Circumcision Decision

By Deena H. Blumenfeld, RYT, RPYT, LCCE

 

Adapted from the original article at Science & Sensibility, “Parental Autonomy in Decision Making: A Follow-Up to the AAP’s Newborn Male Circumcision Policy Statement” http://www.scienceandsensibility.org/?p=5322

 

As parents, we face many decisions regarding how we raise our children.  It’s everything from what to name them; which car seat to purchase; choosing a pediatrician; what school to send them to; and so on.  If you are having a boy, you may be wrestling with the choice of whether to circumcise your son, or to leave his penis intact.  It’s not an easy choice to make for some families; others have no doubt about what they will do when their son is born.  Hopefully, this article will assist you in feeling confident in your decision regarding circumcision.

 

On August 27, 2012 the American Academy of Pediatrics (AAP) released their new Policy Statement on Male Circumcision. http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1989.full.pdf+html It caused somewhat of a stir in the online parenting communities and in the media. Ok, so maybe it caused a big stir…  In much of the coverage I’ve read online, I found much vitriol, anger and self-defensiveness, as well as overly aggressive behavior and dismissive or patronizing attitudes. This is entirely unsurprising. Circumcision has been a “hot button” issue for many years. This reaction comes not only from the mainstream media and individuals, but from the anti-circumcision organizations as well.

 

I’d like to explore the issue in a more objective and compassionate manner. Looking at the rationale behind circumcising (or not), we find multiple reasons, falling into two main categories: social and medical.

 

Social reasons regarding circumcision:

  • Religious beliefs
  • Perceived sense of what’s normal with regards to how his penis should look.
    • Wanting the baby to look like his dad.
    • Fear of the child being the only one in the locker room who doesn’t look like his friends.
  • Ethical belief that:
    • Circumcision is genital mutilation.
    • The child has autonomy.

 

Medical reasons regarding circumcision (cited from the AAP’s policy statement):

  • Reduction in rates of:
    • Urinary tract infections
    • Penile cancer
    • Transmission of some sexually transmitted infections, including HIV
  • Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure.

 

From the new policy statement, the AAP concludes:

 

“Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns. It is important that clinicians routinely inform parents of the health benefits and risks of male newborn circumcision in an unbiased and accurate manner.

Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.”

 

So, as a parent of a baby boy, how do you make this decision?  It is a multifaceted issue and no one person can tell you what the “right” choice is.  For some parents, the medical reasons carry greater weight than do the social or religious reasons.  For other parents, the social or religious reasons carry greater weight over the medical reasons.

 

On the medical side, just as we do with prenatal testing, medications or procedures during labor, vaccines for our children, etc., we look at the benefits of the treatment and the risks. We compare these to our own risk tolerance levels and then decide “Is this treatment / medication / procedure right for me?”

 

On the softer, but no less valid side, are our belief systems. We use our religion, our upbringing, and our societal norms to help us determine the right course of action.

 

How does the AAP feel regarding the social and religious influences on circumcision decision making?

 

“Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.”

 

“Parents and physicians each have an ethical duty to the child to attempt to secure the child’s best interest and well-being. Reasonable people may disagree; however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other. This situation is further complicated by the fact that there are social, cultural, religious, and familial benefits and harms to be considered as well. It is reasonable to take these nonmedical benefits and harms for an individual into consideration when making a decision about circumcision.”

 

This theme of parental choice is written throughout the document, overshadowing the medical evidence presented.

 

Trends and statistics in the United States:

Right now the circumcision rate in this country stands at about 50-60%, depending which survey you look at.  (All of the surveys are in regards to hospital circumcision.)  The rates of circumcision in the U.S. are declining, overall. 

 

Coming full circle: When you, as a parent, are trying to decide whether it makes sense to circumcise your baby boy, or to leave him intact, understand that the decision lies solely in your hands and that there is no “right” choice. Circumcision should be discussed by your obstetrician or midwife.  It should be discussed by your childbirth educator. Your pediatrician will offer guidance. Your family and friends will have their own opinions and the online universe will work diligently to try to convince you one way or the other.

 

Take a deep breath. Understand, as the AAP does, that you are the only one who knows what’s best for your baby, and whatever choice you make will be the right one for him.

 

How is this approached in your childbirth education class?  Every instructor will have her own approach.  However, she should be fair, compassionate and keep the environment of her classroom well balanced and safe for all students.

 

What should be covered in your childbirth class?

  • The medical and social reasons to circumcise (or not)
  • Addressing circumcision in your birth plan
  • How the procedure is done
    • Including risks and benefits
  • Your options, should you choose to circumcise
    • Shortly after birth, in hospital
    • A few days or weeks after birth in your pediatrician’s or family practice doctor’s office
    • At home, with a religious ceremony, such as a Bris
  • Care of the circumcised penis
    • Including warning signs for infection, etc.
  • Care of the intact penis 
    • Including what is normal, bathing, etc.
  • She may provide a handout with additions resources to which you may refer later.

Deena is a Certified Khalsa Way™ Prenatal Yoga Teacher and Lamaze® Certified Childbirth Educator. She has been practicing yoga for more than 15 years. She became a certified Yoga instructor through 3rd Street Yoga in December 2008. She completed her 60 hour Prenatal Yoga training in February 2009 in Los Angeles at Golden Bridge Yoga with Gurmukh.

