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Parental Autonomy in Decision Making: A Follow-Up to the AAP’s Newborn Male Circumcision Policy Statement

Deena Blumenfeld follows up my recent post on the AAP’s new policy statement on circumcision with a great look into what it means to have parental autonomy for minor children and how childbirth educators need to look out into the faces of their students, recognizing that the families in our classes come from a wide variety of backgrounds and bring a diverse set of cultural norms as they enter the world of parenthood. – SM

On Monday, August 27, 2012 the American Academy of Pediatrics released their new Policy Statement on Male Circumcision. This is a follow-up post to the Science & Sensibility post written last week by Sharon Muza. In that post, Sharon did a lovely job of explaining the Policy statement and asking some pertinent questions to us, the childbirth educators, regarding how this affects the classes we teach.

Photo Image Creative Commons Anthony J

The majority of other pregnancy, birth and parenting organizations have played it very safe, by doing nothing more than noting that the AAP has updated their policy. ACOG affirms and supports the AAP’s policy on circumcision, but it is the obstetricians who do the majority of the circumcisions in a hospital setting, so this is logical.  I’ll be the brave one and step out into the frying pan.

This article is not intended to examine every aspect of the policy for its validity, strength of evidence or research points left untouched. My intention is not to debate condom usage, Medicaid, money, the usability of the Africa studies or the fact that the AAP did not mention anything about the function of the foreskin. Enough of this dissecting is going on elsewhere online, in both conference rooms and living rooms.

I wanted to look at the AAP’s circumcision policy statement from a different perspective. In much of the coverage I’ve read online, I find 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 also from the anti-circumcision organizations as well.

I’d now like to look at something that has been touched on, but glossed over by the mainstream media with regards to this policy. It’s also been virtually ignored by the opponents of circumcision as well.

That is, these series of statements made by the AAP in their policy statement:

“Parents should determine what’s in the best interests of their child.”

“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.” (Emphasis mine)

 “It emphasizes the primacy of parental decision-making…”

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

Circumcision is a fundamental part of the core belief system for many people, whether stemming from religious practice or social norms. When we have new scientific evidence that is in contrast to such a core belief, people feel rattled and defensive. A mother recently said,

“I really think they took a stance on the issue because Medicaid dropped coverage. And I agree that it should be covered. But now those of us who choose to leave our sons intact can be left to feel irresponsible.” (Emphasis mine)

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. For example, a Jehovah’s Witness will decline a blood transfusion or other blood products because it is not within their framework. There are those who say this is “silly” or “dangerous,” yet we respect this practice in hospital because it is appropriately respectful of that individual’s autonomy.

When it comes to circumcision, the decision making process should be no less than it is for any other medical procedure. Primum non nocere, first do no harm, must include religious beliefs and societal norms to preserve patient autonomy. By ignoring these, in favor of a strictly medical practice, the physician does emotional harm to the patient. If we are to foster an environment of trust and respect between doctor and patient, then the doctors need to respect the patient’s social norms and mores. Conversely, the patient must respect the doctor’s position providing the best evidence to support or oppose a procedure / treatment / medication, etc.

With circumcision, the patient is an infant. This presents an interesting ethical dilemma. The medical decision may or may not jive with the parents’ personal paradigm. The infant has not the capacity to make the decision for himself. He is, by legal definition, incapable of making such choices for himself, and at a practical level a two day old baby cannot understand nor communicate his desires or reservations about circumcision.  Therefore the decision regarding circumcision lies solely with his parents and the argument for infant or child autonomy becomes moot. The AAP acknowledges as much.

 “The practice of medicine has long respected an adult’s right to self determination in health care decision making. This principle has been operationalized through the doctrine of informed consent. The process of informed consent obligates the clinician to explain any procedure or treatment and to enumerate the risks, benefits, and alternatives so the patient can make an informed choice. As a general rule, minors in the United States are not considered competent to provide legally binding consent regarding their health care, and parents or guardians are empowered to make health care decisions on their behalf.”

This brings me full circle to the first post regarding the AAP’s policy on circumcision and Sharon’s question regarding how as childbirth educators, do we address this in class? Personally, I find it a daunting topic to broach, and I have a vain hope that all my students are having girls, so that I don’t need to discuss it at all.

It’s a tough game of balance to negotiate my own bias towards leaving boys intact, the factual information I need to provide to my students, and their predetermined decision regarding circumcision. From the AAP’s recent policy statement;

 “There is fair evidence that parental decisions about circumcision are shaped more by family and sociocultural influences than by discussion with medical clinicians or by parental education.”

