JOURNAL OF THE AMERICAN BOARD OF FAMILY PRACTITIONERS,
Volume 12, Number 1, Pages 16-20, January-February 1999.



Factors Affecting the Circumcision Decision

Jeffrey D. Tiemstra MD


Background: Studies from more than 10 years ago have shown that most parents choose circumcision for their infant sons for non medical reasons. Since then a wealth of data has accumulated on the relative risks and benefits of the procedure, although the medical community remains divided on the appropriateness of the procedure. Whether the ongoing research effort and medical debate have had an effect on parental decision making is unknown.
Methods: a survey of parents of 55 male infants was conducted to determine when the parents made their decision regarding circumcision, whether discussions with providers affected their decisions, and what the results were for their decisions.
Results: Eighty percent of parents made the circumcision decision before provider discussions. Seventeen percent reported changing their mind based on the provider's discussion, although it did not significantly affect the circumcision rate. Eighty-three percent of parents reported their attitude as neutral, including 7 of 8 patients who changed their mind based on the discussion only; only 1 patient was circumcised based on the provider's recommendation. Predominant reasons were ease of hygiene (67 percent), ease of infant circumcision compared with adult circumcision (63 percent), medical benefit (41 percent), and father circumcised (37 percent). Reasons for no circumcision included unnecessary (73 percent), painful (36 percent), and father uncircumcised (18 percent).
Conclusions: Most parents have made a decision on circumcision before physicians discuss it, and physician discussions appear to have little impact on the decision. Ease of cleanliness is still the most common reason parents choose circumcision. (J Am Board Fam Pract 1999;12:16-20)

After decades of debate and study, the appropriateness of routine male circumcision remains uncertain. Potential benefits traditionally cited include reduced risks of penile cancer, sexually transmitted disease, and infant urinary tract infections.1-13 Some studies have challenged these potential benefits, however, and critics of routine circumcision have questioned the degree of risk involved for a strictly preventive procedure.14-23 Given these uncertainties, in 1989 the American Academy of Pediatrics (AAP) modified its earlier statements opposing routine circumcision24-26 and emphasized instead the importance of informing parents of both sides of the debate: "newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained."9

Studies done before 1988 clearly have shown that few parents were aware of the medical debate regarding circumcision, and most based their choice on concerns relating to hygiene and appearance.27,28 From 1983 to 1987 four separate trials tested formal educational intervenions aimed at discouraging circumcision.29-32 Only one showed a small reduction in the circumcision rate (72 versus 94 percent), but none showed any improvements in parents understanding of the medical issues involved despite the wide range of education levels. In one study the educational intervention was not only ineffective but also increased parental dissatisfaction with care. Only one study specifically addressed the timing of the decision,33 and found that 36 percent of women chose circumcision even before becoming pregnant. Since the AAP's 1989 statement emphasizing the informed consent process, no one has revisited the issue of how or when parents decide whether to have their sons circumcised.

The goal of this study was to determine whether the medical debate has had an impact on parents' decision making. Rather than looking at the content of the consent process and decision from the provider's viewpoint, I chose to look at the discussion and decision from the parents' viewpoint by asking the following questions: (1) when do parents make the circumcision decision, (2) when do parents discuss circumcision with their physician, (3) does the decision have any impact on their decision, and (4) what are the reasons for their decision? The timing of the circumcision decision realtive to the discussion with the physician was of particular interest. If social concerns were more important, it would seem likely that the decision would be apparent well in advance of prenatal and neonatal health care encounters, as indeed, was the case 14 years ago. Conversely, if medical concerns were more important, then it would seem more likely that parents would be more open to physicians discussions and make the final

