Framing the foreskin

Material Information

Framing the foreskin a content analysis of circumcision information handouts for expectant parents
Longley, Gillian E
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xvii, 311 leaves : ; 28 cm


Subjects / Keywords:
Circumcision ( lcsh )
Newborn infants -- Care ( lcsh )
Medicine, Popular -- Handbooks, manuals, etc ( lcsh )
Circumcision ( fast )
Medicine, Popular ( fast )
Newborn infants -- Care ( fast )
Handbooks and manuals. ( fast )
bibliography ( marcgt )
handbook ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )
Handbooks and manuals ( fast )


Includes bibliographical references (leaves 290-311).
General Note:
Department of Humanities and Social Sciences
Statement of Responsibility:
by Gillian E. Longley.

Record Information

Source Institution:
|University of Colorado Denver
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|Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
519442428 ( OCLC )
LD1193.L65 2009m L66 ( lcc )

Full Text
Gillian E. Longley
B.A., Oberlin College, 1974
B.S.N., Creighton University, 1981
A thesis submitted to the
University of Colorado Denver
in partial fulfillment
of the requirements for the degree of
Master of Social Science

2009 Gillian E. Longley
All rights reserved.

This thesis for the Master of Social Science
degree by
Gillian E. Longley
has been approved
Barbara J. Walkosz
Virginia S. Fink
Mark Yarborough

Longley, Gillian E. (M.S.S.)
Framing the Foreskin: A Content Analysis of Circumcision Information Handouts for
Expectant Parents
Thesis directed by Associate Professor Barbara J. Walkosz
This thesis reports on a content analysis of 55 circumcision information handouts for
expectant parents. The handouts were specifically and exclusively coded for the content and
framing of information given on the alternative of not circumcising. Framing theory and
concepts derived from the practice of informed consent provided the framework for the
analysis. The largest number of handouts was from North American medical organizations
and health information sources, with smaller numbers from Australia/New Zealand and from
pro- and anti-circumcision organizations also analyzed for comparison. On average, North
American handouts gave inadequate information on the anatomy, functions, and
development of the intact penis, conservative treatment and prevention, social concerns,
ethics, and other topics. The predominant framing found in North American handouts was
oriented toward and tended to validate circumcision, while ignoring or problematizing the
alternative of not circumcising. Overall, the information found in North American handouts
on the alternative of not circumcising was considered inadequate for the purposes of valid
informed consent. A model for information-giving on not circumcising was developed,
based on the four dimensions of Demystifying, Normalizing, Giving Value, and Support.
This abstract accurately represents the content of the candidates thesis. I recommend its
Barbara J. Walkosz

I dedicate this thesis to my parents, James and Helen Longley, who gave me a love for
intellectual pursuits, particularly in the areas of science and history; who through my early
education gave me the tools to be able to succeed with this scholarly endeavor; and who
implanted in me the ethic of using my talents to make the world a better place. I also
dedicate this thesis to my husband, Frank Tower, for his unfailing emotional support and
good-humored willingness to fill the roles of sounding-board, computer tech, and
housekeeper, as I have worked toward completion of this thesis and my degree.

Special thanks to my advisor, Barbara J. Walkosz, for her gracious and valuable guidance
and sustained support of my research. I also wish to thank the other members of my thesis
committee, Virginia S. Fink and Mark Yarborough, for their supportive interest and helpful
suggestions in furthering the writing of this thesis. Thanks also to Kim Garchar for
sponsoring me in an independent study of informed consent, which formed the foundation
for my conception of this study. Special thanks to Rachel Verbeek who valiantly coded a
portion of the handouts to establish intercoder reliability. And finally, thanks to numerous
individuals who answered questions, offered suggestions, sparked ideas, gave me a leg up, or
just generally inspired me, including Marilyn Milos, Steven Svoboda, John Geisheker, Bob
Van Howe, Ken McGrath, and Hugh Young, among others.

Figures .............................................................xiii
Tables .........................................................xv
1. INTRODUCTION AND STUDY OVERVIEW.....................................1
Informed Consent and Circumcision...............................1
Overview of the Study and Research Questions....................4
Overview of the Thesis..........................................6
2. BACKGROUND AND LITERATURE REVIEW....................................8
Part A: Informed Consent........................................8
Introduction and Basic Concepts...............................8
A Brief Legal History of Informed Consent....................10
The Ethical Underpinnings of Informed Consent................13
The Elements of Informed Consent.............................15
The Importance of Alternatives............................21
Exceptions to Informed Consent............................30
Informed Consent for Neonatal Circumcision:
Special Challenges........................................31

Informed Consent and Elective Surgery.........................32
Informed Consent and Non-therapeutic Procedures...............34
Pediatric Proxy Consent.......................................36
Additional Ethical Concerns with Neonatal Circumcision.......41
Part B: Literature Review..........................................45
Literature Search Strategy.......................................45
The Literature on the Adequacy of Information-Giving for
Circumcision Decision-Making.....................................46
The Literature on the Effect of Parent Education on
Circumcision Decision-Making.....................................48
Selected Literature on Information-Giving on Alternatives........53
Selected Literature Confirming the Need for Education on
Circumcision and its Alternative.................................55
Justification for the Present Study Based on the Literature.....56
Part C: Framing Theory.............................................58
The Roots of Framing Theory: Tversky and Kahneman................58
Framing and Healthcare Research..................................61
Framing Theory Beyond Tversky and Kahneman.......................65
Entmans Clarification of Framing................................68
Part D: Review of Foreskin Anatomy, Function,
Development and Care...............................................72
The Anatomy of the Intact Penis..................................72
Overview of the Penile Skin System............................72
Protective Functions of the Foreskin..........................75

Anatomical Factors Relating to the Foreskins
Sexual Functions.............................................78
Sexual Functions of the Foreskin.............................82
Development and Care of the Intact Penis.......................86
Development of the Intact Penis.............................87
Care of the Intact Penis....................................92
Foreskin Problems: Prevention and Conservative Treatment.....94
Part E: Negative Framing of the Foreskin.........................96
The Advent of Medicalized Circumcision..........................96
Negative Framing of the Foreskin................................98
The Foreskin as Troublesome and Dangerous to Health.........99
The Foreskin as Dirty.......................................101
The Foreskin as Hard to Care For............................102
The Foreskin as Disgusting and Weird........................104
The Foreskin as Useless.....................................107
The Foreskin as Having No Sexual Function...................108
Cultural Polarities, Deep Frames, and the Foreskin.............110
3. THE STUDY: METHODOLOGY...............................................113
Selection of Materials...........................................113
Coding and Scoring...............................................120
Coding, and Definition of Framing..............................120
Scoring, and Definition of Adequacy............................123
Intercoder Reliability, Outcome Measures
and Ethical Considerations.......................................127

Reliability Results..............................................130
Category 1: Anatomy and Function.................................131
Protective Function...........................................140
Sexual Function...............................................146
The Anatomy and Function Adequacy Score..........................154
Category 2: Development and Care.................................157
Care and Development of the Intact Penis......................158
Framing of Smegma.............................................164
Framing of Hygiene of the Intact Penis........................166
Foreskin Problems.............................................171
Associations Between the Intact Penis and Disease.............178
Category 3: Miscellaneous........................................186
Social Concerns...............................................187
National and International Rates and Trends
of Non-Circumcision...........................................191
Ethical Concerns..............................................194
Use of Normalizing Terms......................................197
Framing of Choosing Not to Circumcise.........................199
The General Adequacy Score.......................................206
Difficulties in General Adequacy Scoring......................209
Pattern of Sub-scores of the Four Dimensions..................212

5. DISCUSSION AND CONCLUSION......................................218
Study Summary...............................................218
Results Summary.............................................219
Framing of Specific Topics, Messages Conveyed to Parents, and
Implications for Information-Giving.........................222
Framing by Omission.......................................223
Framing by Equivocation...................................227
Negative vs. Positive Framing.............................229
Entmans Four Functions of Frames Applied to the Study Material.231
Implications of the Studys Findings for Parent Education...234
The Need for Adequate Parent Education about
Not Circumcising..........................................234
A Model for Information-Giving about Not Circumcising:
The Four Dimensions.......................................237
The Process of Information-Giving.........................240
Study Limitations and Directions for Further Research.......249
B. CIRCUMCISION BROCHURES ANALYZED................................255
C. CONTENT ANALYSIS CODING GUIDE..................................259
D. RELIABILITY STATISTICS.........................................286

GLOSSARY .................................................288
REFERENCES ...............................................290

2.1 Cross-section of the Structure of the Intact Penis............................74
2.2 Eversion of the Foreskin, Showing the Ridged Band.............................79
2.3 Fine-touch Sensitivity of the Circumcised Versus the Intact Penis.............81
2.4 The Intact Penis and the Dynamics of Intercourse..............................84
2.5 The Embryological Development of the Foreskin.................................88
2.6 Age at Full Retractability....................................................91
4.1 Percentage of Handouts Giving Adequate Information
About Foreskin Anatomy and Function.........................................134
4.2 Anatomy and Function Adequacy (AFA) Score Distribution.......................155
4.3 Average Anatomy and Function Adequacy (AFA) Scores...........................157
4.4 Information Given on Foreskin Care and Development...........................160
4.5 Age of Retractability Given..................................................162
4.6 Instructions Given on Retraction.............................................163
4.7 Number of US and Australian/NZ Mainstream Handouts Giving
Counter-Information for Foreskin Problems Mentioned.........................174
4.8 Number of US and Australian/NZ Mainstream Handouts Giving
Counter-Information for Disease-Prevention Claims Mentioned.................181
4.9 Comparison of Counter-Information Giving for Medical vs.
Social Rationales for Circumcision..........................................191
4.10 General Adequacy (GA) Score Distribution....................................208
4.11 Average General Adequacy (GA) Scores.........................................209

4.12 The Four Dimensions of Information-Giving about Not
Circumcising, Average Score per Dimension.................................213

3.1 Sources of handouts analyzed................................................118
3.2 Major source groupings of handouts analyzed.................................119
3.3 Distribution of number of words per handout.................................120
3.4 Category 1 score definitions................................................122
4.1 Summary of Category 1 anatomy and function results..........................133
4.2 Anatomical description given................................................136
4.3 Protective functions given..................................................140
4.4 Sexual functions given......................................................148
4.5 Distribution of Anatomy and Function Adequacy (AFA) Scores..................155
4.6 Care and development of the intact penis, information given............159
4.7 Smegma references and framing of smegma.....................................164
4.8 Positive and negative framing of intact hygiene, and scoring................167
4.9 Examples of negative framing of hygiene of the intact penis, quotes........168
4.10 Examples of positive framing of hygiene of the intact penis, quotes........170
4.11 Counter-information given for foreskin problems.............................172
4.12 Variation in absolute risk or number needed to treat (NNT)
information given for foreskin problems and disease mentioned..............177
4.13 Counter-information given for primary medical rationales
for circumcision............................................................180
4.14 Counter-information given for primary social rationales
for circumcision............................................................188

4.15 Circumcision rates and trends, normalizing and non-normalizing
4.16 Framing of ethical concerns................................................195
4.17 Use of normalizing terms, examples.........................................198
4.18 Percentage of handouts using normalizing terms.............................199
4.19 Reasons given for choosing not to circumcise...............................201
4.20 Distribution of General Adequacy (GA) Scores..............................207
5.1 Entmans four functions of framing, mapped to dimensions of
information-giving about the intact penis and not circumcising,
according to a problematizing or normalizing framework..........................233
A. 1 Studies on the effects of parent education on
circumcision decision-making...............................................254
B. 1 Circumcision brochures analyzed...........................................255
C. 1 Coding Category 1: Anatomy of the intact penis............................262
C.2 Coding Category 1: Protective functions of the foreskin...................264
C.3 Coding Category 1: Sexual functions of the foreskin.......................266
C.4 Scoring: Anatomy and Function Adequacy scoring system.....................270
C.5 Scoring: Anatomy and Function Adequacy scoring example....................271
C.6 Coding Category 2: Hygiene and development................................273
C.7 Coding Category 2: Hygiene framing, foreskin problems,
and the intact penis and disease...........................................274
C.8 Coding Category 3: Social concerns, rates and trends,
and ethical concerns.......................................................276

C.9 Coding Category 3: Normalizing terms, framing of choosing not
to circumcise, and illustrations...............................................277
C. 10 The General Adequacy Score: The four dimensions mapped
onto the thirteen areas of Categories 1-3 (sample coding sheet)................280
D. 1 Intercoder reliability results..................................................286
E. 1 The four dimensions of information-giving about
the intact penis and not circumcising, summary table...........................287

Informed Consent and Circumcision
The doctrine of informed consent is one of the cornerstones of modem medical
ethics (J. W. Berg, Appelbaum, Lidz, & Parker, 2001). Based primarily on the ethical
principle of respect for autonomy, it protects the patients rights to bodily integrity and self-
determination, and promotes the patients interest in rational decision-making (Annas, 1977;
J. W. Berg et al., 2001; Faden & Beauchamp, 1986). However, the ideal of informed consent
is not always realized in clinical practice (J. W. Berg et al., 2001; Braddock, Edwards,
Hasenberg, Laidley, & Levinson, 1999; Cassileth, Zupkis, Sutton-Smith, & March, 1980;
Dickens & Cook, 2004).
The contemporary American practice of non-religious circumcision of the majority
of its newborn male infants is unique in the world (Wallerstein, 1985). Aside from Jews,
Muslims, and certain native peoples in Africa and the South Pacific, most societies in the
world have never practiced circumcision, including virtually all of Europe, Asia, and South
America (H. Weiss et al., 2007). In the late 19th century, circumcision was introduced into
pre-germ-theory medical practice, in the English-speaking countries only, for a host of

spurious justifications.1 Over the early years of the 20th century, neonatal circumcision
became entrenched in American culture via a fascinating history of medical and social
pressures (Darby, 2005; Gollaher, 2000; Hodges, 1997; Romberg, 1985). The current
medical consensus, however, is that while neonatal circumcision may have some potential
health benefits, there is insufficient evidence to recommend it as a routine procedure for all
boys (American Academy of Pediatrics Task Force on Circumcision (AAP), 1999; Canadian
Paediatric Society (CPS), Fetus and Newborn Committee, 1996; Medical Ethics Committee,
British Medical Association (BMA), 2006; Royal Australian College of Physicians (RACP),
Paediatrics and Child Health Division, 2002). While the other English-speaking countries
have in recent decades largely abandoned neonatal circumcision (Circumcision statistics,
2006) the United States has seen a slower but significant drop in circumcision rates from a
high point of 80-90% in the 1960s (Laumann, Masi, & Zuckerman, 1997) to about 57% as of
2006 according to hospital discharge data (National Center for Health Statistics, 2006).
Although a number of factors such as immigration, access to information via the Internet,
and the growth of an anti-circumcision advocacy movement may have influenced this drop
(Circumcision's decline, 2007), it is notable that the beginning of the shift coincided with
the incorporation of informed consent into modem medical practice (Faden & Beauchamp,
1 Up to the mid-20th century, circumcision was promoted for the prevention or cure of a myriad of
diseases and conditions, including, among others: masturbation, epilepsy, convulsions, paralysis, hip-
joint disease, digestive disorders, dementia, curvature of the spine, brass poisoning, bed-wetting,
rheumatic disorders, clumsiness, asthma, constipation, general nervousness, restlessness, irritability,
backwardness in studies, insomnia, night terrors, strabismus, rectal prolapse, muscle wasting,
epistaxis, hydrocephalus, nocturnal emissions, tuberculosis, hernia, impotence, and incontinence
(Darby 2005; Gollaher, 2000).

