PAEDIATRICS & CHILD HEALTH (Ottawa),
Volume 9, Number 9: Pages
Circumcision Policy: A Psychosocial Perspective
Ronald Goldman, PhD
R. Goldman. Circumcision policy: a psychosocial perpective. Paediatr Child Health 2004;9(9):630-633.
The debate about the advisability of circumcision in English-speaking countries has typically focused on the potential health factors. The position statements of committees from national medical organizations are expected to be evidence-based; however, the contentiousness of the ongoing debate suggests that other factors are involved. Various potential factors related to psychology, sociology, religion and culture may also underlie policy decisions. These factors could affect the values and attitudes of medical committee members, the process of evaluating the medical literature and the medical literature itself. Although medical professionals highly value rationality, it can be difficult to conduct a rational and objective evaluation of an emotional and controversial topic such as circumcision. A negotiated compromise between polarized committee factions could introduce additional psychosocial factors. These possibilities are speculative, not conclusive. It is recommended that an open discussion of psychosocial factors take place and that the potential biases of committee members be recognized.
Key Words: Circumcision; Evidence-based medicine; Health policy; Peer review
The debate about the advisability of
non-therapeutic neonatal circumcision in English-speaking countries typically
has focused on potential health factors (e.g., prevention of infection and
disease). The conflicting opinions and conclusions in the medical literature on
circumcision, together with the tenacity with which advocates and critics of
circumcision hold on to their viewpoints suggest that deep unrecognized or
implicit psychosocial factors are involved (1). The existence
of these factors may influence decision-making on national circumcision
policies. The present article contends that by taking these factors into
account, the policy making process and the policies produced can be improved.
This discussion focuses primarily on American circumcision
policy, with pertinent discussion of other countries, because the United States
has the highest nonreligious circumcision rate, the most contentious
circumcision debate, the most detailed circumcision policy statement, and the
most international influence. Circumcision practice in other countries has been
introduced by contacts with Americans (2), and American
circumcision advocates promote circumcision to other countries (3). In Canada, the circumcision policy statement is based on
references that are about 75% American (4).
Policy makers do not change policies unless the pressure to change is greater than the pressure to maintain the status quo (5). These pressures can include policy makers’ personal attitudes and opinions (internal emotional factors) and responses from the social environment (external social-political factors). Obviously, psychosocial factors cannot be examined to the degree that empirical data can be. Therefore, the present article explores only plausible options for identifying these factors, with support from psychosocial and medical literature, and statements by members of the American Academy of Pediatrics (AAP) Task Force on Circumcision.
INTERNAL EMOTIONAL FACTORS
The AAP, similar to other English-speaking medical organisations,
does not recommend circumcision but accepts it as a parental option (4, 6-10). Circumcision advocates believe that
‘substantial medical evidence’ favours their view and, because they haven't
received the endorsement of circumcision they want from the AAP, they accuse
that body of ‘anticircumcision bias’ (11). Circumcision
advocates have never explained why policy-makers would have an ‘anticircumcision
bias.’ Circumcision advocates also have not addressed the fact that there are
people who would be expected to have personal, religious, and professional
reasons for supporting circumcision who are against the practice (e.g., some
circumcised men, Jews, and doctors who stopped performing nontherapeutic
On the other hand, there are various factors that may contribute to or suggest a bias in favour of circumcision. A survey of randomly selected primary care physicians showed that circumcision was more often supported by doctors who were older, male, and circumcised (12). Minimising evidence of harm and using medical claims to defend circumcision when that evidence is conflicting at best, could be some of the unconscious ways for some male physicians to avoid the emotional discomfort of questioning their own circumcision (13). (Of note, the AAP Task Force on Circumcision was composed of five men and two women.)
Studies also indicate that protecting self-esteem sometimes takes
priority over being accurate or correct, and potentially threatening information
may be reinterpreted or dismissed, sometimes unconsciously, as a result (14, 15). Other research has demonstrated that
people will continue an endeavour once they have invested time and effort (16). To avoid inconsistency between beliefs and experience
(i.e., cognitive dissonance), beliefs about circumcision tend to be aligned with
the experience of performing circumcisions (17). For
physicians who have performed hundreds or thousands of circumcisions (or have
chosen circumcision for their own son), the possible use of such psychological
defence mechanisms to deny some of the evidence against circumcision could
serve, in part, to protect their self-esteem, which could be adversely affected
by the conscious recognition that circumcision may harm infants. A few members
of the AAP Task Force on Circumcision have routinely performed circumcisions,
and, consistent with the above psychosocial research, those members also tended
to be the ones who advocated circumcision (18). This
relationship suggests that the attitudes about circumcision of at least some
committee members were already set at the start of the policy review, and their
attitudes may have been unaffected by what they found in the literature.