Her Lamaze certification was completed in October 2010, through Magee Women’s Hospital and Lamaze International. She is an advocate of empowered birth for women. Through the teaching of Prenatal Yoga and Childbirth Education classes, she helps women become more confident in their choices regarding pregnancy, birth and parenthood. Deena has also studied yoga with Doug Keller, Max Strom, KK Ledford and Shakta Kaur Khalsa. Her ongoing professional development as a Childbirth Educator has been with Ina May Gaskin, Penny Simkin, Gail Tully of Spinning Babies and other childbirth professionals.

Deena is also a mom of two – a son, born via c-section in April 2005, and a daughter in March 2009, a VBAC. She is an active member of the local ICAN chapter and a member of the Coalition for Improving Maternity Services.

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Comments

  1. Jessica English says:

    Thanks for the interesting article. I disagree that circumcision “should” be discussed in a childbirth class, although many educators may choose to do so. As an educator I see this as a newborn care issue and not a birth issue. I do not discuss care of circumcised/intact penises with my students, this is something that they should be learning in a baby care class. Although I support my students in making their own informed decision on this issue (and all others), I am ethically opposed to circumcision and do not feel comfortable discussing circumcision as if it is an equal option to leaving a boy intact. Neither do I push my students toward intactivism. The best solution for me is to encourage them to make an informed decision on their own, and to offer up resources if they are interested in learning more. I think there is room for CBEs to make their own informed decisions about the best way to handle this in their own class.

  2. Jessica ~

    While I respect your opinion not to teach about circumcision in your CBE class, the AAP believes it should be discussed in a childbirth class, and so do I.

    From the AAP’s Policy Statement:
    “For parents to receive nonbiased information about male circumcision in time to inform their decisions, clinicians need to provide this information at least before conception and/or early in the pregnancy, probably as a curriculum item in childbirth classes. Information to assist in parental decision-making should be made available as early as possible.”

    Since circumcision is often done in hospital, before a family heads home postpartum, it is part of the postpartum information we should provide to our students.

    I do suggest, since you are a CBE, that you pop over to Science and Sensibility and read the version of this post geared towards educators. http://www.scienceandsensibility.org/?p=5322
    There, I discuss, more clearly, how to approach circumcision with your students.

  3. Jessica English says:

    With all due respect, given the AAP’s widely criticized new recommendations on circumcision (in contrast to every other major medical organization in the world), this is certainly not an organization from which I take teaching advice. No more than I would teach based on ACOG’s stance on any given issue, as they are not necessarily evidence-based. Clearly you are entitled to your opinion, but each educator really must make her own determinations on this issue.

  4. This article was disappointing to me as a childbirth educator, as while you started out saying that you were going to be more compassionate and objective, I feel that the issue was not really delved into. To write an article about circumcision is to cover the benefits and risks, which was not included here.

    I have been teaching circumcision for over five years in my class. Not because the AAP says so, but because my experience as a first-time mother going through a hospital practice was that circumcision wasn’t covered. I was only given a pamphlet by the practice I went through and the information I found on my own was so drastically minimalized that only later, when it was too late to make a truly informed decision, did I learn what information I was missing.

    Parents deserve to have evidence-based information to make informed decisions. And that shouldn’t be only secluded to labor and birth, in my opinion. However, I do believe that CBE’s have the right to not teach it if they feel they cannot be unbiased in their teaching. I certainly have changed the way I teach it in the five years I have been teaching. I just wonder where parents get their information otherwise…I know I thought I had enough information to make that decision the first time around and I definitely did not.

  5. Karen says:

    In my classes, I do teach about circumcision, with an eye toward the fact that there will always be some parents who see a benefit in this elective procedure, therefore I feel obligated to provide information to protect the child’s interests as best I can by educating parents on care of the circumcised penis. Many parents take birth prep classes and maybe a breastfeeding class, but not a baby care class, so it’s important to reach as many parents as possible.

    As part of any circumcision discussion, however, parents have a right to know about the normalcy of the foreskin and the fact that the conditions and diseases that circ is supposed to prevent can also be prevented by other means – specifically, not retracting the foreskin, use of condoms (which circumcised men should also do), and breastfeeding, among others. This is the evidence I present. It usually takes about 10 minutes of class time, and I always have parents say, “Wow, I didn’t know all this!” I also encourage them to view circ videos online at home if they wish, as that is part of informed decision-making.

    We should all keep in mind that the AAP is a trade organization and exists, not to further the health and welfare of society, but to further the interests of its members – physicians. As such, its advice can be somewhat biased. As with other aspects of birth and parenting, the established practice for the penis is to do something rather than nothing – a stance that can be good for medical workers but not always for patients.

    As an aside, when I was pregnant with my first and taking childbirth classes (through a different method), every couple in the class was expecting or went on to have a boy. It was not a covered topic, and when a student asked about it, the teacher stuttered through a quick comment about how her son was born at home and so they just never went in to have it done. She provided absolutely no information whatsoever. I still feel like we as her students were shortchanged. The reason parents seek education in the first place is so they don’t have to wade through the excess of information out there. If they wanted to do 100% of their own research on every topic, they wouldn’t pay to take a class.

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