Researchers and commentators have long noted the inadequacy of information-
giving for the purpose of parents circumcision decision-making (Adler, Ottaway, & Gould,
2001; Christensen-Szalanski, Boyce, Harrell, & Gardner, 1987; Ciesielski-Carlucci,
Milliken, & Cohen, 1996; Fletcher, 1999; Herrera & Trouem-Trend, 1979; Lovell & Cox,
1979; Maisels, Hayes, Conrad, & Chez, 1983; McDermott, Wilson, & Marty, 1982; Shaw &
Robertson, 1963; Spinelli, 1988; Svoboda, Van Howe, & Dwyer, 2000). Compounding this
problem, several characteristics of neonatal circumcision pose particular challenges for the
practice of informed consent. These include the facts that it is an elective procedure
(American Academy of Pediatrics (AAP), Committee on Bioethics, 1995; Berry, 2005;
Ciesielski-Carlucci et al., 1996; Haberfield,1996; Lustig & Scardino, 1998; Svoboda et ah,
2000), that it is a non-therapeutic procedure (AAP, Committee on Bioethics, 1995; Boudin,
2005; Jones, 2000; Svoboda et ah, 2000), and that it is carried out by means of proxy consent
(AAP, Committee on Bioethics, 1995; Canadian Paediatric Society (CPS), Bioethics
Committee, 2004; Lashley, Talley, Lands, & Keyserlingk, 2000; R. B. Miller, 2006; Mohr &
Kennedy, 2001; Shalowitz, Garrett-Mayer, & Wendler, 2006). Each of these issues arguably
increases the requirement for a relatively more exacting standard of information-giving in
the case of consent for neonatal circumcision.
The primary elements of information required to be disclosed for the purposes of
medical consent include: information about what the proposed procedure entails, its possible
risks and benefits, and similar information about any reasonable alternatives to the
procedure, including the alternative of doing nothing (J. W. Berg et ah, 2001; Faden &
Beauchamp, 1986). Disclosure of alternatives is of key importance to fulfilling the purposes
of informed consent from both a practical and ethical perspective, and carries legal

implications as well. In the case of circumcision, various procedural alternatives exist, for
example, whether and what type of pain relief may be used, or the surgical method to be
employed. However, the most significant alternative to be explored in the education of
expectant parents is simply that of not circumcising in short, doing nothing and allowing
the boy to grow up with his natural genitals intact.
It would be a rare parent today who truly believes that circumcision of newborn
babies must be done in some absolute legal or biological sense. Most probably understand
that it is a choice. However, because circumcision has been an American cultural norm for
the last several generations, many parents do not seriously consider the alternative of not
circumcising. Not only is there a large knowledge deficit in the general public about the
appearance, structure, function, and care of the normal intact penis (Taylor-Clapp, 2001),
there also exists a great deal of misinformation and norm-based prejudice regarding the
intact penis (Milos & Macris, 1992). Therefore, carefully informing parents about the
alternative of not circumcising is all the more necessary to assure valid informed consent,
and the quality of informational materials and processes, in this regard, is all the more
important and worthy of scholarly scrutiny.
Overview of the Study and Research Questions
The study reported here is a content analysis of written educational materials about
the circumcision decision commonly available to expectant parents. The aim of the study
was to describe the information provided in these materials specifically on the alternative of
not circumcising, and to characterize the adequacy of this information. Because non-

religious neonatal circumcision is practiced primarily in the United States, the focus of the
analysis is on the content and framing found in North American information handouts, as
these are the sources to which expectant American parents are most likely to be exposed and
are most likely to give credibility. The findings are placed in the context of informed consent
doctrine, and analyzed in part in terms of framing theory. Framing theory, one of the prime
concepts applied in communication studies (Entman, 1993), holds that how a subject is
presented can psychologically influence decisions made based on that presentation,
independent of the factual content. Specifically, the material is analyzed according to
Entmans (1993) four functions of frames problem definition, causal diagnosis, moral
evaluation, and suggestion of remedies. Importantly, according to Entman, framing is in part
defined by what is omitted from a communication. Therefore framing is an especially
appropriate theoretical approach for analyzing information-giving in cases where pertinent
information is found to be missing.
This studys results are particularly relevant to health care providers, prenatal
educators, and human sexuality educators, and should provide useful guidance for improving
the quality of their information-giving about the intact penis and about not circumcising.
With this information, parents should have a greater opportunity to make an optimally
informed decision about circumcision, to the ultimate benefit of the primary stakeholder -
the child.
To describe and analyze information-giving on the alternative of not circumcising,
the study will seek to answer the following research questions:

RQ1: What content on the alternative of not circumcising is present in written
circumcision information available to expectant parents?
RQ2: How is the content of written information on the alternative of not
circumcising information framed!
Overview of the Thesis
Chapter 2 of this thesis consists of five parts, covering five areas of background
information necessary for placing the results of this content analysis in context. Part A of
Chapter 2 covers the historical, ethical, and legal foundations of informed consent, with
special attention to the importance of the disclosure of alternatives. The concept of informed
consent is specifically applied to the case of consent for neonatal circumcision. I will argue
that several distinguishing characteristics of neonatal circumcision necessitate a heightened
standard for informational disclosure for the purposes of consent. Part B is a review of the
literature relating to informed consent for neonatal circumcision and education of parents
about circumcision, including evidence of the need for parent education about the alternative
of not circumcising. Part C discusses the concept of framing, with particular attention to
Entmans (1993) influential article entitled, Framing: Toward clarification of a fractured
paradigm. Part D reviews the anatomy, function, development, and care of the intact penis,
establishing a factual basis for identifying the foreskin as a normal and valuable body part.
Part E describes the phenomenon of negative framing of the foreskin, illustrated with quotes
from historical and contemporary sources.

The remainder of the thesis is devoted to the content analysis itself. Chapter 3
describes the methodology of the study. Chapter 4 reports the results of the study in terms of
the content and framing found in the handouts on the alternative of not circumcising, and the
scoring systems that were developed to characterize the adequacy of the information given.
Chapter 5 summarizes the findings of the study; analyzes the findings in terms of their
potential effects on parents; speculates on the reasons for the studys major findings;
develops a model for information-giving about the alternative of not circumcising based on
Entmans four functions of framing; and indicates directions for further research.

Part A: Informed Consent
Introduction and Basic Concepts
In simple terms, the concept of informed consent refers to the competent patients
right to voluntarily give (or withhold) consent for medical treatment based on adequate
disclosure of relevant information (Meisel & Roth, 1981 ).2 The italicized terms in the above
definition are the three main elements that contribute to the valid execution of the practice of
informed consent (Svoboda et al., 2000). Competence refers to the patients capacities to
comprehend and process information and to reason about the consequences of ones
actions (Beauchamp & Childress, 2009, p. 114). Voluntariness refers to the patients ability
to make health care choices free from manipulation or undue influence (Svoboda et ah,
2000, p. 71). Disclosure refers to the provision to the patient of all information material to
his or her decision-making about whether to undergo a proposed treatment or procedure
(Svoboda et ah, 2000). Because of the importance that consent be based on the patient
2 Understanding is a fourth element often included in discussions of the concept of informed consent
(Beauchamp & Childress, 2009). However, understanding can also be conceived of as being
subsumed within the elements of information-giving and competence. It will not be discussed
separately here.

having adequate information with which to weigh the risks and benefits of various treatment
alternatives, disclosure, i.e. information-giving, is often the primary feature of consent
communication in the clinical setting. The goals of the practice of informed consent are,
ethically, to enact respect for the autonomy of the individual who is a patient by protecting
his or her rights to bodily integrity and self-determination; and practically, to involve the
patient in health decisions that affect him or her, and to promote the patients interest in
rational decision-making (Annas, 1977; J. W. Berg et al., 2001; Faden & Beauchamp, 1986).
While the introduction of informed consent into clinical practice was initially met with some
resistance from the medical profession (J. W. Berg et al., 2001; Brody, 1992; Faden &
Beauchamp, 1986), as traditional medical paternalism gave way to more patient-centered
practices, informed consent has come to be widely accepted by clinicians and scholars as a
basic ethical and legal precondition to conscientious medical practice (Dickens & Cook,
2004, p. 309).
Part A of Chapter 2 begins with a discussion of the key concepts that define the
practice of informed consent. After an overview of the ethical and legal underpinnings of the
concept of informed consent, including illustrative developments in its history, the focus
then turns to the primary elements of valid informed consent: information-giving,
voluntariness, and competence. Special attention is given to topics that are most relevant to
this papers thesis, including standards of disclosure, the concept of materiality, the
significance of disclosure of alternatives, and the problem of informational manipulation.
Part A concludes with a discussion of specific issues related to informed consent for
neonatal circumcision, including the facts that it is an elective and non-therapeutic surgery,
and that consent is provided by a surrogate decision-maker. I will argue that these features

necessitate a more exacting standard of information-giving for the purposes of parental
consent for neonatal circumcision. In this paper, general references to information-giving to
or decision-making on the part of the patient may be taken, in the case of neonatal
circumcision, to refer to the parent/guardian as surrogate, or proxy, decision-maker.
A Brief Legal History of Informed Consent
Beginning in the early 20th century, litigation in cases relating to medical consent
laid the foundation for the modern legal doctrine of informed consent. One of the most
influential early cases was Schloendorff v Society of New York Hospital, decided in 1914 by
Justice Cardozo. While the plaintiff had given permission for an abdominal examination
under anesthesia, she had specifically requested no operation; the surgeon, however, did
indeed remove a fibroid tumor while the patient was under anesthesia. This case illustrates
the significance of what is called simple consent, that is, the simple giving (or in this case,
withholding) of permission for a physician to proceed with a treatment or procedure, without
specific reference to the deciders informational base. Simple consent is intended most
directly to protect a patients right to bodily integrity, by requiring the physician to obtain
the patients permission, for example, to invade or remove some part of his body. However,
Cardozos opinion extended beyond the simple principle of the right to bodily integrity,
having since been characterized as a classic statement of the patients right to self-
determination (Faden & Beauchamp, 1986, p. 123). His opinion that every human being of
adult years and sound mind has a right to determine what shall be done with his own body

(Schloendorff v. Society of New York Hospital, 1914) continues to be referred to as a
foundational principle of informed consent.
The first use of the term informed consent came in 1957 with the Salgo v Leland
Stanford Jr. University Board of Trustees case. After an invasive diagnostic procedure, the
plaintiff suffered permanent paralysis, the risk of which his physician had not informed him
at the time he consented to the procedure. The court rendered the opinion that physicians
had the duty not just to obtain simple consent, but had the affirmative duty to disclose any
facts that are necessary to form the basis of an intelligent consent by the patient to the
proposed treatment (Salgo v. Leland Stanford Jr. Univ. Bd. of Trustees, 1957) in other
words, the consent must also be informed. It was in the Salgo case that informational
issues raised in previous isolated consent cases were consolidated into a cohesive statement
of the significance of information-giving for the purposes of consent. According to Faden
and Beauchamp, from Salgo on,
all pertinent topics of consent the nature, consequences, harms,
benefits, risks, and alternatives of a proffered treatment were therefore
conceived as information needed by patients in order that they know
what they are choosing (1986, p. 126, emphasis in original).
In the decades surrounding the Salgo case, other social and legal developments
coalesced to add form and force to the developing concept of informed consent, within the
context of a surge of interest in a new approach to biomedical ethics that moved beyond the
purely beneficence-based paternalism that had long held sway in medicine (Faden &
Beauchamp, 1986). For example, the Nuremberg trials, which passed judgment on the
abusive medical experiments conducted by Nazi physicians on concentration camp
detainees during the Second World War, led to the publication in 1947 of the Nuremberg

Code, the first broadly accepted legal statement of the principles of ethical medical research.
Among the key points found in the Code was the insistence that the voluntary consent of
the human subject is absolutely essential. The element of voluntariness has since become a
key element in informed consent in clinical as well as research settings. Along with the Nazi
abuses, medical research abuses in the United States such as the Tuskegee syphilis
experiment divulged to the public in 1972 fueled a trend toward mistrust of the medical
profession and concern for protecting the rights of both research subjects and patients. The
emergence of the civil rights, womens rights, and other rights movements in the 1960s and
1970s further created an environment in which health-based rights also began to be
demanded by consumers. One response to this was the publication in 1973 of the American
Hospital Associations Patients Bill of Rights, which included sections confirming the
patients rights to information and participation in medical decision-making. By 1981, the
American Medical Association had produced its first statement affirming the central
importance of informed consent in medical practice, which made clear, among other points,
the patients need for and autonomy-based right to enough information to enable intelligent
choice (Judicial Council of the American Medical Association (AMA), 1984, cited in
Faden & Beauchamp, 1986, p. 96). Around the same time, the specially established
Presidents Commission for the Study of Ethical Problems in Medicine and Biomedical and
Behavioral Research (1983) produced a series of reports, one of which dealt specifically
with informed consent. This report affirmed that informed consent was not just a set of legal
rules, but that its requirements were morally based, with the principle of self-determination
described by Faden & Beauchamp (1986) as the bedrock of the Commissions viewpoint
(p. 97).

