the ultimate outcome of their research in question.

6. Have ethical issues been taken into consideration? 
Since the respondents are minors, there are issues of informed consent and confidentiality. Steps undertaken to address these were mentioned in the paper. Ethical approval was also given by their home university in Australia, but I would think that ethical approval from a panel in the Philippines would have been more appropriate.

7. Was the data analysis sufficiently rigorous? Is there a clear statement of findings?
Hasty generalizations abound in the data analysis. For instance, the paper declares: "Despite some methodological limitations, the present study clearly demonstrates the causal role of circumcision in the development of PTSD among Filipino boys." The use of “Filipino boys” is already a misrepresentation, because they were just studying a small section of a province within the Tagalog region.

The next statement is even stronger : “Evidently, there is strong evidence of a causal relationship between circumcision and resultant psychological trauma.” Again, this sweeping claim is not backed with any hard evidence,

The study also does not study the converse of the population, i.e. non-circumcised boys, and whether or not they had any “psychological trauma”. The embeddedness of both circumcised and non-circumcised males within society is ignored, and in this study, only psychological factors are considered, without any attempt to contextualize the definitions to the local culture.

8. How valuable is the research? 
Circumcision is an important practice in the Philippines and many parts of the world, and has been extensively well-documented. However, a research that gives judgments based on a very weak methodology and biased investigators cannot be assigned much value in this growing body of literature on ritual circumcision.

CONCLUSION 
This paper is an example of how “sociological” and “anthropological” studies coming from the outsiders’ (i.e. etic) perspective can be out of touch with the reality they claim to study. Circumcision is as detached from mutilation as an anthropologist is from a judge. Yet, this case underscores the need for us Filipinos to study, understand, and appreciate our own culture. Going back to the circumcision study, the researchers declare: “[Circumcision] is in reality criminal sexual assault.” In reality? Perhaps there is such a thing as an "anthropological reality", portrayed by social scientists and anthropologists, and then imagined (and reimagined) by the rest of the world. If applied on a culture, it can lead to (mis)perceptions that remind us that we have to be a voice in defining our own reality, for if we do not, others will.

REFERENCES
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. pp. 271–280.

Faraone, S. V., Sergeant, J., Gillberg, C., & Biederman, J. (2003). The worldwide prevalence of ADHD: is it an American condition?. World Psychiatry, 2(2), 104.

Hinton, D. E., & Lewis‐Fernández, R. (2011). The cross‐cultural validity of posttraumatic stress disorder: implications for DSM‐5. Depression and anxiety, 28(9), 783-801.

Kleinman, A. (1987). Anthropology and psychiatry. The role of culture in cross-cultural research on illness. The British Journal of Psychiatry, 151(4), 447-454.