Methods
A 13-item questionnaire was distributed at two family practice clinics during a 6-month period. Parents of all male infants younger than six months of age coming for well-child care on select days (determined by staff availability) were approached by a nurse of physican-researcher (not their own health care provider) and asked to complete the form. The completed form was collected when the parents left the waiting room for their infant's examination. Eight questions were directed at the decision making process and timing, with multiple choice or yes-no responses, and 3 questions asked about religion and location of prenatal care. The last 2 questions offered a list of reasons for deciding for or against circumcision, and respondents were asked to check all that applied as well as indicate the most important reason. Analyses of the timing of the decision versus the timing of the discussion was performed by the chi-square test (3 X 3 table: before, during, or after the pregnancy). Circumcision rates for parent

Results
Fifty-five surveys were completed. No parent refused to participate, but 3 surveys were returned uncompleted. Forty-two parents (76 percent) were seen at site A and belonged to an health maintenance organization through an employer or university; of these 23 (42 percent of total) received prenatal care from a private obstetrician or mures midwife, and 19 (35 percent of total) received prenatal care from a family physician. The remaining 13 participants (24 percent) were seen at site B, a community health center for patients without insurance or on public assistance; of these 10 had received prenatal care from a nurse midwife, and 3 listed other clinics. Respondents named 21 different physicians or nurse midwives as their providers, representing 7 different clinics. The most frequently reported provider had 7 patients, and the next most frequent 4 patients; thus the sample was not skewed by the practice of any single provider. Forty-four (80 percent) infants had been circumcised.




(Scanned Image)

Figure 1. Decision timing versus discussion timing.


Timing of the Decision
Most parents appear to make the circumcision decision early. Twenty-four (44 percent) reported making the decision before getting pregnant, but only 4 (7 percent) had discussed circumcision with a provider prenatally. Of the 19 (35 percent) who made the decision during pregnancy, 8 reported doing so in the first trimester. Consequently, most parents (37, 80 percent) reported making the decision before discussing circumcision with their provider. Figure 1 graphically illustrates this significant discrepancy between the timing of the circumcision decision and the discussion with the physician (P<0.005).

The Provider's Role in the Decision
Regarding the character of the providers discussion, 38 of 46 respondents (83 percent) described a neutral process, with 6 (13 percent) having it recommended and 2 (4 percent) being advised against it. Not surprisingly, then, when asked whether the discussion had changed the parent's mind about circumcision, 38 (83 percent) said no. Of the 8 (17 percent who said yes, 5 (62 percent) chose circumcision, not a significant difference, 7 reported a neutral discussion, and only 1 reported a provider expressing an opinion (in that case favoring circumcision, and that infant was circumcised).

Of the 6 infants whose providers recommended circumcision, all were circumcised, whereas of the 2 infants whose providers recommended against circumcision, whereas of the 2 infants whose providers recommended against circumcision only 1 was not. Seven of these 8 parents reported making their decision before the provider's discussion; only one chose circumcision postpartum after having it recommended.

Reasons for the Decision
Table 1 illustrates the relative ranking of reasons for choosing circumcision. Patients were allowed to check all applicable reasons and then asked to choose the most important, if possible. Consistent with past studies, hygiene and preventing the procedure at a later age were the most important factors for parents, with other social concerns being less important. In contrast to past studies, however, medical benefits were reported more often as reasons for circumcision.


Table 1. Reasons Parent (n=44) Chose Circumcision.
                                                                Most
Reason*                                       Number  Percent Important†

It's easier to keep the penis clean             11       67      18
Its easier to do it now than when he's older    29       63       8
Medically, its better to be circumcised         19       41      10
The baby's father is circumcised                17       37       1 
My physician recommended it                      6       13       -
My son should be like the other boys             5       11       2
Its important in my religion                     5       11       2 
Other
   Appearance                                    2        5       -
   Culture                                       1        2       1
   Family pressure                               1        2
   Father insisted                               1        2       -

*Respondents were asked to check as many as applied.
†Not all respondents marked a most important reason.

