Infant male circumcision (IMC) is generally enveloped in a complex web of cultural and religious beliefs and practices.[1] Whether to circumcise an infant is a multifactorial decision, and influenced by numerous factors, including but not limited to parents’ race, ethnicity, insurance status, socioeconomic status, hospital type, geographic region, and healthcare provider (HCP) practices.[2–4]

Existing evidence demonstrates that male circumcision (MC) offers numerous health benefits and protections against certain medical conditions including human immunodeficiency virus (HIV),[5–7] various sexually transmitted infections (STIs),[8–13] urinary tract infections (UTIs),[14] penile,[15, 16] cervical,[13] and prostate cancers,[17] and other penile dermatoses, as well as providing increased penile hygiene.[18, 19] Despite the emerging science demonstrating circumcision’s health benefits, IMC rates are steadily declining in the United States.[20–23]

The research examining IMC reveals that HCPs do not always discuss this procedure with expectant parent(s) or guardian(s). A 2012 study of parents found that 49% of the sample had not discussed the advantages and disadvantages of circumcision with a HCP. Moreover, discussing IMC’s benefits significantly influenced the parents’ decision to circumcise their son.[4] Researchers in Miami asked Hispanic providers about their IMC practices, and found that this procedure is not readily discussed nor recommended with their patients in the predominantly Hispanic community. This lack of discussion and recommendation may stem from providers’ low level of knowledge regarding IMC as well as the belief that patients are not interested in the procedure.[24] Another recent study in 2008, found that 22% of physicians, which included pediatricians, family practitioners, obstetricians/gynecologists, and internists did not feel qualified to discuss IMC with parents due to a lack of understanding of the risk and benefits associated with this procedure.[25] In 2010, the American Academy of Pediatrics (AAP) reported that 57% of pediatricians believed that the medical benefits of IMC are inconclusive; 30% believed that the benefits outweighed the risks associated with this procedure; and pediatricians discussed IMC significantly less in 2006 (66%) compared to 1997 (74%).[26] Current research indicates significant variation among HCPs’ communicative practices with parents regarding IMC, which may influence their decision-making process and stem from a lack of knowledge.

In 2010, the Centers for Disease Control and Prevention (CDC) emphasized the importance of providing evidence-based risk and benefit information for IMC and adult MC to HCPs and parents in order to facilitate informed decision-making and promote parent-provider communication.[27] In August 2012, the AAP published an updated IMC statement explaining that the benefits associated with this procedure outweigh the risks, specifically highlighting the protection against acquisition of HIV and specific STIs.[28] The AAP stated that providers have a responsibility to present unbiased and accurate information in an effort to aid parents with the IMC decision. The statement further explained that the current evidence provides justification that all parents should have access to this procedure and furthermore, a third party payer should cover the procedure’s costs.[28] The American College of Obstetricians and Gynecologists (ACOG) also endorses AAP’s new IMC statement.[29]

At this time, there are no universal communicative guidelines for this procedure as seen with other preference-sensitive decisions. Therefore, the communicative practices are left to the discretion of the individual HCP when disseminating anticipatory guidance related to IMC. Research indicates that variation in provider communication practices may influence parental decisions around IMC.[4] Further, past evidence indicates that HCP knowledge is critical in promoting effective communication and decision support.[30]

In view of the attention that IMC continues to garner coupled with the results of recent research showing the health benefits of MC and IMC, this is a particularly opportune time to explore providers’ IMC knowledge and identify characteristics associated with their knowledge levels. Therefore, we hypothesized that knowledge is an important contributor to promoting informed decision-making for IMC.

One hundred ninety-one HCPs were identified as potential participants for this study, of which 29 were not eligible to participate. The ineligible individuals did not currently practice at the studied academic health center (n = 14, 48%), were first year residents (n = 8, 28%), and/or did not treat newborns/infants or pregnant patients (n = 7, 24%).

Ninety-two participants enrolled in the study and completed the survey, generating a 57% response rate; 40% from obstetrics (n = 37), 31% from pediatrics (n = 28), and 29% from family medicine (n = 27). The population identified as 78% female (n = 72), 83% as a faculty physician/resident/fellow (n = 76), 52% Caucasian (n = 48), 50% as Christian (n = 46), 58% as married (n = 53), 44% completed medical training between 1990 and 2010 (n = 41), and 41% between 30 and 39 years of age (n = 38). For a complete description of the sample, see Table 1.

Responders and non-responders did not differ by medical specialty or position (chi-square = 1.21, P = 0.55 and chi-square = 3.56, P = .31, respectively).

The results of this study demonstrate that significant gaps exist in HCPs’ knowledge about the risks and benefits of IMC, especially regarding results of recent research showing circumcision to have a protective effect against acquisition of HIV and certain STIs. Further, we found significant variation between HCPs, with pediatricians exhibiting greater overall knowledge of the evidence compared to obstetricians and family practitioners. Obstetricians, however, were more likely to answer the HIV knowledge item correctly compared to the other medical specialties.

