Updated parental viewpoints on male neonatal circumcision in the United States

Decision-Making Regarding Newborn Circumcision: A Qualitative Analysis

OBJECTIVES

Circumcision of newborn males is left to parental preference, as medical necessity has not been demonstrated. For medical providers seeking to help parents make decisions and provide informed consent, there is little information regarding how parents gather and process information about circumcision. This study aimed to characterize the comprehensive range of parental attitudes, gaps in knowledge, and decision-making regarding circumcision.

METHODS

Qualitative data was obtained from semi-structured open-ended interviews conducted during the postpartum hospitalization. Interviews were recorded, transcribed, and coded by multiple independent reviewers. A grounded theory approach was used to identify emergent themes regarding attitudes towards, sources of information about, and decision-making surrounding circumcision.

RESULTS

Ten mothers were interviewed, of whom six planned to circumcise and four did not. Major themes emerged: the importance of cultural norms, limited yet influential discussions, and the lack of, but desire for, more knowledge. Discussions with medical providers were often limited, though when physician conversation was more extensive, provider input was highly influential. Parents lacked evidence-based knowledge of the risks and benefits of the procedure. They uniformly desire more information and counseling from their medical providers.

CONCLUSIONS FOR PRACTICE

This study affirms the importance of sociocultural factors and identified a discrepancy between parents' desire for empiric information and the counsel offered by providers, identifying a need for improved parent counseling. The qualitative themes that emerged from this work enabled the development of a comprehensive conceptual model that can be further tested to develop a decision aid for circumcision of the newborn.

Circumcision and its alternatives in Germany: an analysis of nationwide hospital routine data

BACKGROUND/PURPOSE

Circumcisions are among the most frequent operations in children. Health service data on circumcision in the United States has documented an increase in neonatal circumcisions since 2012. We investigated whether a similar effect could be found in Germany, which does not endorse neonatal circumcision.

METHODS

We analysed German routine administrative data for operations conducted on the preputium in order to analyse the frequency, age distribution, and time-trends in hospital-based procedures on a nationwide basis.

RESULTS

There were 9418 [95% confidence interval (CI) 8860-10,029] procedures per year, of which 4977 (95% CI 4676-5337) were circumcisions. Age distributions were highly different between both circumcisions (van der Waerden's χ² = 58.744, df = 4, P < 0.0001) and preputium-preserving operations (van der Waerden's χ² = 58.481, df = 4, P < 0.0001). Circumcisions were more frequent in the first 5 years of life and above 15 years of age, whereas preputium-preserving procedures were preferred in the age groups between 5 and 14 years of age. The number of circumcisions and preputium-preserving operations decreased in absolute and relative numbers.

CONCLUSIONS

The increasing trend towards neonatal circumcision observed in the United States is absent in Germany. The majority of patients were operated after the first year of life and absolute and relative numbers of hospital-based procedures were decreasing. Other factors such as increasing use of steroids for the preferred non-operative treatment of phimosis may play a role. As operations in outpatients and office-based procedures were not covered, additional research is necessary to obtain a detailed picture of circumcision and its surgical alternatives in Germany.

LEVEL OF EVIDENCE

III.

Parental decision making in male circumcision

Purpose:

To study which healthcare professionals (HCPs) firstasked parents about their decision regarding circumcision; whether parents felt they were given enough information by their HCP; and what reasons parents cited for their decision.

Study Design and Methods:

Bilingual questionnaires were administered to parents and expecting parents of boys (N = 60). Close-ended survey responses were analyzed through factor analysis to ascertain what types of beliefs parents used in their decision making, whether they felt they had enough information, and who first asked them about their decision.

Results:

Nurses were most likely to be the first HCPs to ask parents about circumcision. Parental personal and cultural beliefs played an equal or more important role in influencing decision making than medical information received. However, some parents noted that there was a lack of access to accurate information regarding risks and benefits of male circumcision.

Clinical Nursing Implications:

Nurses continue to play a critical role in acquisition of knowledge surrounding male circumcision and serve as important liaisons between parents and the proxy consent process. Nurses, as well as other HCPs, should discuss circumcision early in pregnancy so parents have ample time to ask questions, gather information, and make an appropriate decision.

How do parents make the decision to have their newborn baby boy circumcised? What do they need to know and how can nurses make sure they have adequate information to make a truly informed decision?