The Ethical Underpinnings of Informed Consent
Before continuing to discuss the elements of informed consent doctrine in greater
detail, I will here review the key ethical principles that underlie its practice. The law and
moral philosophy are the two distinct yet overlapping and at times imperfectly related -
conceptual streams out of which flow the current understanding and practice of informed
consent. Moral philosophy not only defines the principles by which the legal doctrine is
justified, it serves as an extra-legal standard for ethical clinical practice where legal doctrine
alone proves too fragmented or restrictive to truly support the rights of the patient.
The ethical principle most universally accepted as the justification for informed
consent is that of respect for autonomy3 (J. W. Berg et al., 2001; Faden & Beauchamp,
1986). Rooted in the Western philosophical traditions of John Stuart Mill and Immanuel
Kant, respect for autonomy as an ethical principle refers to the promotion of self-rule free
from external constraints or internal limitations (Beauchamp & Childress, 2009; J. W. Berg
et al., 2001). Kant (1724-1804) argued that respect for autonomy stems from an
acknowledgment of the intrinsic value and self-determining dignity of the individual. Mill
(1806-1873) argued for the importance of personal liberty in the seeking of ones own good
according to ones own convictions. According to Beauchamp and Childress (2009), to
respect autonomous agents is to acknowledge their right to hold views, to make choices, and
3 Biomedical ethics are usually analyzed in terms of four principles: beneficence, non-maleficence,
autonomy, and justice. This discussion of informed consent is based primarily on the principles of
autonomy and beneficence. Non-maleficence refers to the ethical obligation to avoid doing harm to
patients. Justice most often refers to the ethical obligation to distribute healthcare resources fairly.
(Beauchamp & Childress, 2009)

to take actions based on their personal values and beliefs (p. 103). In the case of medical
decision-making, the principle of respect for autonomy enjoins health professionals not only
to refrain from subjecting patients to controlling constraints, but also to actively foster
patients capacity for autonomous action, for example, through disclosure of information and
removing barriers to understanding.
In medical ethics, the principle of respect for autonomy is weighed in balance with
the principle of beneficence, the goal of which is the promotion of personal well-being.
Indeed, however, the two are intimately entwined in medical decision-making via the
assumption that competent individuals are better judges of their own good than are others
(Buchanan & Brock, 1990, p. 29). It is this melding of the principles of autonomy and
beneficence that underlies the steadfast deference to the self-determining choices of
competent adults in many legal contexts, including situations involving medical consent. In
addition, informed consent is sometimes justified by the consequentialist argument that
autonomous participation in medical decision-making may actually lead to greater patient
well-being through, for example, increased compliance or improved physician-patient
relationships (J. W. Berg et al., 2001). On the other hand, the principle of beneficence can
sometimes come into conflict with autonomy in the sense that patients may make medical
decisions that might cause them harm or that are objectively not in their best interests. Faden
and Beauchamp (1986), however, argue for autonomy as a prima facie principle in the case
of informed consent for competent adults, demanding a heavy burden of proof upon those
who would seek to intervene in anothers freedom of choice.
One further ethical and legal dimension of informed consent is the role of the
physician as fiduciary. The ethical concept of the fiduciary role is concerned with the fact

that physicians are more professionally knowledgeable and therefore more powerful than
the patients who seek their assistance. This power imbalance in turn defines the fiduciary
obligation of the physician, that is, the obligation to act, when exercising ones professional
power, so as to put the best interests of the patient as ones highest priority (Faden &
Beauchamp, 1986). McCullough et al. (1998b) assert that the concept of acting as moral
fiduciary of the patient is central to virtually all of surgical ethics (p. 5), noting especially
the potential in surgery for financial conflict of interest.
The Elements of Informed Consent
Three key prerequisites, necessary to protect the patients autonomy, underlie the
valid execution of informed consent. As previously mentioned, these are that: 1) the patient
must have an adequate informational base upon which to make the decision, 2) the patient
must be allowed to make the decision voluntarily, and 3) the patient must be competent to
make the decision. A deeper understanding of each of these is needed to appreciate the
importance of the proper execution of informed consent in the case of neonatal circumcision.
While the concept of informed consent was bom out of litigation in cases of
intentional or negligent failure to disclose information to patients, Beauchamp and Childress
(2009) note that from the moral viewpoint, informed consent has less to do with liability of
professionals as agents of disclosure and more to do with the autonomous choices of patients

and subjects (p. 121). However, they state, disclosure still plays a pivotal role in informed
consent (p. 121). In terms of communication between physician and patient in the clinical
context, adequate disclosure of relevant information is crucial to patients autonomous
decision-making. Lay persons who are patients do not have the specialized scientific and
technical knowledge of health professionals. They cannot be expected, for example, to have
prior knowledge of the anatomy or physiology associated with their disease process, the
details of how a given surgery or medication might affect a person over the short- or long-
term, nor the uncertainties in the state of the medical evidence on their health concern. Yet,
when a treatment is proposed, knowledge of these and other facts may be very necessary for
appreciating the implications of what they are being asked to agree to. While an abbreviated
medical education is not required, patients do require sufficient explanation, in terms that
they can understand, to help them have an adequate understanding of essentially what is at
stake (Canterbury v Spence, 1972), both cognitively and in terms of their personal values.
Physicians, on the other hand, are the party expected to be in possession of the technical,
scientific, and experiential knowledge relevant to patient decision-making. Because of this,
and out of their duty as fiduciary to promote the best interests of their patients, physicians
have the ethical obligation to provide patients the information needed to support meaningful,
rational, and autonomous decision-making, an obligation enacted through legally defined
disclosure requirements.
It is important to note that, while physicians do have a duty to disclose information
material to the patients decision-making process, patients may also legitimately inform
themselves for the purposes of consent according to other sources to which they have been
exposed. For example, some patients may seek information on their problem independently,

or may apply the advice of family, friends, or health educators to their decision-making.
Informational handouts, such as those analyzed for this project, are part of the body of
information that ultimately may contribute to a patient being informed enough to give valid
consent. Nonetheless, as the party ultimately responsible for assuring that a patients consent
is adequately informed, physicians are expected to assess the patients pre-existing level of
understanding, and correct any misinformation, misconceptions, or false beliefs under which
the patient may be operating, as part of the disclosure element of the informed consent
process (McCullough et al., 1998a).
The courts have employed several standards to legally define what information
should be disclosed to patients. The professional practice standard and the reasonable patient
standard are the most commonly used in legal cases, although a subjective standard has on
occasion been applied in the courts, and several states have adopted hybrid standards. A
review of these standards is relevant to this thesis, in that they cast light on what the ideal
approach to information-giving might be, and why.
According to the professional practice standard, the customary practices of the
professionals community are used to determine the adequacy of disclosure, as defined by an
expert witness (Beauchamp & Childress, 2009; J. W. Berg et al., 2001). This was the
standard initially employed in the early years after the Salgo case, and continues as the legal
standard in roughly half of the states today (King & Moulton, 2006). The professional
practice standard has been criticized on several grounds (Beauchamp & Childress, 2009; J.
W. Berg et al., 2001; Faden & Beauchamp, 1986; King & Moulton, 2006). First, not all
physicians are indeed in agreement on a standard of care for treatment and information
disclosure. Second, if custom alone were conclusive, pervasive negligence could be

perpetuated with impunity (Beauchamp & Childress, 2009, p. 122). Third, physicians are
not in a position to make the evaluative judgments necessary for weighing treatment options.
These are judgments that should properly be based the individual patients own life goals
and preferences. This feeds into the fourth and most fundamental criticism, that the
professional practice standard undermines the patients right of autonomous choice, the very
principle that informed consent is intended to protect.
In response to these problems, the reasonable person standard (or so-called
objective standard) for informational disclosure was developed based on what information
would be judged material to the decision-making of a hypothetical reasonable patient, as
defined by a jury. This patient-oriented standard was first expressed in the landmark
Canterbury v Spence opinion rendered in 1972, and is used today in about half the states
(King & Moulton, 2006). While such a standard improves upon the professional standard by
making the patient the point of reference, this standard has its own problems (Beauchamp &
Childress, 2009; J. W. Berg et al., 2001; Faden & Beauchamp, 1986; King & Moulton,
2006). First, there is no agreement on what the reasonable patient would consider material in
making a decision. What might not matter to one patient in making a medical decision might
be very important to another. Because this standard is embodied by the norms subscribed to
by the deciding jury, it has its limitations in supporting the informational needs of individual
patients, which may be driven by atypical values or circumstances. Also, medical decisions
impact not just physical health outcomes, but affect important quality of life issues as well,
such as employment and financial status, sexuality, physical appearance, mental function, or
valued activities such as hobbies. These quality of life issues may understandably be
evaluated in highly individualized ways by different persons. A second problem with the

reasonable person standard is that its abstract and hypothetical character makes it difficult
for [physicians] to use because they have to project what a reasonable patient would need to
know (Beauchamp & Childress, 2009, p. 123), a situation made all the more difficult when
decisions are complex and involve quality of life concerns (King & Moulton, 2006).
The subjective standard is an attempt to tailor disclosure to assure the decision-
making rights of persons as unique individuals. It judges the adequacy of disclosure by
referring to the specific informational needs of the particular patient, in as much as a
physician can reasonably be expected to know them. This standard has been applied by only
a few courts and legislatures out of concern that it would be even harder to implement in
practice than the reasonable person standard, and that it would be a difficult standard to
apply in court, where it would be subject to hindsight abuse by disgruntled patient-plaintiffs
(J. W. Berg et al., 2001). However, several commentators have argued that the subjective
standard is the preferable moral standard of disclosure, because it alone meets persons
specific informational needs (Beauchamp & Childress, 2009, p. 124, emphasis in original)
and, as such, in practice, should represent the ultimate goal of an informed consent system
(King & Moulton, 2006, p. 445).
The concept of materiality is inherent in the legal standards of disclosure and
requires some additional exploration. Materiality as a criterion for disclosure is generally
understood to mean whether a person would deem a particular piece of information worthy
of consideration in the process of deliberation about treatment options (Faden &

Beauchamp, 1986, p. 303). According to Faden and Beauchamp (1986), core disclosure
should cover both facts that are deemed material by the professional as well as facts that are
subjectively material to the patient. While materiality is often interpreted in the courts via the
legal concept of decision-causation4 (J. W. Berg et al., 2001), Faden and Beauchamp argue
that materiality does not necessarily have to refer to just information that would make a
concrete difference in the patients decision outcome.
Various medical and legal commentators have expanded upon the concept of
materiality, some from the point of view of how a practitioner may protect himself from
litigation, others from the point of view of the patients needs and rights. Nixdorf (1990)
writing in the context of chiropractic care, defines materiality according to the objective
gravity of the potential consequences of treatment, however infrequent. He also states that
risks that are probable, special, unusual, or relevant to the patients specific circumstances
must be disclosed. Dickens and Cook (2004) assert that what a prudent person would
consider a material risk is affected by the risks likelihood and severity. Importantly, they
also affirm that the criteria for what constitutes materiality entail a broader definition of
health that transcends the physical or purely biomedical dimensions to include
psychological, sexual, social, and economic aspects of well-being. These are, again, the
quality of life factors that may be affected by treatments or procedures, which patients
should be able to knowledgeably weigh when making medical decisions. McCullough et al.
(1998a) describe material information in terms of what the lay patient would be unlikely to
know from daily life, but which would be needed for medical decision-making. Svoboda et
4 Decision-causation refers to the nexus between the physicians failure to disclose and the decision
made by the patient. When it can be said that if the physician had made proper disclosure, the patient
would have made a different choice, decision-causation exists (J. W. Berg et al., 2001, p. 138).

al. (2000) argue that a physician has a duty to disclose all information that he or she knows -
or should know would be regarded as material by a reasonable person, which implies a
duty of physicians to keep up to date with the relevant literature. Kettle (2003) states that
physicians have a duty to disclose areas of uncertainty in the scientific evidence regarding a
given treatment. Gert (2002) argues for the moral (i.e. extra-legal) obligation to disclose
based on what she calls the Principle of Avoiding Surprises, out of respect for the dignity
of the patient, even if the information might not make a difference in the patients decision.
According to this approach, patients should receive enough information that they will not
be surprised by whatever happens unless the physician is also surprised (p. 23).
The specific categories of information legally expected to be disclosed usually
include the nature of the proposed procedure, and its risks and benefits, plus similar
information about any medically reasonable alternatives to the given procedure (J. W. Berg
et al., 2001). While it is understood that the physician need not educate the patient about
every detail of applicable medical concepts (McCullough et al., 1998a), it is clear, however,
from the above discussion of materiality that a wide-ranging exposition of information and
considerations may legitimately be needed or desired by the person who is put in the position
of having to make a significant medical decision.
The Importance of Alternatives
The disclosure category of central interest to this paper is that of informing about
the alternatives to a proposed procedure. As part of the valid execution of informed consent,
physicians are legally expected to provide patients with information about any medically

acceptable and reasonably available treatment alternatives for addressing the patients health
problem, including the option of doing nothing (J. W. Berg et al., 2001; Wear, 1998). For
each therapeutic option, the same spectrum of information should be disclosed, so that the
patient has enough information about the nature of each approach, and its relative merits and
disadvantages, to make a valid comparison. Informing the patient about alternatives in this
way allows him to make decisions by weighing the potential implications of each both
medically and in terms of quality of life issues according to his personal values, risk-
tolerance, preferences, life goals, etc. McCullough et al. (1998b) note that, as a general
principle of surgery, offering only one alternative in non-emergency cases is, flatly, an
ethically flawed approach.
The term alternative implies the existence of a primary physician-recommended
treatment. Certainly, in some cases, only one medically reasonable course of care may seem
to exist, as when the evidence of efficacy is overwhelming. Still, at least in theory, the
alternative of doing nothing always exists and, if time allows (i.e. in a non-emergency
situation), the patient should always be informed of the prognosis with no treatment. As one
courts opinion put it,
How can a patient give an informed consent to treatment for a condition
if the patient is not informed that the condition might resolve itself
without any treatment at all? (Cited in J. W. Berg et al., 2001, p. 59)
At the very least, discussing the option of doing nothing provides a backdrop against which
the patient can gain perspective on the relative necessity or value of the one offered
therapeutic option.
On the other hand, valid treatment alternatives do exist for many medical situations,
for example, surgical versus medical treatment, less invasive versus more invasive

procedures, or different drug regimens. Such alternatives may have different profiles in
terms of differing short- and long-term outcomes, differing types of side effects, risks, and
complications, differing effects on quality of life outcomes, and other dimensions. It has
been estimated that about 30-35% of medical decision-making involves a valid choice
between at least two treatments with differing balances of outcomes and risks, including,
sometimes, situations in which there is scientific uncertainty about treatment effects (King &
Moulton, 2006). This type of medical circumstance has come to be known as preference-
sensitive care, because a clear scientific indication of the proper course to pursue is lacking,
and therefore decisions are best made according to the well-informed preferences of the
patient (Center for the Evaluative Clinical Sciences, 2007). In such cases, the patients
subjective judgment of the various factors is what ultimately matters most, because it is his
body and his life that will be affected by the decision. However, the weighing of the medical
and quality of life tradeoffs between more than one viable option compounds the level of
decision-making complexity. Thus, when more than one medically reasonable therapeutic
option exists, out of respect for the patients right to autonomous self-determination, an even
more careful examination and informational disclosure of each option is necessary to assist
patient decision-making (Whitney, McGuire, & McCullough, 2003). Decision-making
between alternatives in preference-sensitive circumstances most appropriately involves a
high level of involvement by the patient (Wennberg & Peters, 2002), and consciously
incorporates the patients evaluative understanding of the alternatives that is, the
appreciation of how each will impact the values he holds important in conjunction with his
cognitive understanding (McCullough et al., 1998a).