EXTERNAL SOCIAL-POLITICAL FACTORS
Social influence can alter scientific inquiry. For example, if circumcision were introduced today, proponents would have the burden of proving that it is safe and effective. Although policy committees agree that this burden has not been satisfied, circumcision is evaluated as a long-standing practice and, as such, it is viewed differently than a new practice. Due to social and professional entrenchment, the burden of proof has shifted to the shoulders of critics.
The ubiquity of circumcision in America may influence which
questions are researched and which are ignored in American medical circumcision
literature. Most American studies that assess the advisability of circumcision
focus on the search for a benefit. Accordingly, one AAP Task Force on
Circumcision member stated that the committee was formed “to determine if there
was scientific evidence to justify circumcision” (18). The
answer is limited by the assumption inherent in the statement of the problem.
Although claims of benefits generally do not withstand the scrutiny of policy
committees, their continued publication over the years has led to medical myths
believed by professionals and the public (19).
Policy statements from medical organisations in other
English-speaking countries are generally more critical of circumcision, but they
still tolerate it. Given the lack of proven safety and effectiveness, the
principle of ‘first, do no harm,’ and the priority of the patient’s welfare over
parental requests, why have these organizations not published stronger
statements opposing circumcision? The answer may be related to the fact that in
public discussions about circumcision in Canada and Britain, religious groups
were the only ones to defend the practice (20-22). Some
Europeans believe that the reluctance to criticize circumcision is due to fear
of being accused of religious intolerance (23). This type of
concern may have been involved when an investigation of circumcision by
Australian authorities was halted after Jewish protest (24).
Furthermore, in response to an inquiry about discouraging nontherapeutic
circumcision, a representative of the United States Department of Health and
Human Services stated that “it is not proper for our Government to adopt a
policy that is directly or indirectly critical of a religious practice” (L.
Mahoney, personal communication, March 8, 1994).
Social factors may also be present and operating within the AAP Task Force on Circumcision itself. In a deposition related to a circumcision lawsuit, a member of the AAP Task Force on Circumcision admitted that the task force was divided on the question of the advisability of circumcision (18). There are also indications of conflict from previous task forces. In the year following the publication of the 1989 position statement (25), one of the dissenting members of that task force published a review article with a different conclusion (26). In an unusual disclosure, the chair of the 1975 task force revealed that the “committee was sharply divided in its opinions, and the resulting statement was a compromise” (27). This documentation is the most direct evidence that AAP circumcision policy statements have required negotiation and compromise, introducing additional psychosocial factors and making the circumcision policy less evidence-based.
The AAP Task Force on Circumcision’s attitude toward recently
published reports on different aspects of circumcision is not known because
these reports were published after the AAP policy was published (28-43). However, subsequent position statements by several other
medical organizations omitted discussion of some or all of this literature.
Specifically, the American Medical Association (7) and the
Canadian Paediatric Society (4) did not mention the sexual,
psychological, human rights, and legal aspects of circumcision. The Royal
Australasian College of Physicians’ policy briefly mentions psychological trauma
and human rights, and discusses legal issues with no mention of sexual issues
(8). The British Medical Association’s policy briefly mentions
sexual and psychological issues, and discusses legal and human rights issues (9).
SUMMARY AND RECOMMENDATIONS
Although medical committee members highly value rationality, a
rational and objective evaluation of an emotional and controversial topic like
circumcision can be difficult. It is suggested that the potential psychological
and social factors surrounding the practice of circumcision could affect the
values and attitudes of circumcision policy committee members, the attitude
toward evaluating the circumcision literature, and the publishing of
circumcision literature itself. If the members are polarized, the process of
negotiating to arrive at a consensus statement could introduce additional
psychosocial factors that could affect the final policy. These possibilities are
speculative, not conclusive.
There are examples of authorities in English-speaking countries
who appear to allow religious circumcision practice to inhibit them from taking
a more progressive position on this issue. This tendency seems to result in a
policy stance that is less evidence-based. Sensitivity to confronting the
religious issue is understandable, but it may undermine the core values (e.g.,
the health of the patient is paramount) and ethics (e.g., first, do no harm)
that drive medical decision-making. Policy makers could respond to accusations
of religious intolerance rationally and compassionately rather than allow the
fear of such accusations to hinder policy development (44).