Shared Decision Making for Routine Infant Circumcision: A Pilot Study

It is important that expectant parents receive accurate information about the benefits and risks of circumcision as well as the benefits and risks of having an intact foreskin when making a decision about routine infant circumcision (RIC). A pilot study was conducted using the shared decision making (SDM) conceptual model to guide expectant parents through a 3-phase decision-making program about RIC as part of their childbirth education class. The participants showed a high level of preparedness following each of the 3 phases. Preparedness score were highest for those who decided to keep their expected sons' penises natural. This SDM program was an effective way of guiding expectant parents through the decision-making process for RIC.

Medical risks and benefits of newborn male circumcision in the United States: physician perspectives

INTRODUCTION

In 2012, the American Academy of Pediatrics (AAP) and the American Congress of Obstetricians and Gynecologists (ACOG) published recommendations that physicians should discuss with parents the benefits and risks of newborn male circumcision. Our objective was to assess physicians' perspectives of newborn male circumcision.

METHODS

A self-administered, cross-sectional electronic survey of US physicians was conducted in 2008 (N = 1500).

RESULTS

Approximately one-third (33.2%) of the respondents reported that their current perspective was that the medical benefits outweigh the risks associated with newborn male circumcision and less than one-third (31.1%) reported they would recommend the procedure when counseling parents.

CONCLUSIONS

In 2008, only about one-third of the physicians surveyed thought that the benefits of male circumcision outweighed the risks and recommended it to parents of newborn sons. These attitudes may be relevant to the declining circumcision rates in the United States. Repeat surveys may be useful, given the new AAP and ACOG recommendations.

Male circumcision performed with 8-figure non-absorbable suture technique

INTRODUCTION

We analyze the outcome of circumcisions performed with 8-figure non-absorbable suture (8FNS) and assess the feasibility of using the technique in male circumcision.

METHODS

We randomly divided 317 patients who would undergo circumcision between February 2009 and January 2012 into 2 groups. Each group was subdivided into children (age range: 7 to 15 years) and adult (range: 16 to 85 years). In the experiment group (n =166), we used 8FNS and in control group (n = 151), commonly absorbable suture (CAS) were used for the circumcised wound closure. The results of 2 groups were compared. We also performed a cost analysis and a mean 6-month follow-up (range: 1-12). Chi-square and Student's t-test were used in statistical analysis. Differences were considered significant (p < 0.05).

RESULTS

No patients were required to remove their sutures postoperatively. Among them, the sutures of the 8FNS for circumcision fell off spontaneously within 9 days (6.2 ± 1.57). There was no statistically significant difference between the 2 groups in surgical duration (16.2 ± 1.73 vs. 15.8 ± 2.01) and follow-up time (6.4 ± 3.82 vs. 6.2 ± 2.39). The overall complication rate of the 2 groups was 6.63% and 10.53% (p = 0.15), respectively. In addition, the complication rate among the adults was significantly lower in the 8FNS group compared to children (2.53% vs. 10.34%, p = 0.04). Also, the average cost (in US dollars) of 8FNS for circumcision was $20.7 ± $3.83 less than $35.8 ± $5.02 of CAS, which is a very significant difference (p < 0.0001).

CONCLUSIONS

8FNS for circumcision is feasible, easy, safe and cost-effective, especially for adult males.

Counseling parents who are considering newborn male circumcision

The American Academy of Pediatrics recently issued a statement that the health benefits of newborn male circumcision exceed the risks and therefore justify access to the procedure for families who choose it. Further, clinicians are charged with providing factually correct information that communicates the risks and benefits of elective newborn male circumcision in a nonbiased manner. However, many clinicians lack adequate information to discuss the risks and benefits of male circumcision. The purpose of this review is to highlight evidence on the risks and benefits of newborn male circumcision and provide clinicians with counseling points that can be used to guide discussion with parents considering newborn male circumcision.

Parents' rationale for male circumcision

OBJECTIVE

To determine which factors parents consider to be most important when pursuing elective circumcision procedures in newborn male children.

DESIGN

Prospective survey.

SETTING

Saskatoon, Sask.

PARTICIPANTS

A total of 230 participants attending prenatal classes in the Saskatoon Health Region over a 3-month period.

MAIN OUTCOME MEASURES

Parents' plans to pursue circumcision, personal and family circumcision status, and factors influencing parents' decision making on the subject of elective circumcision.