In addition to adequate information-giving, a second key prerequisite for valid
informed consent is that the decision be made voluntarily. Faden and Beauchamp (1986)
have provided the most comprehensive exposition of the factors involved with voluntariness
and the validity of informed consent (pp. 161-162, pp. 337-381), upon which most of the
following discussion is based, except where otherwise noted.
For a patients decision-making to be voluntary, it must free of coercive or undue
manipulative influences by other persons or circumstances, such that the decision is freely
and authentically made in short, that it is autonomous. Coercion or manipulation might be
applied consciously with the deliberate intent to exert control over a patients decision, or it
might be applied unintentionally through subtle or unconscious communicational or social
effects. In either case, the patients decision is altered from what she would have chosen of
her own accord. Consent given under the influence of such pressures is considered legally
and ethically invalid.
All human behavior, including decision-making, is subject to external influences,
but such influences exist on a spectrum in terms of their compatibility with autonomous
action, and therefore the acceptability of their effects on voluntariness. For example,
persuasion is considered an acceptable form of influence upon an individual contemplating a
medical decision, because it appeals to the persons faculty of reason. Because no attempt is
made to exert control over the deciding patient, and she is free to accept or reject the
arguments given without fear of reprisal or loss, persuasion does not impinge on the
voluntariness of the patients decision-making. On the other hand, coercion is a type of

influence that is not compatible with voluntariness, because it presents a credible threat of
unwanted and avoidable harm so severe that the person is unable to resist acting to avoid it
(Faden & Beauchamp, 1986, p. 261) an obvious constraint on autonomy. The threatened
harm may be physical, psychological, economic, legal, or of other types. An example of
coercion, from the history of research ethics, is the forced participation in the Nazi medical
experiments of concentration camp detainees, whose only other choice would have been
certain, perhaps immediate, death.
Manipulation is the term Faden and Beauchamp use for a third category of influence
that covers a large gray area between these two extremes. According to them, manipulation
consists of influence of a person by noncoercively altering the actual choices available to
the person or by nonpersuasively altering the persons perceptions of those choices (p. 261).
Various types of manipulation exist. Manipulation of options operates through modification
of the environment, particularly by offering rewards or punishments. Manipulation of
information alters a persons perception of options by affecting his or her understanding of
the situation. Psychological manipulation influences mental processes other than
understanding, such as via subliminal suggestion, appeals to emotional weaknesses, or
inducing feelings of guilt. In the health care setting, the most likely form of manipulation is
informational manipulation, which is recognized by a number of authors as a major
problem for informed consent (Faden & Beauchamp, 1986, p. 261). It is an especially
important problem in that it affects two of the elements required for valid informed consent -
information-giving itself and the principle of voluntariness. Informational manipulation is
one of the primary concerns of this thesis.

Only minor manipulations those that affect autonomy in minor ways only, or not at
all are considered compatible with valid informed consent. What standard should be used
to determine whether a manipulation is compatible with the requirement that informed
consent be voluntary? The ability to resist an applied threat is a standard useful in
distinguishing a coercive from a non-coercive influence. However, since some informational
manipulations are of the type such that they may not be consciously perceived by the person
being manipulated, the ability to resist the manipulation is not a valid criterion for deciding
whether a given informational manipulation is compatible with voluntariness. A more
appropriate approach focuses on the need for a deciding patient to have a substantial enough
understanding of the implications of his choices, such that one may say that he is making an
autonomous decision. The question is then, to what degree is the substantiality of a persons
understanding affected by a given informational manipulation? Faden and Beauchamp
propose that both objective and subjective criteria be applied. An influence is thus
considered incompatible with the requirement of voluntariness if it affects, in more than a
minor way, the objective adequacy of the disclosure made by the professional, or if it
adversely affects understanding of information subjectively material to a patients decision-
Deception is the most common form of informational manipulation, encompassing a
variety of strategies that have the conscious intent to cause persons to believe things that are
not true. Lying, withholding of information, consciously promulgating partial truths, or
deliberately exaggerating or unduly minimizing risks or benefits are clearly forms of
deception. Manipulation, however, can shade into less blatant but no less distorting forms of
influence, such as subtler misrepresentation or slanting, or simple omission of information,

which may be brought about either intentionally or unintentionally. Similarly, and even more
subtly, formulation effects or framing effects where information is couched in terms
that distort the patients cognitive processes can result in responses involuntarily altered
from what would rationally be expected (Faden & Beauchamp, 1986; Haward, Murphy, &
Lorenz, 2008; Lustig & Scardino, 1998; McCullough et al., 1998a). An example of the effect
of framing is the difference in the proportion of patients choosing one treatment alternative
over another, depending on whether the outcomes of the treatment options are presented in
term of their mortality rates or their survival rates (Haward et al. 2008; Moxey, O'Connell,
McGettigan, & Henry, 2003). The concept of framing is covered in more detail in Part C of
this chapter.
Besides direct manipulation of information, the process of informing is subject to
influences and variations in execution such that patients may participate in a more or less
autonomous way. For example, the timing, manner, and order of a presentation may tend to
steer a patient toward one or another choice, or overwhelm his ability to understand the
information or consider it judiciously all of which undermine the requirement of
voluntariness (Svoboda et al., 2000). On an even broader level, certain factors in the health
care context itself may put patients at increased risk of undue influence. According to Faden
and Beauchamp (1986),
in comparison to many commercial transactions, health care contexts
exhibit an imbalance of knowledge and power; these contexts are often
imbued with a background of credibility, trust, and dependency. Thus,
attempted informational manipulations are more likely to be both
successful and more controlling in health care contexts (p. 363).

Because of these concerns, they conclude that as a practical matter, it is not likely that
many informational manipulations would be judged compatible with [...] informed consent
(p. 363).
Competence is the third element required to ensure legally valid informed consent.
This element is intended to protect patients well-being by ensuring that they have the
cognitive capacities necessary to support rational decision-making. As a general legal
presumption, adults are considered to be competent for the purpose of medical decision-
making, thus warranting that their decisions are respected by others, unless some specific
finding calls their competence into question. This presumption is based on the prima facie
principle of respect for autonomy in association with the principle of beneficence, on the
premise that the competent adult will be the best judge of his or her own best interests.
However, certain conditions, such as mental illness, developmental disability, or
brain damage, might so impair an adults cognitive capacity as to render him incompetent to
make medical decisions, thus justifying an exception to the right to give informed consent.
Here the principle of beneficence is judged to outweigh the principle of autonomy in
determining the best course of action to fulfill the incompetent persons best interests. In
such cases, a competent surrogate (proxy) is assigned to make medical decisions for the
incompetent patient, either through pre-designation by the patient at a time when he was
competent, or through institutional or judicial channels. While adults are presumed to be
competent to give informed consent unless proven otherwise, children are generally legally

regarded as incompetent to give informed consent. In the case of children, the parents are
most often designated as surrogate decision-makers when medical decisions are necessary.
The same elements of adequate informational disclosure and voluntariness are required for
valid informed consent in the case of surrogates, as for informed consent by a competent
patient for himself.
Decision-making by surrogates is guided by reference to several standards
(Beauchamp & Childress, 2009; Buchanan & Brock, 1990). The subjective, or pure
autonomy, standard directs surrogates to make decisions based on previously articulated
decisions of their wards, such as via legally issued advance directives. This standard is based
on respect for the previously competent patients self-determined and express preferences.
Lacking advance directives, the preferred standard to guide surrogate decision-making is the
substituted judgment standard, in which surrogates are directed to choose what they believe
the patient would have wanted for himself, based on their familiarity with evidence of the
previously competent patients values and preferences. Note that, under the substituted
judgment standard, surrogates are directed to refer only to what they believe the patient
would want under the circumstances, not what the surrogates would themselves want. The
substituted judgment standard is also based on the principle of respect for autonomy and
fosters the self-determination of the patient. When no evidence of the patients preferences
or values is available, or when the patient has never been competent, as in persons
developmentally disabled since birth, or in the case of infants, decision-making guidance
reverts to the best interests standard. Under the best interests standard, surrogates are
directed to make necessary decisions based on what in their estimation would produce the
highest net benefit to the incompetent patient, by their careful and informed weighing of the

patients interests against the risks and costs of available treatment options. Thus, the best
interests standard is based on the principle of beneficence, and not on respect for autonomy,
as the patients personal preferences are not able to be known or reliably intuited.
Surrogate decision-making in relation to children, will be discussed further later in
Part A of this chapter, as part of the discussion of the special challenges that neonatal
circumcision poses for informed consent.
Exceptions to Informed Consent
Besides situations involving incompetent patients, there are several other legally
accepted exceptions to the patients right to informed consent. Several are based on the
principle of beneficence and are applicable in cases where the best interests of the individual
or society are deemed significant enough to take priority over the patients right to self-
determination (Faden & Beauchamp, 1986). These exceptions include public health
emergencies, such as when individuals with TB are legally required to be quarantined and
treated, out of a need to promote public safety; and medical emergencies, in which a delay in
order to obtain informed consent would place the patient at imminent risk of death or
significant harm. Another exception, based on the principle of non-maleficence, is the so-
called therapeutic privilege, in which a physician withholds material information out of
concern for its possible harmful effects on the patient, such as causing emotional
destabilization (Beauchamp & Childress, 2009). However, a too casual invocation of the
therapeutic privilege exception risks a return to the paternalism that produced the need for
informed consent in the first place. Most commentators hold that therapeutic privilege

should only be applied under very narrowly formulated circumstances (Beauchamp &
Childress, 2009; J. W. Berg et al., 2001). The final exception allowed for informed consent
is patient waiver, in which the competent patient voluntarily waives his right to information
and/or cedes decision-making to the physician or a designated other. The justification for
this exception is not beneficence or non-maleficence, but is an extension of the competent
patients right to self-determination that is the underlying principle of informed consent
itself. However, in the same way that the power imbalance between patients and physicians
may increase the risk of informational manipulation, the risk of improper solicitation of
patient waiver also exists (Beauchamp & Childress, 2009, p. 132), thus careful oversight of
the waiver exception is necessary.
Informed Consent for Neonatal Circumcision: Special Challenges
Neonatal circumcision differs from most medical decision-making situations in a
number of specific ways. First, neonatal circumcision is commonly considered to be an
elective surgery (AAP, 1999; AAP, American College of Obstetricians and Gynecologists
(ACOG), 2002), that is, surgery that is not clearly medically indicated and is therefore
optional. Second, it is a non-therapeutic procedure (Council on Scientific Affairs, American
Medical Association (AMA), 1999), that is, it is not performed to treat an existing medical
problem. Third, it is a procedure that is decided upon not by the patient himself, but by
parental proxy. Individually and in conjunction with each other, these factors pose special
challenges to the proper conduct of informed consent, and raise the standard of care with

which information about circumcision and the alternative of not circumcising must be
Informed Consent and Elective Surgery
Elective surgery refers to surgery as a possible treatment option for non-emergent
disease, in which evidence on the ratio of risks to benefits has not reached a decisive
balance in favor of surgical management (Lustig & Scardino, 1998, p. 133). Lustig and
Scardino (1998) describe two types of medical situations in which surgery may be judged
elective. The first type is in the case of chronic and slowly progressive conditions that are
relatively benign, thus allowing for at least a trial of nonsurgical management. The second
type relates to conditions in which surgery could be used to avoid a rarely seen but very bad
outcome, but where the risks of morbidity and the potential for adverse effects on the
patients quality of life militate against making an outright recommendation. The physicians
fiduciary role is of special importance in the case of informed consent for elective surgery,
with the attendant need of the surgeon to guard against financial self-interest when surgery is
not clearly indicated. The surgeon must take care to make clear the elective nature of the
surgical management route i.e. that it is not clearly required or recommended and to
present all reasonable alternatives and the implications of each, without bias (Lustig &
Scardino, 1998).
Because of the lack of certainty about the relative merits of treatment options and
the greater availability of time for deliberation, Lustig and Scardino (1998) have argued that
elective surgery demands a more stringently process-oriented rather than discrete event

model of informed consent. In other words, information-giving should involve a relatively
extensive dialogue over sufficient time to allow the patient to fully assimilate, appreciate,
and deliberate upon the relevant information, so as to gradually come to a settled response to
his options in the light of his own values and life plan (J. W. Berg et al., 2001). In regard to
decision-making in the case of elective surgery, Lustig and Scardino argue unequivocally for
the centrality of the patients own values in determining the choice of treatment. They
therefore endorse a subjective rather than reasonable person standard of disclosure in
elective situations, so that the patients individual preferences and values may be
appropriately respected and incorporated into the decision-making process. Indeed, elective
surgery is subsumed within the category of preference-sensitive care, discussed
previously. Decision-making in preference-sensitive care requires a higher degree of patient
involvement and of attention to incorporating the patients values, as well as a higher
standard of disclosure in exploring the therapeutic options, so that patients may fully
appreciate the potential impact of their decisions on the things they value in life.
A number of legal and medical scholars have suggested that the duty of care for
disclosure should be higher when the procedure is elective (Berry, 2005; Ciesielski-Carlucci
et al., 1996; Haberfield, 1996; Schuck, 1994; Somerville, 1981; Svoboda et al., 2000).
Schuck (1994), seeking to reconceive informed consent so as to make it more tenable within
the time and cost constraints of modem health care, has suggested that the extent of
disclosure should vary according to certain factors present in the clinical context. He lists
elective procedures and procedures with a controversial risk-benefit ratio as medical
situations that would merit a higher legal standard of disclosure. Whitney et al. (2003) argue
that, ethically and practically, the added attention to disclosure and patient involvement, in

consent situations where more than one valid therapeutic option exists, shows respect to
patients who are confronted with complex decisions, and enables them to have more control
over their medical care.
As previously noted, neonatal circumcision is regularly characterized as elective
surgery. As such, the above discussion makes the case for an elevated standard of
informational disclosure for circumcision of newborns, not only in terms of the adequacy of
disclosure, but also in terms of allowing time for a process-oriented pattern of disclosure and
deliberation that attempts to consciously consider the patients (the childs) values. Beyond
its elective nature, however, several additional aspects of the practice of neonatal
circumcision differentiate it from most other surgeries. These include the facts that neonatal
circumcision is a non-therapeutic procedure, and that it is not chosen by the patient himself,
but by his parents for him. Both of these features of neonatal circumcision pose further
challenges to the practice of informed consent.
Informed Consent and Non-therapeutic Procedures
Neither of the two medical categories mentioned above, into which elective
surgeries are suggested to fall (Lustig & Scardino, 1998), applies to neonatal circumcision.
The intact newborn penis is typically not diseased; it is simply a normal, healthy body part.
Nor can it be rationally said that an intact boy is at risk of some rare but potentially very bad
outcome because of his possession of a foreskin, any more than he would be for the
possession of any other normal body parts. The usual practice of informed consent and
disclosure of treatment alternatives is based on the premise that a medical problem exists

