Decreased Circumcision Rate with Videotaped Counseling

Southern Medical Journal, Volume 69, Issue 6: Pages 717-20, June 1986.

ROBERT W. ENZENAUER, MD, MPH, JOHN M. POWELL, MD, THOMAS E. WISWELL, MD, and JAMES W. BASS, MD, Honolulu, Hawaii

ABSTRACT: Despite the lack of medical indication for routine circumcision in the newborn, neonatal circumcision continues to be done on the vast majority of male infants in the United States. A trial of videotaped "informed consent" counseling was undertaken to determine whether such counseling could affect the parental choice about circumcision. We studied the circumcision frequency rate (CFR) after videotape counseling. We compared it to the rates following standard oral counseling. Videotaped counseling, in contrast to the standard physician-parent oral counseling, significantly reduced the incidence of parents' requests for routine neonatal circumcision.

Since 1975, the American Academy of Pediatrics' position on circumcision is that "there is no absolute medical indication for routine circumcision of the newborn."¹ The decision to perform routine circumcision should be made after the parents have been properly counseled regarding the risks and benefits of the procedure.^1-2 Frequently, however, parent are either not properly counseled or not counseled at all.^2-5

The anti-circumcision movement is now supported by the American Academy of Pediatrics¹ and the American College of Obstetricians and Gynecologists.⁶ Non professional groups such as INTACT are now lending support. Additionally, circumcision as an unnecessary position is gaining attention in the popular lay pres.^6,7-13 Despite the abundance of of medical evidence and opinion against the procedure, most clinicians still recommend routine neonatal circumcision,¹⁴ and there has been no substantial decline in the percentage of male infants circumcised.^2,14 At our institution, the neonatal circumcision rate has remained essentially unchanged (at approximately %) during the last decade.

Patient education using printed materials has only rarely resulted in the reduction of the neonatal circumcision rate,¹⁵ and most authors have concluded that detailed counseling makes no difference in the incidence of circumcision.^16-20

Audiovisual counseling for certain routine, non-emergency surgical conditions is gaining popularity.¹⁹ A videotaped presentation ensures uniformity, especially in cooperative studies, and provides documentation of the degree of informed consent. In contrast to written and oral counseling, videotaped counseling is more applicable for various educational levels of parents.

We hypothesized that circumcision counseling using videotaped presentations would be effective in reducing the frequency of routine neonatal circumcision. We designed a clinical trial to test this hypothesis.

MATERIALS AND METHODS

A videotape summarizing factors relating to neonatal circumcision was prepared. The videotape included the major points of the Report of the Ad Hoc Committee on Circumcision Statement of 1975.¹ Specifically mentioned was the fact that there is no medical indication for routine neonatal circumcision. Complications of routine circumcision, absolute contraindications to neonatal circumcision, and a description of the circumcision using the Plastibell device (Hollister, Inc., Chicago, Ill) were also included. Additionally, official permission was obtained from NBC, Inc. to present Douglas Kiker's NBC News Magazine commentary, "Circumcision: The Casual Cut," which aired in November 1981.

In the experimental group, all parents of male children born between Jan 1, 1982 and June 30, 1982 were required to view the two video tapes before deciding for or against routine circumcision. The counseling was usually done within 36 hours after birth, in the evening of the first or second day of hospitalization. Both parents were required to attend. A house officer was present to answer questions.

In the control group, parents of all male children born during the six months after the initial intervention were counseled about circumcision by the house officer on call, without the videotape presentations. The counseling included an explanation of the procedure and its risks and benefits, but no specific instructions were given to direct their "informed consent" circumcision counseling. These oral presentations represented the same method of counseling that had been practiced before untaking the study.

The circumcision frequency rate (CFR) refers to the percentage of newborns circumcised during a given period. The circumcision frequency rate of the videotape-counseled group (the "experimental group") was compared with that of the control group. Additionally, the CFR of the experi--mental group was compared with that of the circumcision data from previous years at our institution, along with data from the year after completion of the study. Circumcision data obtained from a local civilian children's hospital were also evaluated. Data were tested for significance using chi-square analysis.

RESULTS

The 70.5% circumcision rate in the experimental group was significantly less than the average rate of 90% which characterized the previous years at our institution (P < .001) (Table 1). The CFR of the experimental group was also significantly less than the 75.9% rate of the control group (P/ < .05). The CFR has increased steadily after the cessation of videotaped counseling. During the six-month period after the completion of the study, the CFR further increased to 94.0% (P < .001). During the 12-month period after the first comparison group, the CFR has increased to levels that characterized the decade preceding the study.

During the study period the CFR at Kapiolani Children's Medical Center was essentially unchanged from what it had been during the previous nine years (Table 2) (D. Seto, MD, writen communication, September 1983).

DISCUSSION

Our results indicate that a videotaped presentation can effectively reduce the rate at which parents request circumcision. Videotaped counseling can markedly reduce physician time required to ensure informed consent. Videotaped counseling may help to ensure the consistency of counseling offered, and additionally may serve to protect the physician in litigation by documenting the material presented for making the informed consent.