“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.”

So, I do broach the subject. I find most parents are receptive and open to the information I offer in class. The comments I hear most are “Oh, I didn’t know I couldn’t go with my son for the procedure.” “I didn’t know I had a choice, I thought everybody circumcised.” “That’s how they do it?!?”

Parents need to know all of their options, with regards to circumcision. Do it, or not; do it in hospital, in the doctor’s office or at home in a religious setting; do it now, do it later; benefits and risks, and so on.

 They also need to know that their upbringing, social norms, religion, etc. matter. Not only does the AAP think they matter, but I do too. I don’t walk in my student’s shoes. I don’t know their life experience, their religion or their conventions. We are relative strangers, yet we discuss some very personal topics. I find it imperative that I give my students all the information I can, so they can make the best choices for their family.

“Be kind, for everyone you meet is fighting a hard battle.” -Plato

We can never fully understand from whence another person’s opinions rise. Our beliefs polarize us. The middle is often lost in the shuffle because we defend our ideals to the death. The other person is wrong, no matter what. Somewhere along the way we lost compassion and empathy. When we have such strong feelings towards another group we lose sight of the others’ humanity.  “Remember, the other person is you.” – Yogi Bhajan

 Please, keep your sense of compassion when discussing the issue of circumcision with new parents in your classes and with those whom you interact with online.

 “If you want others to be happy, practice compassion. 

If you want to be happy, practice compassion.”

Dalai Lama

American Academy of Pediatrics, Babies, Childbirth Education, Circumcision, Evidence Based Medicine, Guest Posts, informed Consent, Newborns, Parenting an Infant, Research, Social Media , , , , , , ,

  1. September 6th, 2012 at 07:31 | #1

    Deena, thanks for writing this post! It is always important to acknowledge that parents bring their values, culture, ethics and religion to both class AND to parenting. As educators, we must recognize that and respect that. Whether or not a person agrees with the AAP’s newest policy statement or not, the APP was clear that parental autonomy has a very important place in the decision. Thank you for your thoughtful post!

  2. avatar
    Sarah White
    September 16th, 2012 at 10:43 | #2

    Deena,
    Thank you for writing this. In my opinion, the choices of the parents need to be respected either way and as a provider, we all need to do our best to give the information unbiased and be supportive.
    Thanks again!

  3. October 4th, 2012 at 17:36 | #3

    Deena, this is very helpful and thoughtful. I have also worried about how to cover circumcision in class. Especially as a new CBE. My own preference for leaving boys intact isvery strong and I worry about how to present all the information fairly and accurately. I think it is important to cover as parents are asked to make the decision upon admission to hospital during labor.

  4. October 22nd, 2012 at 09:21 | #4

    Thank you for addressing this issue, Deena. Parent autonomy is important, as any CBE worth anything strives for that in their classes. I do disagree (respectfully yet) strongly with you, however, about not teaching circumcision to families who are having girls. I always teach it, despite my feeling uncomfortable, even if there are all girls expected in the class. Why?
    First, because ultrasounds are not 100% correct and someone might end up with a boy who was just coy or shy during ultrasounds (or the tech might get it wrong–they are human after all). I realize this most likely does not happen too often these days, but it is a possibility.
    Second, because if the parents go on to have another child who is a boy in the future, they most likely will not take another class. And perhaps they won’t know where to look for information or resources.
    Regardless, as a former patient/client who was given very limited information on circumcision, I feel that presenting information on this topic is important. I have had some really great discussions in my classes about this topic. I have also had only crickets sound when I ask if there are questions or information others have. As it always goes, each class is different.

  5. avatar
    Karen
    November 2nd, 2012 at 08:56 | #5

    I just wanted to offer a thought: yes, childbirth education *must* be sensitive to the social and cultural factors that affect parents’ choices. However, we don’t teach our classes according to what parents *want* to do, we teach according to what the evidence says.

    Look at it this way: in the care provider-patient relationship, the care provider has their own preferences and values that they operate within, yet the patient is the one who has to live with the outcomes of the decisions that are made. So just because a care provider believes that all women must receive an episiotomy, that does not mean that routine episiotomy is best for their patients. I’m not talking about the ones who cut an episiotomy as the mother is very vocally refusing one (though I’ve seen that happen), but the care providers who just go ahead and cut one without first obtaining consent or having any discussion at all about it either before or during the birth. We all know it happens often, but that doesn’t make it best for women. Just because you can do it without consent and then convince the mother afterward of its necessity, doesn’t mean you should do it. For most women there are alternatives to episiotomy, and so I’m not going to teach in my classes that my students should get one just because their doctor prefers to do them, even though they do in effect have to give birth within the framework of their doctors’ preferences and values.