Table 2. Reasons Parents (n=11) Refused Circumcision.
                                                                 Most
Reason*                                       Number  Percent  Important† 
It's just not necessary                          8      73        6 
It's painful for the baby                        4      36        1 
The baby's father is not circumcised             2      18        1
Not sure                                         2      18        1 
Other 
Hospital failed to do it after birth             1       9        1
Medically its better not to be circumcised       0       0        -
My physician advised against it                  0       0        - 
I never thought about it                         0       0        -

*Respondents were asked to check as many as applied.
†Not all respondents marked a most important reason.

Religious requirement for circumcision was not a significant factor in this sample: only 2 patients (4 percent) belonged to religious groups who require circumcision (although 3 Christians checked religion as a secondary reason). Most parents reported their religioun as Christian (42, 76 percent); 9 (16 percent) reported no religious affliation: and 1 each (total 4 percent) reported Hinduism and Buddhism.

Reasons for avoiding circumcision are ranked in Table 2. No parents reported thinking the uncircumcised state was medically better: rather, most believed it was simply unnecessary. Parents did not report the father's status as important in the decision very often: however, of 8 infants with reportedly uncircumcised fathers, only 2 were circumcised.

Discussion
Although this study is clearly limited by the small and heterogenous sample, the findings are consistent with those from studies from 15 years ago, which showed that (1) that the circumcision decision is most often made before parents discuss the issue with their care providers, (2) that social concerns are more important than medical ones, and (3) that providers' discussions have limited impact on the decision made. Medical benefits were cited more frequently in this study than in past studies, although medical issues remain secondary to hygience and convenience. Given the limitations of this study, the minor increase in parents citing medical issues might or might not be important. The study design could have contributed to this finding as well, because the mere presence of this item on the survey could have prompted parents to choose it.

If this change is real, then advocates of circumcision might argue that parents are correctly interpreting the medical information given them. It is also possible, however, than parents are choosing the data that support their earlier decision, or than physicians' neutral discussions of circumcision might be subtly biased to support the parents' earlier decision. Two of the 8 physicians who offered a recommendation had more than 1 patient in the study, and both were reported by another patient to provide a neutral discussion. Thus, neutral discussions of circumcision can be influenced by parents' previous decisions, whether in the provider's content or presentation or the parent's perception.

Parents choosing against circumcision did not display strong beliefs that being uncircumcised was in any way better or healthier; they simply saw circumcision as unnecessary. An uncircumcised father appeared to be a strong predictor of the choice, although it is unclear how this fact affected the parents' decision-making process. Because these parents did not rate the father's status as important, having a similar appearance is probably not the issue. This finding also raises the issue of whether parents are being provided with information about the potential medical benefits of not being circumcised.

The multiple choice design used in this study could have introduced another bias in this study by forcing parents to make a decision. This format assumes that parents had some level of information, at least about the choices they indicated, when in fact parents might have had very little information to guide their decision. Thus while some conclusions can be made regarding the relative weight of social versus medical concerns, nothing can be inferred from this study regarding the depth of understanding of circumcision issues by the respondents.

In summary, then, this study suggests that parents continue to have preformed decisions regarding circumcision based primarily on non-medical concerns, which are unlikely to be changed by attempting neutral discussion of the relative risks and benefits. Physicians should be aware that parents who have already made the circumcision decision might perceive a neutral discussion of circumcision differently from parents who are undecided. In the former case a supportive approach is unlikely to change most parents' decisions, while in the latter a more complete discussion would be appropriate. Given that most parents make the circumcision decision early, physicians who wish to affect the decision should consider discussing it at preconception visits or early in prenatal care. Regardless of the extent of the discussion informing the parents' choice, if circumcision is chosen, informed consent noting the specific immediate risks must still be obtained.

References

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Submitted, revised 8 June 1998.
From the Family Health Center,
Provena Saint Joseph Medical Center,
Napierville, Ill.
Address reprint requests to Jeffrey D. Tiemstra, MD,
Provena Saint Joseph Family Health Center,
24024 West Brancaster Dr,
Napierville, IL 60564.



Citation:
(File revised 7 October 2002)

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