RESULTS

The reasons that parents most often gave for supporting male circumcision were hygiene (61.9%), prevention of infection or cancer (44.8%), and the father being circumcised (40.9%). The reasons most commonly reported by parents for not supporting circumcision were it not being medically necessary (32.0%), the father being uncircumcised (18.8%), and concerns about bleeding or infection (15.5%). Of all parents responding who were expecting children, 56.4% indicated they would consider pursuing elective circumcision if they had a son; 24.3% said they would not. In instances in which the father of the expected baby was circumcised, 81.9% of respondents were in favour of pursuing elective circumcision. When the father of the expected child was not circumcised, 14.9% were in favour of pursuing elective circumcision. Regression analysis showed that the relationship between the circumcision status of the father and support of elective circumcision was statistically significant (P < .001). Among couples in which the father was circumcised, 82.2% stated that circumcision by an experienced medical practitioner was a safe procedure for all boys, in contrast to 64.1% of couples in which the father of the expected child was not circumcised. When the expecting father was circumcised, no one responded that circumcision was an unsafe procedure, compared with 7.8% when the expecting father was not circumcised (P = .003).

CONCLUSION

Despite new medical information and updated stances from various medical associations, newborn male circumcision rates continue to be heavily influenced by the circumcision status of the child's father.

Review: a critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries

A potential impediment to evidence-based policy development on medical male circumcision (MC) for HIV prevention in all countries worldwide is the uncritical acceptance by some of arguments used by opponents of this procedure. Here we evaluate recent opinion-pieces of 13 individuals opposed to MC. We find that these statements misrepresent good studies, selectively cite references, some containing fallacious information, and draw erroneous conclusions. In marked contrast, the scientific evidence shows MC to be a simple, low-risk procedure with very little or no adverse long-term effect on sexual function, sensitivity, sensation during arousal or overall satisfaction. Unscientific arguments have been recently used to drive ballot measures aimed at banning MC of minors in the USA, eliminate insurance coverage for medical MC for low-income families, and threaten large fines and incarceration for health care providers. Medical MC is a preventative health measure akin to immunisation, given its protective effect against HIV infection, genital cancers and various other conditions. Protection afforded by neonatal MC against a diversity of common medical conditions starts in infancy with urinary tract infections and extends throughout life. Besides protection in adulthood against acquiring HIV, MC also reduces morbidity and mortality from multiple other sexually transmitted infections (STIs) and genital cancers in men and their female sexual partners. It is estimated that over their lifetime one-third of uncircumcised males will suffer at least one foreskin-related medical condition. The scientific evidence indicates that medical MC is safe and effective. Its favourable risk/benefit ratio and cost/benefit support the advantages of medical MC.

A 'snip' in time: what is the best age to circumcise?

BACKGROUND

Circumcision is a common procedure, but regional and societal attitudes differ on whether there is a need for a male to be circumcised and, if so, at what age. This is an important issue for many parents, but also pediatricians, other doctors, policy makers, public health authorities, medical bodies, and males themselves.

DISCUSSION

We show here that infancy is an optimal time for clinical circumcision because an infant's low mobility facilitates the use of local anesthesia, sutures are not required, healing is quick, cosmetic outcome is usually excellent, costs are minimal, and complications are uncommon. The benefits of infant circumcision include prevention of urinary tract infections (a cause of renal scarring), reduction in risk of inflammatory foreskin conditions such as balanoposthitis, foreskin injuries, phimosis and paraphimosis. When the boy later becomes sexually active he has substantial protection against risk of HIV and other viral sexually transmitted infections such as genital herpes and oncogenic human papillomavirus, as well as penile cancer. The risk of cervical cancer in his female partner(s) is also reduced. Circumcision in adolescence or adulthood may evoke a fear of pain, penile damage or reduced sexual pleasure, even though unfounded. Time off work or school will be needed, cost is much greater, as are risks of complications, healing is slower, and stitches or tissue glue must be used.

SUMMARY

Infant circumcision is safe, simple, convenient and cost-effective. The available evidence strongly supports infancy as the optimal time for circumcision.

Acceptability of neonatal circumcision by Hispanics in southern Florida

This study attempted to determine the acceptability of neonatal circumcision in Hispanic expectant and new parents and to explore potential associations with lower acceptability. Overall, we found surprisingly high rates of acceptability in this community that contrasts with the actual low rates of circumcision in Hispanics in the USA. This gap is important since newborn circumcision has been suggested as an additional long-range tool in reducing longstanding ethnic disparities in HIV incidence in the USA. A larger study will be needed to determine what factors are associated with low acceptability and how one might effectively address these concerns in this population.