Other recommendations for improving circumcision policy-making include
acknowledging any conflicts, paying focused attention to psychosocial factors,
and expanding professional and public discussion.
Dealing with psychosocial factors can start with recognizing the
potential bias of committee members. Conflict of interest is not just financial.
Perhaps future candidates for membership in circumcision policy committees
should disclose their circumcision status (previously suggested ), number of circumcisions performed, circumcision status of
any male children, and religious or ethnic background. Disclosure of this
information would help in the assessment of the credibility of the committee and
its work. Members of such committees should be held to at least the same
standard as peer reviewers. As stated by the International Committee of Medical
Journal Editors, “any conflicts of interest that could bias their opinions”
should be disclosed, and reviewers “should disqualify themselves from reviewing
specific manuscripts if they believe it to be appropriate” (46). Similarly, those responsible for selecting members of
circumcision policy committees should be aware of potential members' conflicts
of interest to determine if a member should be disqualified. Including more
women, to minimize the influence of internal emotional factors, and a member
with psychosocial training and background could also help deliberations. Policy
statements from other fields, such as psychology, sociology, anthropology, and
ethics could expand perspectives and understanding.
In the meantime, medical organizations should be aware of the potential legal implications associated with a flawed policy. A law journal article (47) claimed that the failure to act in a scientifically responsible manner could make a medical society liable for trade association misconduct connected with publishing negligent recommendations on circumcision.
Disclosure: The author is Jewish, circumcised, has no male children, and has not circumcised anyone.
- Circumcision-The debate goes on. Pediatrics 2000105:681-5. (Lett)
- Kim D, Lee J, Pang M. Male circumcision: A South Korean perspective. BJU Int 1999;83 (Suppl 1):28-33.
- Schoen E. Benefits of newborn circumcision: Is Europe ignoring medical evidence? Arch Dis Child 1997;77:258-60.
- Canadian Paediatric Society, Fetus and Newborn Committee. Neonatal circumcision revisited. Can Med Assoc J 1996;154:769-80. (Reaffirmed March, 2002)
- Hennessey B. Public Opinion, 5th edn. Monterey, California: Brooks/Cole Publishing, 1985.
- American Academy of Pediatrics. Task Force on Circumcision. Circumcision policy statement. Pediatrics 1999;103:686-93.
- American Medical Association. Neonatal circumcision 2000. <www.ama-assn.org/ama/pub/article/2036-2511.html> (Version current at October 6, 2004).
- The Royal Australasian College of Physicians. Policy statement on circumcision 2002. <www.racp.edu.au/hpu/paed/circumcision/> (Version current at October 6, 2004).
- British Medical Association. The law and ethics of male circumcision - guidance for doctors 2003. <www.bma.org.uk/ap.nsf/Content/malecircumcision2003> (Version current at October 6, 2004).
- British Association of Paediatric Surgeons. Statement on behalf of the British Association of Paediatric Surgeons concerning male ritual circumcision 1997. <www.cirp.org/library/statements/BAPS1997/> (Version current at October 6, 2004).
- Schoen E, Wiswell T, Moses S. New policy on circumcision: Cause for concern. Pediatrics 2000;105:620-3.
- Stein M, Marx M, Taggert S, Bass R. Routine neonatal circumcision: The gap between contemporary policy and practice. J Fam Pract 1982;15:47-53.
- Goldman R. The psychological impact of circumcision. BJU Int 1999;83 (Suppl 1):93-102.
- Raynor J, McFarlin D. Motivation and the self-system. In: Sorrentino R, Higgins E, eds. Handbook of Motivation and Cognition: Foundations of Social Behavior. New York: Guilford Publications, 1986: 315-349.
- Steele C, Liu T. Dissonance processes as self-affirmation. J Pers Soc Psychol 1983; 45: 5-19.
- Arkes H, Blumer C. The psychology of sunk cost. Organ Behav Human Decis Process 1985;35:124.
- Festinger L, Carlsmith J. Cognitive consequences of forced compliance. J Abnorm Soc Psychol 1959;58:203-10.
- Shoemaker C. Deposition: Flatt v. Kantak 2002. <www.boystoo.com/legal/shoemakerdepo.htm> (Version current at October 6, 2004).