that requires therapeutic intervention of some type for relief or correction of the problem.
Yet in the case of neonatal circumcision, no medical problem exists, making the procedure
by definition non-therapeutic. The worlds major medical organizations, having reviewed the
evidence on the possible medical merit of neonatal circumcision acknowledge this fact,
variously describing it as non-therapeutic (Council on Scientific Affairs, AMA, 1999;
Medical Ethics Committee, BMA, 2006), as having no medical indication (RACP, 2002),
or likening it to a cosmetic procedure (American Academy of Family Physicians (AAFP),
2002), i.e. primarily for appearance, rather than for health reasons.
Since neonatal circumcision is categorized as an elective procedure, we have already
seen that a higher standard for informational disclosure is expected. When the procedure is,
moreover, understood to be non-therapeutic, additional disclosure expectations are overlaid
on this already elevated standard. According to legal scholar and bioethicist Somerville
(1981), the non-therapeutic nature of the procedure must be carefully made clear to the
patient, particularly because
patients tend to identity physicians with therapy, and find it hard to
believe that a physician would carry out a non-therapeutic procedure on
them, even when they are expressly informed of this fact (page number
not available).
Note that this comment invokes concerns about the patient-physician power imbalance
mentioned previously. As for information-giving, Somerville (1981) states, in general, a
very full disclosure is needed when non-therapeutic medical intervention is involved (page
number not available), justifying this assertion on the grounds of giving patients a chance to
more carefully consider deciding against procedures that have no therapeutic function. The
disclosure expectations generated by the non-therapeutic nature of neonatal circumcision are

compounded to an additional degree by the fact that consent is provided by a proxy.
According to Somerville,
when one moves outside the competent adult model, then whether a
medical intervention is therapeutic or non-therapeutic becomes most
important. [...] It must always be kept in mind that more care is needed
in giving permission for an intervention on another person than when we
consent to have something done to ourselves (page number not available,
emphasis added).
Pediatric Proxy Consent
As already noted, children are legally regarded as incompetent to give informed
consent, due to their lack of cognitive capacity and experience, although some exceptions to
this rule may be instituted in deference to circumstance or the childs advancing
development (Buchanan & Brock, 1990). For example, both the American Academy of
Pediatrics (AAP) (Committee on Bioethics, 1995) and the Canadian Paediatric Society
(CPS) (Bioethics Committee, 2004) acknowledge the ethical and practical importance of
including children in information-giving and the decision-making process (termed child
assent), as developmentally appropriate. Parents are most often designated as the surrogate
or proxy decision-makers for a child, in recognition of their role of responsibility and
presumed concern for the childs well-being, absent any evidence of incompetence,
negligence, abuse, or conflict of interest (Buchanan & Brock, 1990). Technically, parents are
not giving consent derived from an examination of their own values and preferences, as
they would for a procedure on themselves, but are giving permission as guardians on behalf

of the child, for procedures deemed necessary to ensure the childs well-being (AAP,
Committee on Bioethics, 1995).
As we have seen above, the preferred standards for surrogate decision-making -
advanced directives and substituted judgment are modeled on decision-making by
competent adults, in that they are based on the principle of respect for autonomy and place a
priority on carrying out the incompetent patients explicit or inferred preferences. However,
in the case of pediatric medical ethics, the prima facie principle of autonomy takes a
secondary position to the principle of beneficence (R. B. Miller, 2006). This shift is justified
by the concern for protecting children from making ill-considered medical decisions for
themselves, and the assumption that a competent and caring surrogate would be in a better
position to make any necessary decisions in a manner that best protects the childs interests
(Buchanan & Brock, 1990; R. B. Miller, 2006). In the case of young children, since no pre-
existing evidence of maturely considered preferences exists and a substituted judgment
cannot therefore be made directly, decision-making guidance typically reverts to the
beneficence-based best interests standard.
Various authors and medical organizations have proposed guidelines for factors to
be considered in determining a childs best interests (Bouclin, 2005; AAP, Bioethics
Committee, 2004; Medical Ethics Committee, BMA, 2006; Mercurio, 2006). Overall, the
concept of best interests should guide surrogates to make necessary medical decisions in
such a way as to attempt to maximize benefits while minimizing harms to the child patient.
Factors to be considered include, for example: the balance of the harms and benefits of
treatment options; the evidence on long- and short-term outcomes of treatment options; long-
term implications for the childs suffering and quality of life; how likely the proposed

treatment is to improve or prevent deterioration of the childs condition; the childs chances
of survival; and whether the proposed treatment is the least restrictive and least intrusive
way to obtain the hoped-for benefits. These factors suggest some of the content necessary to
assure an adequate level of informational disclosure to surrogates. The British Medical
Association (BMA) (Medical Ethics Committee, 2006), reviewing criteria for best interests
specifically in the case on non-therapeutic circumcision, includes the familys views and
cultural background as part of the context that defines best interests (as in the case of
religious circumcision), along with the childs physical and emotional well-being. The BMA
additionally states that the best interests standard also entails the prioritising [s/'c] of options
which maximize the patients future opportunities and choices (p. 4).
Despite this guidance, in actual practice, what constitutes a childs best interests is
not always easy to define (AAP, Committee on Bioethics, 1995). In circumstances where a
childs best interests are unclear, the CPS recommends that when it is possible to defer or
delay acute treatment, such a delay is encouraged while further information is gathered to
clarify the issues (Bioethics Committee, 2004, p. 100). A number of authors have argued
for a heavy burden of proof by surrogates regarding decisions made based on the best
interests standard, because of the fundamental legal and ethical presumption against invasion
of an individuals bodily integrity (Medical Ethics Committee, BMA, 2006; R. B. Miller,
2006; Svoboda et al., 2000). In regard to circumcision, the BMA specifically states that
parents must explain and justify requests for circumcision, in terms of the childs interests
(2006, p.4).
As with other child-rearing scenarios, parents are generally given wide discretionary
authority in medical decision-making, not only from the presumption that they are in the best

position to further the well-being of their children, but in respect for the privacy of the
family and for the right of parents to raise their children according to their own values and
standards, within reasonable limits (Bouclin, 2005; Buchanan & Brock, 1990; Schoeman,
1985). While acknowledging the strong legal presumption against intervention into parental
decision-making, various authors and professional organizations have voiced concerns about
the ethical issues raised by pediatric proxy consent (AAP, Committee on Bioethics, 1995;
CPS, Bioethics Committee, 2004; Svoboda et al., 2000). The AAP has stated the ethical
dilemma of proxy consent in pediatric practice in this way:
[P]roxy consent poses serious problems for pediatric health care
providers. Such providers have legal and ethical duties to their child
patients to render competent medical care based on what the patient
needs, not what someone else expresses. [... T]he pediatrician's
responsibilities to his or her patient exist independent of parental desires
or proxy consent (Committee on Bioethics, 1995, p. 315).
This passage makes clear that it is not the parents personal beliefs, values, goals, or
preferences that should drive the medical decision-making process, but that the focus should
be on the child himself, and the effect of the proposed intervention on his actual needs and
on his lifes potentials.
Surrogate decision-making, in general, raises concerns for consent in several ways.
First, the risk of surrogates making decisions for incompetent patients based on their own
concerns and values, instead of those of the patient, is real (McCullough et al., 1998a). The
ethical principle of best interests is problematic in this regard because it relies on the
decision-maker referring to his or her own conception of quality of life, and then being able
to appropriately apply this conception to the patient and his future life (S. Bailey, 2006).
According to nursing ethicist Bailey (2006), in cases involving surrogate consent, there is

clearly great potential for moral errors to be made in these circumstances (p. 289). This is
especially so because a surrogate has no intrinsic motivation to fully consider the impact of a
medical decision made for a ward, as it is not his or her own body or life that will be
affected. Thus there may be more of a tendency for surrogates to overlook or minimize
harms that may result from decisions made for others.
A further problem with decisions made by surrogates is that there is considerable
evidence to show that surrogates do not always make choices that conform to what their
wards would actually have chosen for themselves. A review of 16 studies involving 2595
pairs of still-competent patients and their pre-designated surrogates, found that nearly one
third of the surrogates failed to predict the treatment preferences of their designated wards,
when presented with hypothetical end-of-life treatment decision scenarios (Shalowitz et al.,
2006). An even greater lack of accuracy in surrogate decision-making has been found in
research on hypothetical situations concerning elective surgery (Mantravadi, Sheth,
Gonnering, & Covert, 2007).
It is the concern with countering such risks that justifies a more stringent standard
for informed consent in cases of consent by proxy. Careful, process-oriented attention to
comprehensive and unbiased information-giving is the foundation for helping surrogate
decision-makers become well-informed enough to have a realistic appreciation of the ways
that their decisions may impact the lives of the incompetent persons who are dependent on
them. As we have seen, concerns regarding proxy consent are compounded when associated
with decision-making for elective and non-therapeutic procedures (Somerville, 1981), as is
the case with neonatal circumcision. In such cases, disclosure must meet the highest possible

Additional Ethical Concerns with Neonatal Circumcision
I have argued that the elective and non-therapeutic nature of neonatal circumcision,
and the fact that it is undertaken by parental proxy consent, ethically requires a more
stringent standard of information-giving than in other medical decision-making situations.
This assertion provides sufficient foundation for the analysis to be made later, in the research
portion of this paper. However, two further aspects of parental consent for neonatal
circumcision which move the issue into a more deeply controversial moral realm deserve
to be noted. A detailed exploration of these issues is beyond the scope of this paper.
However, the key point is that they reinforce the need for scrutiny of the implementation of
valid informed consent, if neonatal circumcision is to be offered.
The first ethical issue brings into question the very validity of parental consent for
neonatal circumcision. The current AAP position is that,
in the case of circumcision, in which there are potential benefits and
risks, yet the procedure is not essential for the childs current well-being,
parents should determine what is in the best interest of the child. [...] It
is legitimate for parents to take into account cultural, religious, and
ethnic traditions, in addition to the medical factors, when making this
decision (1999, p. 691).
However, according to Bouclin (2005), Canadian legal precedent limits parental authority to
consent to therapeutic treatment only, or in situations of imminent and serious danger
requiring immediate treatment (p. 214). Similarly, Svoboda et al. (2000) argue that in the
case of elective or cosmetic surgery, U.S. legal precedent suggests that only the patient (not
a proxy) can give consent, and conclude that parents have no legal authority to consent to
medically unnecessary procedures on their children. Recently, in Australia, the Tasmania

Law Reform Institute has released a legal review of non-therapeutic male circumcision that
concludes that there is uncertainty as to whether the consent of a parent for the circumcision
of their child is sufficient to allow a circumciser to legally perform the procedure (Marshall,
2009, p. 6). While these papers are geared exclusively to circumcision and its legal
interpretation, British pediatrician Jones (2000) proposes a related ethical argument
stemming from a discussion of parental consent to cosmetic (i.e. non-therapeutic) facial
surgery for children with Downs syndrome. He compares this to both female and male
circumcision in terms of being a form of surgery undertaken with the primary intent of
helping a child fit in to society. He argues that parental authority to consent to treatment is
invalid if it is not possible to demonstrate personal benefit to the child, or that the public
interest is in any way served. Despite the questions that these arguments raise, neonatal
circumcision by parental proxy consent continues in the United States without any effective
legal challenge, although several foreign jurisdictions are considering or have implemented
regulatory restrictions (Marshall, 2009).
The second ethical issue that affects the adequate execution of informed consent for
neonatal circumcision has to do with the appropriate standard for decision-making, and the
moral status of the child. While the best interests standard is generally viewed as the only
valid standard that can be applied in the case of infants, on the grounds that the preferences
of infants cannot be known, the principle of autonomy cannot be overlooked in guiding
parental decision-making for children. On this point, and citing Joel Feinbergs argument for
the childs right to an open future (Feinberg, 2007), Berg et al. (2001) have written:

It may seem strange to speak of promoting the autonomy of incompetent
patients. Yet some patients are only temporarily incompetent and non-
autonomous, as when they are briefly unconscious or are infants. These
patients will regain consciousness or mature; decisions made on their
behalf should, therefore, safeguard their future autonomy and their
opportunities to make future autonomous decisions. For this reason, for
example, parents generally may not elect to sterilize their children; to do
so would infringe on the future reproductive autonomy of their children
(P- 94).
This echoes the best interests guidance from the British Medical Association (Medical Ethics
Committee, 2006), in regard to the prioritising [s/c]of options which maximize the patients
future opportunities and choices (p. 4).
As an irreversible and medically unnecessary amputative procedure that alters not
only the appearance but also the function of the penis (see Part D of Chapter 2), neonatal
circumcision can be seen as infringing on the future autonomy of the child to make his own
decisions about how much of his natural penis he prefers to have. Feelings about body
appearance and sexuality are quality of life factors that are highly preference-sensitive,
and likely to be very individual. As the best interests standard recognizes, in the case of very
young children, it cannot be known with any certainty whether a child would prefer to be
circumcised or not. The AAP has stated that
parents and pediatricians should not exclude children and adolescents
from decision-making without persuasive reasons. [...] A [minor]
patients reluctance or refusal to assent should [...] carry considerable
weight when the proposed intervention is not essential to his or her
welfare and/or can be deferred without substantial risk (Committee on
Bioethics, 1995).
These ideas may reasonably be extrapolated to encompass giving some weight to the infants
inability to assent. The simple fact that an infant is not able to give consent is not a
persuasive enough argument, in itself, to justify excluding the infant who will one day

become competent from decision-making about his own body. Therefore, in the absence of
evidence that circumcision is essential to the childs welfare, or that its deferral entails
substantial risk, the most conservative approach and the one that is most respectful of his
future autonomy would be to let the child be the definer of his own best interests, leaving
the decision to him when he is old enough to give his own informed consent.
In the U.S., the ethical quandaries associated with parental decision-making for
circumcision are rarely acknowledged. However, these issues are weighty, and can only add
to the need for the impeccable conduct of informed consent, if the procedure is to be offered.
Having established the crucial importance of informed consent in the case of
neonatal circumcision, I will next review, in Part B of Chapter 2, the literature on the
practice of information-giving for circumcision and the literature on parent education about
circumcision, including supporting evidence on the need for information-giving about the
alternative of not circumcising.

