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

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