The Mystery of the Missing Foreskin: Investigation and Interventions Regarding Infant Male Circumcision in the United States Open Access

Abstract

Over the last several decades, medical research has failed to prove that routine infant circumcision provides American males with significant medical benefits, leading bioethicists to question whether its continuation is appropriate. Despite these philosophical discussions, little work has been done to understand and address the fact that parents in the United States continue to circumcise their sons at rates that far exceed those of other similar countries. In order to conceptualize how to advocate for more mindful and ethical practices going forward, this thesis investigates what factors lead American parents to continue to choose circumcision at such high rates. To answer this question, I present an original research study in which parents of young boys were surveyed and interviewed to assess their knowledge, experiences, and decision-making processes regarding the procedure. The study is the first in its field to use a wide and large sample of American parents, include both quantitative and qualitative data, and statistically test what other variables correlate with parents’ decisions. These attributes allowed the study to reveal the roles of societal factors such as social surroundings and insurance policy in parents’ decision-making. By mapping the data onto social norm theory, I conclude that in the United States, infant circumcision is perpetuated by a combination of medical misinformation, social pressure (otherwise referred to as normative expectations), and inertia. After substantiating these findings, in the spirit of libertarian paternalism, I use social norm theory to suggest interventions that can improve our practices regarding circumcision decision-making going forward.

Table of Contents

Chapter 1: Introduction 1

History 2

Prevalence 3

Anatomy 4

Medical Benefits 5

Medical Risks 8

Existing Philosophical Scholarship 10

Principlist Analysis 11

Nonmaleficence 13

Beneficence 14

Autonomy: Proxy Decision-Making 15

Autonomy: Informed Consent 17

Existing Research on Why Parents Choose Circumcision 20

Chapter 2: Survey 23

Overview 23

Method 24

Participant Acquisition 24

Survey Procedures 25

Results 27

Participant Demographics 27

Knowledge Assessment 31

Correlations with Circumcision Decision 37

Demographics Variables 37

Knowledge Variables 40

Factors Involved in the Decision 46

Valid Reasons to Circumcise 48

Other Variables 50

Correlations Between Input Variables 57

Regression Test Results 62

Limitations 65

Discussion 66

Chapter 3: Interviews 68

Overview 68

Method 69

Results 72

Interview Summaries 72

Valerie — California, did not circumcise 72

Megan — Wisconsin, did not circumcise 74

José & Sofia — Florida, did not circumcise 75

Jane — Florida, did not circumcise 1st son, did circumcise 2nd son 77

Katie — Tennessee, did circumcise 79

Lainey & Ben — Rhode Island, did circumcise 80

Major Themes 82

Misinformation 82

Real or Apparent Social Pressure 84

Indifference and Inertia 89

Limitations 91

Discussion 92

Chapter 4: Answers & Interventions 94

Answering the Research Question using Social Norm Theory 94

Social Norm Definitions & Diagnosis 95

Why Social Norms Persist 97

Mapping the Data onto the Theory 98

Suggestions for Positive Change 100

Key Principles 103

What the Healthcare Sector Can Do 104

Remove Insurance Coverage 104

Public Statements with Concrete Data 106

Don’t Ask Without Facts 109

Employ Thoughtful Choice Architecture 111

What Anyone Can Do 113

Change the Language 113

Elicit Strong Emotions 114

Highlight Conflicting Values 116

Broader Societal Messaging 118

Conclusion 120

Bibliography 121

Appendix 130

Survey Questionnaire 130

Section 1 (Decision-Making) 131

Section 2 (Knowledge) 138

Section 3 (Demographics) 142

Section 4 (Quality Control & Interview Sign Up) 146

Interview Protocol 147

About this Honors Thesis

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School	Emory College
Department	Interdisciplinary Studies in Society and Culture
Degree	B.A.
Submission	Honors Thesis
Language	English
Research Field	Health Sciences, Public Health Psychology, Social Ethics
Keyword	Decision-Making Circumcision Social Norm Theory Parenting Sexual Health
Committee Chair / Thesis Advisor	Mark Risjord, Emory University
Committee Members	Shannon Morris Stevenson, Emory University Elizabeth Kim, Emory University

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