Part B: Literature Review
In Part B of this chapter, I review the research literature on several topics related to
parent circumcision education that together provide justification for the present study. Part B
focuses on comprehensive reviews of the literature on the adequacy of information-giving
for circumcision decision-making, and of the literature on the effect of parent education on
circumcision decision-making. In addition, selected literature on associated supporting topics
is reviewed, including information-giving on alternatives to medical interventions, and
evidence confirming the need for education on circumcision and its alternative. The
recommendations from the several most recent circumcision position statements of the
American Academy of Pediatrics (AAP, 1999; Task Force on Circumcision, 1989;
Thompson, King, Knox, & Korones, 1975) are included in the discussion of parent education
studies, as they guide the content found in many parent information handouts.
Literature Search Strategy
A computerized search of the published literature relating to circumcision education
of expectant parents was conducted in the Fall of 2008, primarily through Medline (1960-
2008) and World Cat dissertations and theses listings (1982-2008). The search strategy
combined key words such as circumcision, foreskin, and prepuce with other modifying terms
including: information, patient/parent education, decision-making, informed consent,
alternatives, and prenatal. Other databases searched included the Cumulative Index of

Nursing and Applied Health (CINAHL), Psych Info, ERIC, Sociological Abstracts, and
Communication and Mass Media Complete. These produced no additional references. The
Circumcision Information and Resource Pages5 (listed as an on-line resource by the British
Medical Journal6) were also searched for articles on parent education, parent decision-
making, and informed consent. Finally, a hand search was carried out by examining citations
found in retrieved publications.
The Literature on the Adequacy of Information-Giving
for Circumcision Decision-Making
Ciesielski-Carlucci et al. (1996) surveyed practitioners at two large hospital systems
in San Francisco to ascertain their attitudes about circumcision and their circumcision
information-giving practices. Nearly half of the practitioners who performed circumcisions
did not discuss the medical pros and cons of circumcision with mothers prior to delivery. Of
those who performed circumcisions and provided prenatal care (i.e. had contact with
mothers before delivery), 26% did not discuss circumcision before the birth of the child. In a
companion survey of mothers receiving care in these same institutions, only 29% of those
who had delivered male infants stated that they had discussed the decision with their
obstetrician, while 28% had discussed it with their pediatrician. About 25% of mothers
reported that they had not received enough information from their health care providers in
order to make their decision about circumcision. Overall, the authors concluded that the
process of informed consent for circumcision is inadequate (p. 235), citing provider bias,
6 http://www.bmj .com/archive/7128/7128ip3 .htm

incomplete or incorrect information, and the expressed maternal desire for more information.
They recommended that accurate circumcision information be offered early in the prenatal
period, in an understandable, individualized, and unbiased format, and that it be offered in a
variety of formats (e.g. video as well as written) and over more than one encounter.
In an American clinic-based survey, by Adler et al. (2001), of 149 parents of male
infants and toddlers, 37% of parents reported they were not given adequate information for
decision-making about circumcision. Likewise, in a recent national survey of 6421 Canadian
mothers, 30.1% of mothers of male infants reported not having received enough information
about circumcision (Sauve & Royle, 2009).7
Several investigators have surveyed health care providers specifically regarding their
disclosure of the risks of circumcision. In a survey of 36 obstetric and pediatric residents,
Christensen-Szalanski et al. (1987) found that these practitioners routinely informed parents
of only three of the many possible medical complications associated with circumcision
(bleeding, infection, and pain), and none of the several possible risks of not being
circumcised. Similarly, in a survey of 250 practitioners, the majority of which were family
practice physicians, Fletcher (1999) found that bleeding, infection, and pain were the only
categories of complication discussed more than half of the time, and that only 52% of
respondents always educated both parents about the possible risks before the surgery.
7 The Maternity Experiences Survey, conducted in 2006 by the Public Health Agency of Canada,
surveyed a stratified random sample of 6421 mothers 5 to 14 months after delivery (Sauve & Royle,
2009). About one-third (31.9%) of these Canadian women reported having had their male baby
circumcised. For comparison, the Canadian circumcision rate for 1972 was reported at 48.3% (Wirth,
1975), although this statistic is not strictly comparable to the Maternity Experiences Survey result.
This is because the 1972 data from some provinces included only newborn circumcisions (within the
first 10 days), and may not have captured circumcisions done outside of the hospital or later in
infancy, as the Maternity Experiences Survey did. Canadian circumcision rates vary widely by
province (Sauve & Royle, 2009).

The Literature on the Effect of Parent Education
on Circumcision Decision-Making
Seven published experimental studies (see summary in Table A.l in Appendix A)
were found on the subject of educational practices for neonatal circumcision, only one of
which was published more recently than the 1980s. In these studies, specific educational
interventions, varying in terms of content and process aspects, were studied according to two
main study designs. Five studies used a design that compared circumcision rate outcomes in
separate groups who did or did not have the educational intervention (Enzenauer, Powell,
Wiswell, & Bass, 1986; Herrera, Hsu, Salcedo, & Ruiz, 1982; Herrera, Cochran, Herrera, &
Wallace, 1983; Maisels et al., 1983; Rand, Emmons, & Johnson, 1983). The other two
studies used a design that studied a single group, comparing stated desire for circumcision
before and after the intervention (Binner, Mastrobattista, Day, Swaim, & Monga, 2002;
Christensen-Szalanski et al., 1987). Three of the studies provided the educational
intervention in the prenatal period (Herrera et al., 1982; Herrera et al., 1983; Maisels et al.,
1983), three after the birth of the baby (postpartum) (Binner et al., 2002; Christensen-
Szalanski et al., 1987; Enzenauer et al., 1986), and one compared information-giving in the
prenatal vs. postpartum periods (Rand et al., 1983).
The primary focus of these studies was on the effects of providing information on
the risks and benefits of circumcision. No study specifically mentioned education on the
alternative to circumcision (e.g. foreskin anatomy, function, or care) as part of its research
design. The information provided in six of the studies was specifically noted to be in
accordance with the circumcision position statement of the AAP current at the time. The

seventh study focused solely on the effect of providing complete versus partial risk
information; its educational intervention was based on a review of the literature on
circumcision risks (Christensen-Szalanski et al., 1987). In six of the seven studies, the
educational intervention consisted of giving a written informational handout, with or without
additional verbal discussion. In one of these studies, the investigator additionally used a
black-and-white illustration to explain how a circumcision is performed (Rand et ah, 1983).
A seventh study used a video presentation for the intervention, based in part on AAP
information, but also incorporating an outtake from an NBC News report on circumcision
(Enzenaueret ah, 1986).
As six of the seven studies were published in the 1980s, their educational materials
were based on the 1975 AAP circumcision position statement, whose conclusion reads:
There is no absolute medical indication for routine circumcision of the
newborn. The physician should provide parents with information
pertaining to the long-term medical effects of circumcision and non-
circumcision, so they may make a thoughtful decision. It is
recommended that this discussion take place before the birth of the
infant, so the parental consent to the surgical procedure, if given, will be
truly informed. A program of education leading to continuing good
personal hygiene would offer all the advantages of circumcision without
the attendant surgical risk. Therefore, circumcision of the newborn
cannot be considered an essential component of adequate total health
care (Thompson et al., 1975, p. 611).
The 1975 statement contains minimal detail on the anatomy of the foreskin and no
discussion of its functions. The exact content of the educational materials used in these
earlier studies is not known, but can be assumed to reflect the above contents and omissions.
In the one study performed since the 1980s, Binner et al. (2002) studied the
interventional effect of what they characterized as an unbiased source, the AAP parent
circumcision information handout current at the time (2001). This information handout is

based on the 1999 AAP circumcision position statement whose conclusions, as stated in its
abstract, read:
Existing scientific evidence demonstrates potential medical benefits of
newborn male circumcision; however, these data are not sufficient to
recommend routine neonatal circumcision. In circumstances in which
there are potential benefits and risks, yet the procedure is not essential to
the childs current well-being, parents should determine what is in the
best interest of the child. To make an informed choice, parents of all
male infants should be given accurate and unbiased information and be
provided the opportunity to discuss this decision. If a decision for
circumcision is made, procedural analgesia should be provided (p.686).
The AAP parent information handout used in Binners study is still current at the time of this
writing, and is among the materials analyzed in the study reported in this paper. It contains
no substantive information about the foreskin.8
In terms of the studies results, five of the seven studies reported no difference in
circumcision rates, or in desire for circumcision, after the intervention (Binner et al., 2002;
Christensen-Szalanski et ah, 1987; Herrera et ah, 1982; Herrera et ah, 1983; Maisels et ah,
1983). This led the respective authors to conclude that education makes no difference in
circumcision decision-making, attributing this result to the overriding influence of social
factors on parental preferences. The presence or absence of verbal reinforcement of written
information, or of additional discussion opportunities, made no apparent difference in
outcomes. One investigator conducted two separate studies, one in a population with a low
8 The AAP released an additional statement in 1989, but none of the studies here reviewed based their
educational intervention on this statement. However, several of the handouts analyzed in my content
analysis, although produced since the 1999 statement, still used the recommendation language from
the 1989 statement, which reads as follows:
Newborn circumcision has potential medical benefits and advantages as well
disadvantages and risks. When circumcision is being considered, the benefits
and risks should be explained to the parents and informed consent obtained.
(Task Force on Circumcision, 1989)

socio-economic level (Herrera et al., 1982) and one with a higher socio-economic level
(Herrera et al., 1983). Circumcision rates were not affected by the education intervention in
either population.
On the other hand, two of the studies did report a reduction in circumcision rates
with the educational intervention used. Rand et al. (1983) reported a significantly lower
circumcision rate among boys born to the intervention group of 82 mothers compared to
those bom to 44 mothers who acted as controls (72% vs. 94.4%). Enzenauer et al. (1986)
found a significant reduction in the circumcision frequency rate from the baseline of 90.4%
before the study period to 70.5% during the six-month intervention period, during which 831
male infants were bom. A distinguishing factor in these two studies was the use of
illustrations (pictorial or video) of the actual procedure, along with other verbal or written
information-giving, an educational feature not present in the other studies.
Interestingly, Enzenauer et al. found that circumcision rates also dropped among
control group families who did not receive the educational intervention, to a level of 75.9%
(which was, however, significantly higher than the rate of the intervention group). In
attempting to explain this phenomenon, the authors hypothesized a spillover effect in the
close-knit military community in which they practiced, from the families who had received
the educational intervention. They also speculated on the effect of particularly outspoken
physicians and increased staff education current at the time of the study, which
conceivably could have resulted in more active counseling in favor of
noncircumcision during this period, and also more subtle support of
the noncircumcision choice by the staff (p. 718).

After the study period, when intensive staff education ceased, and with personnel
turnover typical of the military environment, circumcision rates gradually
returned to near baseline levels.
Christensen-Szalanski et al. (1987), who studied the effects of partial vs. full
disclosure of the risks of circumcision during the postpartum period, found no difference in
parental desire for circumcision after full risk disclosure, but also identified a number of
untoward psychological effects of this approach. Overall, mothers receiving full disclosure
were less confident in their decision to circumcise, while some expressed personal
discomfort or guilt, and others expressed resentment or hostility toward the physician
providing the risk information. The authors speculated that provision of extensive risk
information may have contradicted mothers pre-established nonmedical convictions and
create[d] an undesirable internal conflict (p. 863). They argued that more information may
do more harm than good, and suggested that partial disclosure (the typical practice they
found) may be acceptable, since disclosure made no practical difference in the circumcision
decision in any case. They suggested that addressing circumcision information during
prenatal visits when parents may still be undecided may be a helpful approach, and that a
series of encounters may be better received than a one-time presentation.
The timing of parent education (prenatal vs. postpartum) did not appear to make a
difference. Two out of the three studies done postpartum and all three prenatal studies found
no difference in circumcision rates. The one study that compared information-giving
prenatally vs. postpartum, did find a drop in circumcision rates as a result of the education
intervention, but there was no difference in the rate drops between the prenatal vs. the

postpartum education groups (Rand et al., 1983). Again, this was one of the studies that used
a visual representation of the circumcision procedure as part of the educational intervention.
Selected Literature on Information-Giving on Alternatives
A comprehensive literature search was not conducted on information-giving on
alternatives to proposed procedures. Following is a review of two selected large-scale studies
that indicate a lack of adequacy in the discussion of alternatives for the purposes of medical
decision-making and consent. Braddock et al. (1999) conducted a study evaluating informed
decision-making practices in outpatient surgical and primary care settings (i.e. not including
maternity care). A total of 1057 patient-physician decision-making encounters involving 124
practitioners were audiotaped and analyzed for the elements of informed consent, including
information-giving about alternatives. The investigators found that fewer than 11% of all
encounters included information about alternatives. When analyzed according to the
complexity of the decision, the rate of discussing alternatives increased with complexity, but
was still less than 30% even in the most complex category of decisions (defined as: those
with an extensive effect on the patient, those in which medical consensus was lacking, and
those with multiple and uncertain outcomes).
Bottrell et al. (2000) conducted a content analysis of 540 hospital informed consent
for procedure forms from 157 hospitals nationwide, examining the forms for evidence of the
basic elements of informed consent (nature of the procedure, risks, benefits, and
alternatives). Only 26% of the forms included all four basic elements of informed consent.
The investigators found that while 51% mentioned the possibility of alternatives to the

procedure in general terms, only 2.3% specifically described alternatives, and another 2.8%
provided a space for filling in information on the alternatives. No treatment as an
alternative was mentioned in general terms in 12.4% of the consent forms, with only 1.7%
describing the alternative of no treatment in any detail. The authors concluded that existing
forms are inadequate for demonstrating legal or ethical standards for informed consent. Nor
do existing forms facilitate the informed consent process [...] (p. 31).
Little exists in the literature on education about the alternative of not circumcising,
and most of what is available is several decades old. Several non-experimental commentary
articles refer to the alternative of not circumcising. One circumcision review article briefly
noted the legal implications of discussing alternatives, but did not discuss the foreskin per se,
or any other specific content on the alternative of not circumcising (McDermott et al., 1982).
Another author, in a letter to the editor, reported on a written educational intervention that he
claimed reduced circumcision rates in his practice, which included illustrated information on
care of the intact penis (containing some misinformation) (Gorske, 1980).
Two research studies address the element of the alternative to circumcision. In the
first of these, Harris (1986) conducted in-depth interviews in Louisiana with new and
expectant parents, as well as with a wide variety of health care practitioners. She
qualitatively analyzed these interviews using grounded theory to identify factors that
influenced circumcision reasoning and decision-making. Among other constructs that
emerged, she identified knowledge of the physiology of the prepuce as one factor likely to
lead parents to question circumcision. Knowledge of the prepuce, as defined by Harris,
included the development and care of the foreskin. However, she did not mention knowledge
of the functions of the foreskin. She found that many parents were surprised when given

development and care information and, interestingly, noted that it made the decision more
difficult (p. 102).
More recently, Ciesielski-Carlucci et al. (1996) studied physicians circumcision
information-giving practices. Through videotapes of pre-consent discussions with parents,
the authors found that some physicians appeared to assume when parents requested
circumcision after the birth of the baby that the arguments for and against had already been
discussed with another health provider. It was found that these physicians typically
explained the procedure and identified several risks, but they did not discuss the alternatives,
namely nontreatment. No other indication of specifics to be covered under the label of
nontreatment was provided by the studys authors.
Selected Literature Confirming the Needfor Education
on Circumcision and its Alternative
A general lack of parental knowledge about circumcision itself has been found by a
number of investigators over the last 30 years (Ciesielski-Carlucci et al., 1996; Herrera &
Trouem-Trend, 1979; Lovell & Cox, 1979; Rand et al., 1983; Taylor-Clapp, 2001), as
evidenced by the following examples. Rand et al. (1983) interviewed 82 low-income
expectant or new parents prior to circumcision education. Each was asked the following four
questions: 1) Do you know what a circumcision is? 2) Do you know what is removed in a
circumcision? 3) In a circumcision, do you think there is any cutting? 4) Do you think that
the baby is given a pain killer or put to sleep during the operation? Only one quarter of the
parents answered all of the questions knowledgeably. Ciesielski-Carlucci et al. (1996) found

that 25% of mothers choosing circumcision believed there were no associated risks, even
after having just given informed consent minutes earlier. A recent survey of mostly college-
educated Canadian expectant parents found that one in three did not know that circumcision
is painful, and one in five did not know that routine circumcision was not medically
indicated (Taylor-Clapp, 2001).
Evidence also exists to verify the lack of parental knowledge specifically of the
foreskin (Griffiths, Munro, & Freeman, 1986; Harris, 1986; Marino, 1983; Osbom, Metcalf,
& Mariani, 1981; Spinelli, 1988; Stein, Marx, Taggart, & Bass, 1982; Taylor-Clapp, 2001).
In the most recent example, Taylor-Clapp (2001) found that only half of expectant Canadian
parents surveyed were knowledgeable about hygiene of the intact penis, and less than a third
were aware of when the foreskin normally becomes retractable.
Other evidence points to a general lack of knowledge about sexuality and sexual
health by the public (Clark, Baldwin, & Tanner, 2007; Synovitz, Hebert, Kelley, & Carlson,
2002), implying the need for education about the intact penis as a functional part of the male
sex organ.
Justification for the Present Study Based on the Literature
Given the practical, ethical, and legal implications of the importance of disclosure of
alternatives as part of informed consent, the paucity of information in the literature on
parental education about the alternative of not circumcising, and evidence of a lack of
parental knowledge on the topic, my study fills a large and important gap. By documenting
the informational content on the alternative of not circumcising in written parent

circumcision education materials, and by assessing the presence of framing bias in these
materials, this study provides critical data to stimulate improvement of parent education in
this regard.
Next, in Part C of this Chapter, I will discuss the concept of framing as a general
psychological concept operating in communication situations. Attention will be given to the
application of framing to communications specific to healthcare. Robert Entmans (1993)
conception of framing will be discussed in detail including his four functions of framing -
as a basis for later analysis of the study results.

