Common Concerns About Circumcision

A page of thinking and talking points for midwives

Created by Dr. Teri Mitchell, CNM, and the Your Whole Baby team

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How can I facilitate unbiased conversations about circumcision with my clients?

Some midwives in the U.S. believe that saying anything positive about foreskin displays bias, and they must talk primarily about the perceived “pros” of circumcision in order to remain neutral. But a midwife needs to discuss the harms of surgery and the purposes of normal body parts in order to represent two sides of the circumcision debate. Some cultures view the United States’ highlighting of the benefits of male circumcision as another form of bias. To learn more: 10.1542/peds.2012-2896 and www.yourwholebaby.org/balance-bias

What about talking with my co-workers or employer?

It may help to keep in mind that while the issue of neonatal circumcision is typically framed in medical terms, for many people — healthcare workers included — it feels extremely personal. Circumcision has touched the lives of most American HCPs, whether through their own circumcisions, family members’ circumcisions, or decisions made around providing or assisting with the procedure. This is why discussion can quickly become difficult.

To help diffuse possible tensions, you can lead with how important it is for clients to have correct intact penis care information (both to facilitate their informed consent and to prevent iatrogenic injuries). It’s okay to have the discussion in small chunks. Consider small shifts in the perspectives/practices of other providers to be a big deal. Change often comes in stages.

I’m concerned about offending clients. They might leave my care.

It’s very possible to provide information in a non-confrontational way. Consider asking parents: “Have you given thought to leaving your baby natural versus requesting surgery for him? Would you like some information to help you make an informed decision? Some parents feel regret about the decision to request surgery for their son, so I like to make sure that my clients feel very confident in their choice, since there is no going back once it’s done.” In my experience, clients are grateful for the information and discussion.

Midwives may be concerned that clients could perceive them as prejudiced against some religions and cultures if they share information about the harms and risks of circumcision. It’s important to remember that the vast majority of infant circumcisions in the U.S. do not take place in the context of a religious or cultural ceremony, and families of all backgrounds deserve accurate, adequate information with which to make a decision.

It’s the parents’ choice, and supporting them is my job.

Providing parents with accurate information is also part of your role. The majority of parents who choose surgery for their sons are simply perpetuating a non-decision that was made for the baby’s father a long time ago. Most adult men in the U.S. today are circumcised, and these surgeries happened without informed decision on their parents’ part. Circumcision was basically automatic in American hospitals throughout the 1970s and ‘80s. Our clients today are much more active in decision-making. I find that many are very open to the idea that their son will be capable of making his own decision someday.

Isn’t it the pediatric provider’s job to provide information on circumcision?

The American Academy of Pediatrics and ACNM have suggested that it’s our job — that such information should be provided before conception or as early as possible in the pregnancy, long before most parents have even thought about finding a pediatrician. I have made it my routine to have this discussion at the same visit as I discuss sonogram results. It’s the perfect time, as they may have learned the fetal sex and are just starting to consider this decision. They may never see the pediatrician until after the baby is born, when research shows that they are not as capable of integrating new information about the decision to leave their sons whole or consent to surgery.

Can I jeopardize my employment status by refusing to provide or refer for circumcisions?

Performing circumcisions is not part of ACNM’s core competencies. U.S. midwives can opt to train in circumcising infant boys. Such a decision is up to the individual midwife. While it’s possible that some institutions may place expectations and pressures about circumcision upon midwives in their employ, as a certified independent practitioner, a midwife should be able to make the decision not to perform the surgery.

As stated in ACNM’s document on conscientious refusal, “Midwives have an ethical, moral, and legal obligation to ‘respect the human rights and the dignity of all persons.’” This includes the person upon whom irreversible non-therapeutic genital surgery may be performed, permanently altering the normal form and function of his penis, with no possibility for obtaining his direct consent.

According to the same document, a midwife is obligated to refer a patient to another provider in order to prevent delay of health care if s/he does not provide a service within her/his scope of practice due to ethical or religious objection. However, many midwives do not think neonatal circumcision constitutes “health care”; furthermore, infant circumcision does not fall within the required scope of midwifery practice.

We encourage you to familiarize yourself with documents from your professional midwifery and nursing organizations if you are considering conscientious objection. This way, you can support your position with knowledgeable confidence.

 
 

 

Published: May 4, 2018