To our knowledge, this is the first study of HCPs’ IMC knowledge focusing on an academic health center and one of very few conducted in the United States. In 2012, Carbery et al. reported that 22% of physicians said that they did not understand IMC’s risks and benefits well enough to counsel parents.[25] Our findings that overall knowledge of IMC is variable, combined with those of Carbery et al., are important because the CDC and the AAP recommend that HCPs deliver accurate and unbiased information to parents, guardians, and patients regarding IMC’s risks and benefits.

Participants were relatively knowledgeable about some aspects of IMC, including its protective effects against phimosis, UTIs, and penile cancer, all of which were highlighted in the AAP statement published in 1999 and reaffirmed in 2005.[41, 42] HCPs were less knowledgeable about the more recent research results, including HIV, cervical cancer, bacterial vaginosis, and genital ulcer disease. This indicates that further education is needed to enable practitioners to more effectively communicate the scientific evidence regarding IMC and MC; thereby fostering dialogue and informed decision-making with the parents and guardians.

HCP’s medical specialty surfaced as an explanatory factor for overall knowledge and HIV knowledge item as mentioned previously. Pediatricians scored higher for overall IMC knowledge compared to those in obstetrics and family medicine; whereas, obstetricians were more knowledgeable about circumcision’s protective effects against HIV acquisition. These differences between medical specialties at this academic health center may be related to the center’s practice of allocating IMC procedures to pediatricians, who perform the procedure at an outpatient facility once a week. Consequently, the pediatricians may be motivated to be up-to-date with the most current research and guidelines that are associated with newborns and infants. Whereas obstetricians treat predominantly adult females, they may be more focused on remaining current regarding results of research related to HIV acquisition.

HCPs that had ever refused to circumcise a newborn or infant boy were significantly more knowledgeable than those who had never refused. The reasons that HCPs refused to circumcise were not related to cultural or religious beliefs, but stemmed from medical indications that create a risk with the procedure (e.g., hypospadias, penile abnormalities, small penis size, and concern for sepsis). In order to make an informed unbiased decision about IMC and to counsel parents accordingly, the HCP must be familiar with the associated risks as well as the medical and health benefits of the procedure.

Educational intervention is warranted to increase HCP’s level of knowledge with the support of institutional organizations and governing medical bodies as well as policy makers. Past research indicates that in order to systemically promote the translation of knowledge, all decision makers including patients, HCPs, institutional administrators, and policy makers must have access to current evidence-based research.[30]

The educational intervention should be specific to the clinic or institution depending on their IMC protocols. To increase HCPs’ knowledge and promote informed decision-making, a multi-prong approach is necessary. This approach may include the following: (1) the creation of a module about IMC for HCPs through a continuing medical education course and/or implemented within HCPs’ training curriculum (2) distributing AAP’s statement about male circumcision to HCPs and discussing this at staff meetings and/or (3) creating fact sheets and pamphlets for HCPs and parent(s)/guardian(s) to increase their level of knowledge and facilitate discussion.

In the case of IMC, institutional support is necessary to engender an environment which allows HCPs to communicate accurate and unbiased information to promote informed decision-making processes.[43, 44] The AAP recommends that professional organizations including the ACOG, the American Academy of Family Practitioners, the American Urological Association, the American Society of Anesthesiologists, and the American College of Nurse Midwives should work together with the AAP to develop educational materials and standards of trainee proficiency, and ensure inclusion of IMC procedural techniques in postgraduate training programs.[28] This collaboration will also help in fostering the dialogue at the institutional level as well as targeting providers at the individual level.

Our study has several limitations. The sample is drawn from a single institution in one geographical location with very specific processes for performing IMC, and therefore, limits the generalizability outside of the studied population. Secondly, the response rate was 57% for the online survey, and this might not represent the full range of HCPs. While nonresponse bias could be present, we found no significant differences between non-responders and responders for position and medical specialty. The confidence intervals for some results were wide; a larger sample size would result in more precise estimates. Further, the results indicate that there may be other factors that we did not measure that explain additional variance in HCPs’ IMC knowledge. The knowledge score was constructed incorporating current evidence-based literature in collaboration with MC experts. The authors acknowledge that this is not the only way to measure IMC knowledge, and as a result, we have clearly outlined how we measured this construct in detail within the manuscript.

The results of this study indicate that there is considerable variation in level of IMC knowledge among providers. We recommend an IMC system-based educational intervention for HCPs involved in the IMC decision process focused on increasing knowledge and working in collaboration with health centers, hospitals, healthcare accreditation organizations, and medical bodies. Dissemination of the AAP’s IMC statement coupled with educational materials and other interventions will promote systemic knowledge translation and facilitate informed, evidence-based decision-making processes for parents and guardians.