Part C: Framing Theory
The Roots of Framing Theory: Tversky and Kahneman
The concept of framing has interdisciplinary roots in psychology and the sociology
of interpersonal interaction. According to Dahinden (2005), anthropologist Gregory Bateson
(1972) was the first author to use the term frame as a psychological concept. To Bateson,
frames guide the perception of reality by including certain messages that fit into a specific
frame and by excluding others (Dahinden, 2005, p. 1). Sociologist Erving Goffman (1974),
in his book Frame Analysis, expanded on the concept of the frame in relation to face-to-face
interaction. Says Dahinden, in [Goffmans] view, frames define social situations by
providing an answer to the question: What is it that is going on here? (p. 1). The concept
of framing is perhaps most notably associated with the work of cognitive scientists Amos
Tversky and David Kahneman (1981), also known for their research on heuristics (the
mental short cuts that reduce complex problem-solving to simpler judgment operations)
(Fiske & Taylor, 2008).
Tversky and Kahnemans work developed out of the observation that persons
judgment and decision-making choices do not always conform to the expected consistency
of rational choice theory. Certain choices seem to violate a central tenet of rational choice
theory, the invariance axiom, which prescribes that choice should remain invariant across
logically equivalent versions of the decision options (Maule & Villejoubert, 2007, p. 26).
The term framing refers to how a choice is presented, such that preferences between

equivalent options may be altered from what would rationally be expected. These alterations
in preference are called framing effects.
The classic example used by Tversky and Kahneman to illustrate the effect of
framing is known as the Asian Disease problem, described as follows:
Imagine that the US is preparing for the outbreak of an unusual Asian
disease, which is expected to kill 600 people. Two alternative programs
to combat the disease have been proposed. Assume that the exact
scientific estimate of the consequences of the program are [sic] as
follows: If Program A is adopted, 200 people will be saved. If Program B
is adopted, there is a one-third probability that 600 people will be saved,
and two-thirds probability that no people would be saved. Which
program would you favor?
Now imagine the same situation with these two alternatives: If
Program C is adopted, 400 people will die. If Program D is adopted,
there is a one-third probability that no one will die, and a two-thirds
probability that 600 people will die. (1981, p. 453)
The descriptions of Programs A and B are logically equivalent to Programs C and D,
respectively. However, whereas rational choice theory would have predicted similar rates of
choice for the two logically equivalent proposals, when the scenario was framed in terms of
lives saved, participants made significantly different choices from when it was framed in
terms of lives lost. In the lives-saved scenario, study participants tended to be risk-averse,
with 72% favoring Program A, the sure option, over Program B, the less certain option.
However in the lives-lost scenario, participants tended to be willing to take more risk, with
78% favoring Program D, the uncertain option, over Program C, the sure option. Kahneman
and Tversky (1979) embed the concept of framing in a broader concept they call Prospect
Theory, which includes a further accounting of value-weighting and probabilities to explain
subjects preferences.

The psychology of framing effects is complex and incompletely understood
(Nelson, Oxley, & Clawson, 1997). In regard to gain vs. loss framing, evidence suggests the
psychological tendency for receivers to cognitively weight negative information more
heavily than positive information, when met with circumstances requiring interpretation or
decision-making (Hallahan, 1999). Neurobiological experiments that used magnetic
resonance imaging to record subjects brain activity when performing decision-making tasks
indicate that gain/loss framing effects have an underlying emotional component (De
Martino, Kumaran, Seymour, & Dolan, 2006). In gain- or loss-framed decision scenarios,
the amydala was found to be strongly activated. Based on knowledge of the amygdalas role
in emotional processing, the investigators state that this supports] the hypothesis that the
framing effect is driven by an affect heuristic underwritten by an emotional system (De
Martino et al., 2006, p. 686). In terms of cognition, Kahneman and Tversky (1984) have
noted another feature of the psychology of framing, the tendency of people to evaluate
options in relation to the reference point that is suggested or implied by the statement of the
problem (p. 346). Thus when a treatment option is described as having a 25% failure rate,
as opposed to a 75% success rate, failure is the reference point suggested to the mind of
the subject or patient, which stimulates his reactance against the possibility of a negative
outcome, in turn influencing his judgments and decisions about the treatment option. As the
study of framing and framing effects has evolved, other scholars have elaborated on various
hypotheses for the cognitive mechanisms that may account for framing phenomena, such as
the relationship of framing to heuristics, schemata, and priming (Chong & Druckman, 2007;
Domke, Shah, & Wackman, 1998; Maule & Villejoubert, 2007; Nelson et al., 1997; Pinon &
Gambara, 2005). A discussion of these concepts is, however, beyond the scope of this paper.

Tversky and Kahneman (1981) have claimed that the framing effects they
demonstrated are large and systemic... [and] not restricted to hypothetical questions
(1981, p. 457). Maule and Villejoubert (2007) have recently confirmed the applicability and
impact of Tversky and Kahnemans seminal work, noting as evidence
the vast body of literature that has since been generated on the concept,
both in extending the theory and applying it to a wide variety of practical
settings, such as politics, business, psychology, media studies, and health
care (p. 28).
Before continuing to examine the general concept of framing, I will here discuss the
use of framing theory in healthcare research, to set the context for the content analysis to be
discussed later in this paper.
Framing and Healthcare Research
The concept of framing has been commonly applied in healthcare research. A recent
review of 427 articles on framing effects found that 19% of the articles were from the
healthcare field (Maule & Villejoubert, 2007).9 Communication and decision-making are
essential aspects of healthcare (Chapman & Sonnenberg, 2000; Teutsch, 2003), and both are
processes that are subject to framing and framing effects. Patients are not the only ones who
are affected by framing of information, but evidence suggests that the thinking, judgments,
and decision-making of physicians are also influenced by framing (Marteau, 1989;
McGettigan, Sly, O'Connell, Hill, & Henry, 1999).
9 Articles associated with the field of psychology constituted the largest group in this review (33%),
followed by articles on applications in the field of business and economics (26%), health and
medicine (19%), and political science (10%), with the remaining 12% in various areas including
sociology, law, and communication studies (Maule & Villejoubert, 2007).

The use of framing in health-related situations whether deliberate or unconscious -
may produce beneficial or detrimental effects. Following are several examples of framing-
related health research that attempt to understand how framing can be used for benefit, or
how it can be managed to avoid harmful effects.
As an example of the intentional use of framing for benefit, studies have been done
to determine what type of framing is most effective in motivating patients to adopt important
health behaviors, for example, messages emphasizing potential benefits to be obtained (gain-
framing) versus messages emphasizing the costs of not engaging in the behavior (loss-
framing) (Rothman & Salovey, 1997). Such studies include investigations of framing to
encourage screening procedures, like mammograms (Banks et al., 1995) or Pap smears
(Rivers, Salovey, Pizzaro, Pizzaro, & Schneider, 2005), or to encourage adoption of
prevention-oriented health behaviors, like using sunscreen (Detweiler, Bedell, Salovey,
Pronin, & Rothman, 1999).
On the other hand, framing effects may have an untoward effect on patient
understanding and, by extension, on patient autonomy in decision-making (Moxey et al.,
2003). An example of framing effects that can adversely affect patient understanding
concerns the various ways that risk can be explained in a clinical situation (Edwards &
Elwyn, 2001a). The relative risk of a disease for persons with differing risk factors, or the
relative risk reduction of a certain treatment, is more frequently reported in the medical
literature and lay press, as well as more commonly conveyed in clinical encounters

(Malenka, Baron, Johansen, Wahrenberger, & Ross, 1993).10 However, without information
on the base rate of the disease (the absolute risk), risk expressed only in relative terms can
give an unrealistic or exaggerated picture of, for example, a treatments risk-reducing
effects, and may lead to patients making ill-founded treatment choices. Malenka et al. (1993)
studied subjects preferences for two hypothetical medications of equivalent effectiveness,
one whose risk-reducing effects were described in relative terms and one in absolute terms.
A framing effect was seen that caused most subjects, even well-educated ones, to select the
drug whose benefits were described in relative terms. The artificially magnified perception
of risk or benefit created by relative-risk-generated framing effects can thus bias decision-
making, and could indeed be used by physicians to manipulate patients choices, an ethically
concerning consideration (Edwards & Elwyn, 2001b; Thornton, 2003). Malenka et al. (1993)
argue that the use of absolute risk in the presentation of risks and benefits gives patients a
greater ability to be informed and to choose treatment preferences rationally (p. 547).
Scholars and professional bodies have expressed concern for the potentially
distorting effects of framing of health information on patients, professionals, and the public,
which impact both rational decision-making and the ethical practice of informed consent
(Faden & Beauchamp, 1986; Lustig & Scardino, 1998; McCullough et al., 1998a). Examples
of efforts to address these concerns include: guidelines in the journalism profession that
encourage the use of absolute risk figures in healthcare reporting, along with relative risk
10 Relative risk (RR) is a ratio comparing the risk of a certain health problem in one group to that in
another group, for example, comparing the incidence of lung cancer in people who smoke versus the
incidence in people who dont smoke. Absolute risk (AR) indicates the actual likelihood of some
health problem occurring in a population over a certain time period. While a medication might reduce
a persons chance of getting a certain health problem by 30% (RR reduction), if the base rate of the
disease in a population were very low, the AR reduction might be negligible. For example, reducing
the risk of getting a health problem from 3 in a million (0.000003%) to 1 in a million (0.000001%)
produces a RR reduction of 30%, but an AR reduction of 0.000002%.

(Schwitzer, 2004); efforts to educate patients and the lay public to be more critical
consumers of health information (Absolute risk and relative risk, 2009); and including
discussion of these issues in medical curricula (Barratt et al., 2004).
The framing in these two healthcare examples is of the type that is dependent on
simple wording manipulations in information-giving that produce alterations in choices.
However, the concept of framing in health-related research has also been applied to the types
of messages that are conveyed in texts and arguments, which frame issues in such as way as
to promote a certain understanding or agenda. (The distinction between these different types
of framing will be discussed in more detail below.) This broader type of framing is often
studied via the methods of content analysis, as in my study of circumcision information
materials. An example of this type of study, and the kinds of insights that can come from
them, is Frerichs et al.s (2006) content analysis of how breastfeeding and formula-feeding
are framed in articles published in U.S. womens and parenting magazines. Frerichs et al.
found that magazines of different types (parenting vs. general womens vs. African-
American) framed the benefits of, barriers to, and advice about breastfeeding differently,
using different and conflicting messages. The authors interpreted the overall predominance
of breastfeeding frames over formula-feeding frames as suggesting to readers that
breastfeeding is the better choice, but viewed the emphasis on advice-giving as suggesting
that breastfeeding is problematic. The more equal coverage of breast- and formula-feeding
found in parenting magazines than in other sources was interpreted as suggesting to that
audience that both options are equally acceptable. The authors concluded from their findings
that magazine readers need to be given a more accurate and complete view of breastfeeding,
and that more attention needs to be paid to individual and social concerns relating to infant

feeding. Studies such as this, including my content analysis, are examples of how the lens of
framing can be used to expose problems in health communication, and suggest ways to
improve the provision of health information.
As can be seen from these health-related examples of framing research, the concept
of framing has evolved beyond the straightforward wording-manipulation applications that
stemmed from Tversky and Kahnemans (1981) original work. As framing has been applied
in many different arenas, it has come to be understood not just in terms of a choice scenario
based on the subjective perception of gains and losses, but as a way to construct meaning. In
the following sections, the differentiation of the concept of framing, specifically as
conceptualized by Robert Entman (1993), will continue to be examined.
Framing Theory Beyond Tversky and Kahneman
De Vreese (2005) has characterized Tversky and Kahnemans definition of framing
as rather narrow [emphasis added], and not easily compatible with more complex
communicative situations and politics (p. 53). He claims that the majority of framing
studies in fact apply a more broad definition of framing. For example, in the case of the
extensive research on framing in the media, frames are conceived, according to Gamson and
Modigliani (1987), as a central organizing idea or story line that provides meaning, [...]
suggesting] what the controversy is about, the essence of the issue (p. 143). Nelson et al.
(1997) define framing in similarly broad terms, as the process by which a communication
source constructs and defines a social or political issue for its audience (p. 221). Both of
these broader definitions of framing reflect back more clearly to Goffmans early conception

of frames as defining what is going on here, than to Tversky and Kahnemans gain/loss
choice scenario.
Importantly, however, both the narrow and broad definitions of framing carry the
common implication that how information is presented can influence the perceptions,
judgments, preferences, and choices of the receivers of the information. In the case of the
narrow gain/loss choice scenario, framing is found to alter the cognitive processes and
therefore the preferences of individuals presented with a specific choice problem. On the
other hand, the broader framing dynamics found in the news media (Scheufele, 1999) and
political rhetoric (Lakoff, 2004), as well as other communication situations such as business
(Fairhurst & Sarr, 1996) and public relations (Hallahan, 1999), serve to cultivate and shape
public or organizational opinion, through their influence on the cognitive predispositions of
The fact that there are at least two common meanings of the word frame may seem
to add ambiguity to the theoretical concept of cognitive framing, but a closer look at these
everyday meanings may actually help to clarify the concept (Gamson & Modigliani, 1989).
For example, when framing a picture in the everyday sense, the framer may crop the image
to display it to its best advantage (in the framers view), and the choice of the type of picture
frame can bring out stylistic, spatial, or color aspects of the picture that the framer may wish
to highlight. By analogy, the kind of cognitive picture frame that a communicator places
on an issue or choice, highlights certain elements in the mind of the receiver and diminishes
others. This may be accomplished, for example, through variations in wording or
presentation that characterize a classic gain/loss choice frame, or in the emphasis on selected
elements or messages in the media on a given news topic. On the other hand, the everyday

meaning offraming a house refers to providing the underlying structure on which the
proposed edifice can be built. By analogy, this house-building type of cognitive framing is
used, for example, by journalists to help the public grasp and follow the underlying issues of
complex current events with which they may be unfamiliar (Wicks, 2005), or by business
managers or policy makers to enlist support for a new program (Fairhurst & Sarr, 1996).
However, at the same time, the construction of the frame affects the shape and potentials of
the house that is to be built on that frame. Thus in media framing, the way information is
packaged for the public and importantly, the indirect influence of the elite sources of that
information on the choice of packaging (Entman, 2007) again raises the issue of how
frames can influence, or even manipulate, cognitive responses among receivers that might
not otherwise occur.
Adding to the complexity of the concept of framing is the fact that observed framing
effects vary from strong to weak depending on a wide variety of mitigating factors. For
example, small variations in the design, content, and context of a given frame can influence
its effects (Maule & Villejoubert, 2007). It is also clear that individuals vary in their
susceptibility to framing effects based on such factors as the presence in the individual of
strong values-based predispositions (Chong & Druckman, 2007), of a high or low need for
cognition (Maule & Villejoubert, 2007), or of a high or low personal relevance of the issue
in question, among others (Maule & Villejoubert, 2007; A. J. Rothman, Bartels, Wlaschin, &
Salovey, 2006).
In the end, the proliferation of a diverse array of research among so many different
conceptual threads has led, over time, to a sense of framing having a scattered
conceptualization and to an increasing ambiguity of the meaning of the term (Entman,