- Fletcher C. Circumcision in America in 1998: Attitudes, beliefs, and charges of American physicians. In: Denniston G, Hodges F, Milos M, eds. Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice. New York: Kluwer Academic/Plenum Publishers, 1999; 259-71.
- Humphreys A. Circumcision is against the Charter, group says. National Post, Toronto, 12 February 2001, February 12: A1.
- General Medical Council. Guidance for doctors who are asked to circumcise male children 1997. <www.gmc-uk.org/standards/default.htm> (Version current at October 6, 2004).
- Beecham L. GMC issues guidelines on circumcision. BMJ 1997;314:1573.
- Esbensen L. Circumcision: A half debate. Politiken 2002. <www.courtchallenge.com/news/politik2.html> (Version current at October 6, 2004).
- Alhadeff V. Circumcision defended to Queensland law body. Australian Jewish News, Sydney edition, June 10, 1994:6.
- American Academy of Pediatrics. Report of the Task Force on Circumcision. Pediatrics 1989;84:388-91. Erratum in: 1989;84:761.
- Poland R. The question of routine neonatal circumcision. New Engl J Med 1990; 22: 1312-5.
- Thompson H. The value of neonatal circumcision: An unanswered and perhaps unanswerable question. Am J Dis Child 1983;137:939-40.
- Cold C, Taylor J. The prepuce. BJU Int 1999; 83 (Suppl 1): 34-44.
- Coursey J, Morey A, McAninch J, Summerton D, Secrest C, White P, Miller K, Pieczonka C, Hochberg D, Armenakas N. Erectile function after anterior urethroplasty. J Urol 2001;166:2273-6.
- Fink K, Carson C, DeVellis R. Adult circumcision outcomes study: Effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol 2002;167:2113-6.
- Ozkara H, Asicioglu F, Alici B, Akkus E, Hattat H. Retrospective analysis of medicolegal cases and evaluation for erectile function. Am J Forensic Med Pathol 1999;20:145-9.
- Stinson J. Impotence and adult circumcision. J Nat Med Assoc 1973; 65: 161.
- Boyle G, Goldman R, Svoboda J, Fernandez E. Male circumcision: Pain, trauma and psychosexual sequelae. J Health Psychol 2002; 7: 329-43.
- Hammond T. A preliminary poll of men circumcised in infancy or childhood. BJU Int 1999;83 (Suppl 1):85-92.
- O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83 (Suppl 1):79-84.
- Warren J, Smith PD, Dalton DJ, et al. Circumcision of children. BMJ 1996;312:377. (Lett)
- Goldman R. Circumcision: The Hidden Trauma. Boston: Vanguard Publications, 1997.
- Rhinehart J. Neonatal circumcision reconsidered. Transactional Anal J 1999;29:215-21.
- Boyle G, Svoboda J, Price C, Turner J. Circumcision of healthy boys: Criminal assault? Journal of Law and Medicine 2000; 7: 301-10.
- Povenmire R. Do parents have the legal authority to consent to the surgical amputation of normal, healthy tissue from their infant children? The practice of circumcision in the United States. J Gender Soc Policy Law 1998/99;7:87-123.
- Re J. Family Court Reports 2000;1:307-14.
- Svoboda J. Routine infant male circumcision: Examining the human rights and constitutional issues. In: Denniston G, Milos M, eds. Sexual Mutilations: A Human Tragedy. New York: Plenum Press, 1997; 205-16.
- Svoboda J, Van Howe R, Dwyer J. Informed consent for neonatal circumcision: An ethical and legal conundrum. J Contemp Health Law Policy 2000;17:61-133.
- Goldman R. The growing Jewish circumcision debate. In: Denniston G, Hodges F, Milos M, eds. Flesh and blood: Perspectives on the problem of circumcision in contemporary society. New York: Kluwer Academic/Plenum Publishers, 2003; 171-94.
- Hinman F Jr. Circumcision. BJU Int 1999;84:543. (Lett)
- International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Ann Intern Med 1997;126:36-47.
- Giannetti M. Circumcision and the American Academy of Pediatrics: Should scientific misconduct result in trade association liability? Iowa Law Rev 2000;85:1507-68.
Circumcision Resource Center, Boston, Massachusetts, USA
Correspondence to: Dr. Ronald Goldman, Executive Director, Circumcision Resource Center, P. O. Box 232, Boston, Massachusetts 02133 USA.
Telephone/fax: 617-523-0088, email: firstname.lastname@example.org