THE CIRCUMCISION REFERENCE LIBRARY
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
TABLE 1. Frequency Rate of Circumcision of Newborn Males at Tripler Army Medical Center
Total No. Newborn Circumcision
Male Circumcisions Frequency
Period Births Done Rate%
Before study 15,904 14,370 90.4
(1973-1981)
Videotape 831 586 70.5
counseled
group
(January-June 1982)
Control group 866 657 75.9
(July December 1982)
After study
(July-December 1983 819 718 84.7
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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.
TABLE 2 Newborn Circumcision Frequency Rate at
Kapiolani Children's Medical Center, Honolulu, Hawaii*
Total Circumcision
Male Newborn Frequency
Year Births Circumcision Rate%
1973 2,544 2,297 90
1974 2,537 2,327 92
1975 2,614 2,310 38
1976 2,853 2,480 87
1977 2,950 2,405 82
1978 2,918 2,214 76
1979 3,009 2,672 89
1980 3,287 2,576 78
1981 3,310 2,867 97
1982 3,259 2,777 85
Totals 29,281 24,925 85
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D Seto written communication, September 1983
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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.
TABLE 3. Newborn Circumcision Frequency Rate at
Tripler Army Medical Center, Honolulu, Hawaii
Total Circumcision
Male Newborn Frequency
Year Births Circumcision Rate%
1973 1,794 1,701 95
1974 1,775 1,580 89
1975 1,777 1,675 94
1976 1,899 1,799 94
1977 1,838 1,720 93
1978 1,701 1,509 89
1979 1,840 1,692 92
1980 1,726 1,488 86
1981 1,554 1,226 79
Totals 15,904 14,370 90
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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.
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).
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).
Table 4. Newborn Circumcision Frequency Rate at TAMC
After Four Months of Counseling by One Senior Pediatric Resident
(July Through October 1978)
Total Circumcision
Male Newborn Frequency
Month Births Circumcision Rate %
July 152 122 80
August 142 115 81
September 180 143 79
October 135 111 8
Totals 609 491 81
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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.
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