    In short, we teach what the evidence says is best for mothers and babies. Not what cultural preferences dictate is the “appropriate” course for labor, birth, and early parenting.

    Therefore I’m not going to teach that circumcision is justified by the evidence, because it isn’t – no matter what the parents like or prefer or want. Instead I’m teach solely what the evidence says. I tell my students about the normal structure and function of the intact penis, including the protective functions of the foreskin. I teach them how to care for the penis (you know, the normal one, the one with a foreskin.) I teach them what the evidence says about avoiding retraction and breastfeeding being equally effective to circ in preventing UTIs. I teach what the evidence shows about the risks of circumcision as well. Because that’s what the evidence shows, not because I’m catering to any particular belief system.

    I do teach them how to care for the circumcised penis, because I know that there are some who will choose that no matter what. I also teach perineum care after episiotomy, cesarean recovery and comfort measures, etc, because I know there will be some who need that information. But none of these things are physiologically normal and I don’t teach them as an equal and viable alternative to the norm. Instead I teach them ways to avoid interventions and stick to what their bodies are designed for.

    It’s also important to note that there are many people of faith who are choosing not to circumcise their sons. I am such a one. We can’t assume that just because someone in our classes subscribes to such a faith, that they automatically will want to circumcise.

    By teaching just the evidence and leaving emotion out of it, we will always teach the truth.

  6. avatar
    Kelly
    November 13th, 2012 at 09:09 | #6

    I am not a childbirth educator but wanted to add that I sure wish the truth about circumcision had been discussed in my childbirth class before having my first son. If I had learned the value and functions of the foreskin, I would not have consented to my son being cut. All I got was a family practice doc that said “I’m pro-circ, I think it should be done.” And a husband that insisted on doing it. So I went against my instinct and my son was handed back to me with stitches in his penis. Please, share the truth, share accurate information, share facts – it is time to end this barbaric practice. Baby boys have no voice – someone needs to speak up for their basic human right to genital integrity.

  7. avatar
    mary lanser
    January 20th, 2013 at 15:35 | #7

    While this is an excellent article….and I agree with most of it….no where is it made clear that a parent is making a “proxy” consent for their child to be circumcised. A proxy consent has specific criteria…..which although the AAP never once mentions it by name….that infant circumcision does NOT fit. Not to mention that the first sentence of the Doctors oath is to “DO NO HARM”….. and even the AAP recognizes that there is risk of harm. The truth is that you can’t surgically alter form…without altering normal function…there is no way around it, so the harm that is possible and probable is far more vast than we are lead to believe. The AAP states that they do not recommend routine infant circumcision for all infant boys…..and of course they don’t, how could they? The real evidence only suggests “benefits”….. which is shaky at best….but what the AAP fails to highlight or even mention is that foreskin is NORMAL and is supposed to be on a baby boy and it is a necessary part of his nature made natural body. For the AAP to completely disregard this very fact is unethical, just as down playing the complications that can and often do occur when performing this very unnecessary and traumatic surgical procedure on a newborn. Foreskin is NOT a birth defect……in fact, when a baby boy is born rarely without one….it IS considered a birth defect! This is the core of the lack in ethics with the AAP revised statement. Of course, the fact that the AAP is basically a “trade” organization….also puts them in an unethical light as they openly advocate for an unnecessary surgical procedure to be funded by insurance and medicaid. No other unnecessary surgical procedure is covered under these so one must ask themselves, why should this be covered when it is not done as an immediate medical necessity to the infant? Good question.

  8. avatar
    Kristine
    January 20th, 2013 at 16:04 | #8

    Let all babies keep all of their body parts. Circumcision rates are dropping with more education. So get educated, and find out why the way babies are born, are the way they should stay!

  9. avatar
    Samantha M Gale
    January 20th, 2013 at 16:05 | #9

    Since I have yet to hear about an intact boy experiencing genitalia explosion, I refuse to believe it’s not a choice that can be left for a man to decide on his own when he’s old enough. Female circumcision is illegal in the US–why don’t boys get equal protection?