The experience at our hospital, however, also suggests that "outspoken" pediatricians can affect the circumcision rate, though to a lesser extent and only after much physician time and effort. The decreased circumcision rate in the 1981 prestudy period (Table 3), though not perceived at the time, is no doubt the result of the vocal leadership by two senior pediatric residents (R.W.E. and J.M.P.), who aggressively counseled against neonatal circumcision to a wide audience. Formal didactic lectures, including slide presentations, were given to the pediatric house staff, obstetrical house staff, and the pediatric and obstetric nursing services. All rotating interns and family practice house staff were similarly instructed before their rotation through the pediatric department. This conceivably could have resulted in more active counseling in favor of non-circumcision during this period, and also more suitable "support" of the noncircumcision choice by the staff. A similar reduction in the neonatal CFR occurred in 1978 when another outspoken senior resident in pediatrics at Tripler Army Medical Center personally counseled all parents of newborns over a four-month period. (Table 4) (M.E. Holton, DO), written communication, January 1979).

The gradual increase in the CFR after the sysematic videotaped counseling was discontinued is intriguing. An apparent "residual" effect on the CFR is apparent at least 12 months after termination of the intervention. Several explanations for these findings are plausible. The prolonged reduced rate of circumcision is no doubt in part a function of "contamination" of the poststudy comparison groups by the experimental group families. Particularly in the context of the rather close social organization of an army post, information and opinion gleaned from the videotaped presentation may have been sytematically shared among other families with pregancies in progress. This form of bias would have been served to underestimate the true effect of the intervention by disseminating its effects into "control" group families having an infant later in the year.

During the period of videotaped counseling, there was a noticably increased interest in the subject of neonatal circumcision amongst the non-physician postpartum staff. However, military life is characterized by frequent moves (every two or three years). A "washout" effect will be evident among the supporting professional staff in the postpartum unit as departing nurses and aides leave, being replaced by by individuals who were not exposed to the videotaped presentations for six months. There was considerable support by the hospital staff for the non-circumcision choice during the time when the videotapes were being aired.

Since the NBC documentary was aired publicly in November 1981, the decrease in CFR may instead represent a general effect on the population at large. However, no similar trend was evident in the local civilian population. The particularly low rates during the six-month intervention period could be viewed as a kind of anamnestic response to the second viewing of the NBC tape.

Consistent, informative videotaped counseling can affect parental choice about circumcision as late as after delivery, but we believe that all parents should be counseled about the risks of circumcision long before delivery to allow enough time to deliberate and reach a fair and knowledgeable decision.

Pediatricians should be outspoken child advocates. We strongly agree with Gellis²⁰ that physicians should become much more vigorous than they have been in discouraging circumcision of the newborn. Wallerstein's conclusion is that "routine infant circumcision is archaic, useless, potentially dangerous, and therefore should cease."⁶ Videotaped counseling is perhaps a means to that end.

Acknowledgements. We thank Mr. Douglas Kiker and NBC, Inc. for permitting us to use "the Casual Cut" as part of the circumcision counseling. We also thank Dr. Dexter Seto, Director of Research at Kapiolani Children's Medical Center, for obtaining the circumcision data from his hospital.

References

1. American Academy of Pediatrics Committee on Fetus and Newborn: Report of the Ad Hoc Task Force on Circumcision. Pediatrics 56:610-611, 1975.
2. Boyce WT. Care of the foreskin. Pediatr Rev 5:26-30, 1983.
3. Herrera AJ, Trouern-Trend JB: Routine neonatal circumcision. Am J Dis Child 133,1069-1070, 1979.
4. Patel H: The problem of routine circumcision. Can Med Assoc J 95:576-581, 1966.
5. Wallerstein E: Circumcision: An American Health Fallacy Appendix C The ACOG Position on Circumcision. New York, Springer Publishing Co. 1980, p 218, p 197.
6. To circumcise or not? (Medicine section) Newsweek 94 40, 1979.
7. A son's rite: circumcision is unnecessary (Medicine section) Time, August 31, 1981.
8. Otten C: The case against newborn circumcision (Speaking Out Section) Saturday Evening Post 253:26-29, 110, 1981.
9. Panter GG. Circumcision: making the choice. Parents 56:82-84, 1981.
10. Brown WA, Kane L: Routine circumcision--a re-evaluation. Mother's Manual 18:14-15, 1982.
11. Kiker D: Circumcision: the casual cut. NBC News Magazine November 1981.
12. Patel DA, Flaherty EO, Dunn J: Factors affecting the decision about circumcision. Am J Dis Child 136:624-636, 1982.
13. Gorske AL: Circumcision and patient education. Am J Dis Child 134: 327, 1980.
14. Herrera AJ, Hsu AS, Salcedo CT, et al.: The role of parental information in the incidence of circumcision. Pediatrics 70: 597-598, 1982. [Abstract]
15. Bennett HJ, Weissman M: Circumcision knowledge isn't enough. Pediatrics 68:750, 1981. [Abstract]
16. Maisels MJ, Hayes B. Conrad S. Chez RA. Circumcision: the effect of information on parental decision making. Pediatrics 71:453-455, 1983. [Abstract]
17. Herrera AJ, Cochran B, Herrera A, et al. Parental information and decision making in highly motivated couples with higher education. Pediatrics 71:233-234, 1983. [Abstract]
18. Land JN. Parental information and circumcision. Pediatrics 72:142-143, 1983. [Abstract]
19. Barbour GL, Blumenkrantz MJ. Videotape and informed consent decision. JAMA 240;2741-2742 1978. [Abstract]
20. Gellis SS. Circumcision. Am J Dis Child 132;1168-1169. 1978.

• Enzenauer RW, Powell JM, Wiswell TE, et al. Decreased circumcision rate with videotaped counseling. South Med J 1986;796:717-20.

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