  10. January 20th, 2013 at 19:02 | #10

    This whole discussion reads very oddly from a developed country outside the USA (New Zealand) where infant circumcision was once almost universal and is now almost unknown. It must read even more oddly in countries such as Denmark, where infant circumcision has always been a purely minority-religion practice. Nowhere but the US is it even offered to parents.

    “With circumcision, the patient is an infant.” No, the infant is not a patient – there is nothing the matter with him or his penis.

    You are so busy being respectful of the parents’ right to decide the fate of their son’s foreskin that the son’s right to decide for himself (when he is old enough, of course) has been thrown out with the surgical waste. It is not true that later circumcision is more painful or risky, and very, very unlikely that he will ever want it or need it.

    More and more men are expressing their impotent rage that (the best) part of their genitals was cut off without so much as a by-your-leave. Infant circumcision is a human rights issue. His body, his rights. Girls’ genitals are already Federally protected from not just the horrors of sub-Saharan Africa, but ANY genital cutting whatsoever. Equality of the sexes demands no less for boys.

  11. avatar
    Rachel
    January 20th, 2013 at 22:32 | #11

    I guess I’m the only one here who has noticed the fundamental problem with this article. When other non-therapeutic practices are called into play (lets say a tonsillectomy) my rights as a parent are revoked. I have zero rights to use my religion, preferences or societal pressure as a reason to remove my child’s tonsils. Only in a situation where a tonsillectomy would be considered therapeutic am I able to enforce ‘informed consent’. Likewise, it is unlawful to remove healthy erogenous tissue from a child in the name of prevention. Any deviation from this fact is simply pandering and special pleading. We aren’t talking vaccines here people(additive process), we’re talking about a ‘subtractive’ process that has equal if not greater risk than benefit.

  12. avatar
    Juan Alzate
    January 20th, 2013 at 22:40 | #12

    In order to give unbiased information, I would recommend comparing the AAP statement to the Royal Dutch Medical Association’s Viewpoint or The Royal Australasian College of Pediatrics’ Policy on Circumcision from 2010. That will show that there is no real consensus on potential health benefits and or assessment of the damage.

    Also realizing that there is no other procedure where a parent brings a baby to have a healthy part of the body removed. This should on its own be a strong indicative of how abnormal infant circumcision is.

  13. January 21st, 2013 at 04:04 | #13

    People want to pretend like the latest AAP statement is something grand and “different.”

    Read it again.

    They try very hard to sell the line that “the benefits outweigh the risks,” but hidden in the statement, the part that nobody wants to talk about, is the fact that they *still* say these self-same “benefits” were not enough to endorse the practice; EXACTLY WHAT THEY SAID IN THEIR LAST STATEMENT.

    Let me run this by readers again; the AAP, a professional medical organization, could not use the latest “benefits” in order to issue a recommendation for circumcision. Yet, parents, most of whom are incapable of discerning medical literature, are expected to take the same information, that medical professionals could not use to recommend circumcision, and somehow come up with a more reasonable conclusion (than medical professionals with professional licenses???).

    Let’s also get serious about the idea that we actually care about what “studies” and “research” says. The AAP. Isn’t this the self-same organization that tried to endorse a “ritual nick” for girls?

    The “research” surrounding circumcision is actually flawed, and people would know this if they took the time to read it.

    But even assuming it were 100% accurate, is this any justification to perform needless surgery on a healthy, non-consenting minor?

    Is there a determined number of scientific papers that would ever convince you to circumcise your daughters?

    What if it could be proven beyond the shadow of a doubt that removing your child’s labia reduces AIDS, STDs and everything male circumcision was supposed to prevent? Would you do it?

    Let’s stop pretending like this is about “research” and “studies.” Most parents were planning to circumcise their child anyway because it’s become American tradition. All the research and what the AAP has to say is ad-hoc.

    But parents aren’t to be blamed for making “choices” based on limited information that their doctors, who make money from the procedure, give them.

    The bottom line question is this; without medical or clinical indication, how is it doctors can even be performing non-medical procedures on healthy, non-consenting infants?

    Let alone be giving parents any kind of a “choice?”

    How is it American parents have come to feel entitled to do this to their children?

  14. avatar
    Jessica
    July 1st, 2013 at 13:18 | #14

    You could start out with circ info by not even addressing circumcision itself. How about, “Let’s talk about the function and form of the foreskin- something a lot of you might not know about”. It’s non-confrontational, and then when circumcision does come up it’s not about pros or cons, it can go back to “Well, remember that his foreskin does belong to him, it’s his. Period.”

  1. September 21st, 2012 at 09:38 | #1
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