1993; Maule & Villejoubert, 2007). This in turn has produced ongoing attempts to reconcile
the apparently different faces of framing into a more unified understanding of its core
dynamics (D'Angelo, 2002; Entman, 1993; Levin, Schneider, & Gaeth, 1998; Scheufele,
1999). The following section will review media-specialist Robert Entmans (1993) attempt
to clarify the fractured paradigm of framing.
Entmans Clarification of Framing
In his often-cited article, Framing: Toward clarification of a fractured paradigm,
Entman (1993) argues that communication studies have the potential to become a master
discipline that synthesizes the scattered contributions of other fields into a comprehensive
and rigorous conception of framing. Entmans stated goal, in furtherance of this vision, is to
identify and make explicit common tendencies among the various uses of the terms [frame
and framing] and to suggest a more precise and universal understanding of them (p. 52).
He begins his article by distilling the concept of framing down to its simplest
elements framing essentially involves selection and salience (p. 52, emphasis in
original). Selection elevates certain features of a communication in salience. Salience is
understood in cognitive psychology to mean making a piece of information more noticeable
such that receivers will be more likely to process it, ascribe meaning to it, and remember it
(Fiske & Taylor, 2008). Entman goes on to expand this simple characterization to specify
four key functions of framing:

To frame is to select some aspects of a perceived reality and make them
more salient in a communicating text, in such a way as to promote a
particular problem definition, causal interpretation, moral evaluation,
and/or treatment recommendation for the item described (p. 52,
emphasis in original).
Thus, according to Entman, frames:
1) define problems, i.e. determine what a causal agent is doing, with what costs;
2) diagnose causes, i.e. identify the forces creating the problem;
3) make moral judgments, i.e. evaluate causal agents and their effects; and/or
4) suggest remedies, i.e. offer and justify treatments for the problems.
While these four functions form a concrete and useful guide for analyzing frames in texts,
Entman notes that a frame in any particular text may not necessarily include all four
He then suggests that frames have at least four locations in the communication
process. Frames are active in the communicator, the text, the receiver, and the culture. In
deciding what to say and how to say it, communicators are guided by their own cognitive
frames that organize their belief systems. Importantly, Entman notes that the process of
framing by communicators may be conscious or unconscious. For example, framing is
commonly used consciously to sway beliefs or behavior, as in the spin of public relations
releases (Hallahan, 1999) or encouraging adoption of healthy behaviors (Rothman &
Salovey, 1997). On the other hand, unconscious framing may also occur in texts, reflecting
unacknowledged biases that affect the communicator. The text contains frames that Entman
characterizes as thematically reinforcing clusters of facts or judgments (p. 52). Textual
frames are manifested by the presence (or absence), for example, of key words, stock
phrases, images, information sources, repetition, placement, and/or culturally familiar

symbols that make salient the intentionally desired or unconsciously emphasized
impressions. The receiver of a communication is guided in her response to the
communication (e.g. her perceptions, judgments, or decisions) by her own individual
preexisting cognitive frames, or beliefs. The receivers personal frames may make the
receiver more or less susceptible to the frames that communicators provide. Thus while the
notion of framing implies that the frame has a common effect on large portions of the
receiving audience, [...] it is not likely to have a universal effect on all (p. 54). Finally,
culture is
the stock of commonly invoked frames; in fact, culture might be defined
as the empirically demonstrable set of common frames exhibited in the
discourse and thinking of most people in a social grouping (p. 53).
Cultural frames in turn help define the personal frames of communicators and receivers,
likely affecting the dynamics of framing choices and effects on a more unconscious level
(Goldman, 1997). Thus the four locations of frames influence each other and must all be
taken into account when analyzing frames in communication.
Entman then proceeds to discuss how frames work in terms of cognitive processes
relating to salience. He explores in particular why the omission of information or
interpretations by frames is as important as what is included. While frames select and call
attention to particular aspects of a given situation or informational text, inevitably this
implies that frames at the same time draw attention away from other aspects. According to
most frames are defined by what they omit as well as include, and the
omissions of potential problem definitions, explanations, evaluations,
and recommendations may be as critical as the inclusions in guiding the
audience (p. 54).

Framing by omission can have a significant impact on the cognitive processing of receivers,
and thus on their ability to look at an issue from a variety of points of view. Says Entman,
receivers responses are clearly affected if they perceive and process
information about one interpretation and possess little or
incommensurable data about alternatives (p. 54).
He concludes his article with suggestions for how a consistent concept of framing,
such as the model he describes, can have benefits in resolving areas of contention in media
studies, such as the question of to what extent an audience, exposed to frames connoting a
dominant meaning, would have the capacity to think independently enough to mitigate that
In this thesis, Entmans (1993) description of the concept of framing will be used as
a basis for analyzing information given on the subject of male infant circumcision to
determine how the alternative of not circumcising is framed.
With the concept of framing in mind, in the next section of this chapter, Part D, I
will review the anatomy, function, development, and care of the intact penis factual
information that frames the foreskin as a normal, healthy, and valuable body part. Following
that, in Part E, I will discuss some of the negative frames that have been and continue to be
- commonly associated with the foreskin and the idea of not circumcising.

Part D: Review of Foreskin Anatomy, Function,
Development, and Care
John Taylor, the Canadian pathologist whose groundbreaking research on the
anatomy of the foreskin provides a foundation for appreciating its functionality, has said,
In the equation, the value of the actual foreskin is often put at zero. Put a
value on it. It is a structure in its own right (Milne, 2001).
Education about not circumcising begins with education about the foreskin. The most
straightforward and unbiased framing of the foreskin is a review of the essential facts about
its anatomy, function, and natural history. In this part of Chapter 2, this information is
presented in the interest of demystifying, normalizing, and ascribing value to a unique body
part that few Americans are familiar with. A Glossary of technical terms is found after the
The Anatomy of the Intact Penis
Overview of the Penile Skin System
The phalluses of virtually all mammals, male and female, have some kind of sheath
or covering (Cold & Taylor, 1999). In the human male, this covering is called the foreskin,
also known as the prepuce (adj. preputial).
The foreskin is not a discretely demarcated structure, but is an integral part of the
skin system of the penis. The penile skin begins from a point of attachment at the pubic

mound, and continues forward along the shaft and usually some distance beyond the tip of
the glans. It then doubles back under itself to attach in the sulcus behind the corona of the
glans (see Figure 2.1). Thus the foreskin is not as it is commonly described a simple
flap of skin, but a double-layered fold of tissue. Neither is the foreskin just a piece of
skin, but consists of uniquely differentiated and specialized tissue. The foreskins outer
layer is continuous with and the same type of tissue as the regular shaft skin. However, its
inner layer is mucous membrane, as is the surface of the glans of the intact penis. Mucous
membrane is the thin moist tissue that lines the inner cavities of the body (Tortora &
Derrickson, 2006). Thus, like the glans clitoris, the glans penis in the non-erect state is
naturally designed to be an internal structure. Nor is the foreskin just a little piece of skin.
Due to the double-layered nature of the foreskin, when unfolded, the actual amount of tissue
subject to removal by circumcision is on average about 50% of the skin with which the penis
is naturally endowed (J. R. Taylor, Lockwood, & A. J. Taylor, 1996). What may be a
quarter-sized area in the newborn may equate to fourteen square inches of tissue in the adult
penis (Werker, Temg, & Kon, 1998).
Except for its two points of attachment at the pubis and the coronal sulcus, the entire
length of the tubular penile skin including the two layers of its forward fold, the foreskin -
is not tethered to the underlying structures of the penis. Thus it is free to glide extensively
over the penile shaft, as well as to furl and unfurl over the head of the penis with manual
retraction, erection, or the motions of sex. The skin mobility of the intact penis is unique in
the body, and plays a significant role in sexual function, as I will discuss later (Scott, 1999).

Figure 2.1: Cross-section of the Structure of the Intact Penis.
From The Joy of Uncircumcising! 2nd Edition, by James Bigelow.
Morris Publishing, Kearney, NE, 1998. Used with permission.
The skin system of the penis and scrotum contains a thin layer of muscle called the
dartos fascia, or peripenic muscle (Jefferson, 1916). This is the muscle that, in the presence
of cold, contracts to draw the male genitalia closer to the body. Due to the foreskins double-
layered structure, when in its normal forward position, the foreskin contains two layers of
muscle. The tone of this double muscle layer allows the foreskin to fit snugly over the glans
throughout life (Lakshmanan & Prakash, 1980). At the opening of the foreskin, the muscle
fibers are arranged in a circular pattern that gives the outlet sphincter-like properties
(Jefferson, 1916; Lakshmanan & Prakash, 1980). Thus the foreskin opening can relax to
allow urine to flow out, then contract again after voiding to prevent the introduction of
contaminants. The state of contraction or relaxation of the peripenic muscle can affect the
apparent tightness or openness of the preputial opening found during a clinical examination
(Jefferson, 1916).

Because the penile skin sheath does not attach to underlying structures except at its
ends, it has its own vascular system separate from the deeper structures of the penis (Werker
et al., 1998). This superficial penile blood supply travels along the shaft skin and through the
prepuce. While some of the superficial blood vessels end at the border of the glans, other
branches enter the glans and provide part of the blood supply to the ventral glans and the
urinary outlet (Hinman, 1991; McGrath, 2001). When these vessels are truncated with
circumcision, the normal circulation to these areas can be disrupted. The naturally reddish or
purplish coloration (the vascular blush) of the inner foreskin and glans in the intact penis is
due to the capillary beds rising close to the thin mucous membrane surface.
Protective Functions of the Foreskin
As previously mentioned, the glans is designed to be an internal structure, normally
exposed only during sexual arousal. In the flaccid state, the glans is covered by the prepuce,
which protects it, the urinary opening, and the inner foreskin itself in a number of ways.
In the baby and child, the foreskin is normally fused to the head of the penis (Das,
1993) and the preputial outlet is naturally tight (Lakshmanan & Prakash, 1980). (I discuss
the development of the intact penis later in this section.) Also in the baby and child, there is
typically some overhang of the preputial fold past the tip of the glans (Jefferson, 1916). This
overhang helps to keep the preputial space and the urinary opening at a greater distance from
the exterior environment. These features prevent entry of contaminants underneath the
foreskin during the diaper years, working in concert with the foreskins sphincteric action,
which closes the preputial space off from the exterior environment in between voids (Fleiss,

Hodges, & Van Howe, 1998). Voiding itself helps keep the foreskin free of contaminants.
Multiple times a day, the preputial outlet is flushed outward with the passage of urine, which
is sterile as it exits from the bladder.
The foreskins coverage also protects the glans and urinary opening from friction,
drying, and injury. Without the coverage of the foreskin, the glans of the circumcised penis
becomes keratinized, or thickened, due to constant exposure to air and friction (Cold &
Taylor, 1999). Although the foreskins primary function is often said to be to protect the
sensitivity of the glans, the glans is in fact inherently not very sensitive to light touch (Halata
& Munger, 1986; Sorrells et al., 2007). However, by preventing thickening of the surface of
the glans, the foreskin optimizes what light-touch sensitivity the glans does have (Sorrells et
al., 2007). The coverage of the foreskin also protects the glans against damage from a variety
of chemical and mechanical irritants, such as ammonia in diapers and chafing with exercise.
The vascularity of the foreskin keeps the glans warm and protected from cold in extreme
The urinary opening, or meatus, is particularly delicate mucosal tissue. While the
foreskin protects the meatus of the intact penis from irritation, in the circumcised penis, the
urinary opening commonly becomes inflamed during the diaper years, due to exposure to
urine, feces, and friction, a condition called meatitis (Patel, 1966; Van Howe, 2007). Meatitis
may progress to ulceration and eventual scarring, a condition called meatal stenosis in which
the urinary opening is constricted with scar tissue. Meatal stenosis is found in 7-10% of
circumcised males, and is almost never seen in intact males (Angel, 2006; Van Howe,
2006b). Besides local irritation, it is hypothesized that loss of blood supply to the urinary

outlet, from truncation of the frenular artery with circumcision, may also contribute to the
incidence of meatal stenosis (Angel, 2006).
In addition to its mechanically protective functions, the foreskin provides
immunological protection as well. While more research is needed, human and animal studies
exist that indicate the presence of immunoactive cells in the foreskin and immunoprotective
substances in the preputial space. For example, lysozyme, an immunologically active
enzyme on mucous membrane surfaces and in secretions such as tears, saliva, and mothers
milk, has been found in the moisture under the human foreskin (Parkash, Jeyakumar,
Subramanyan, & Chaudhuri, 1973). Also, maternal antibodies in breastmilk are excreted in
the infants urine and prevent E. Coli from adhering to the urinary tract and inner foreskin
(Fleiss et al., 1998). Plasma cells in the prepuces of bulls have been found to increase in
number in response to bacterial infection, and to secrete immunoglobulins into the preputial
space in response to bacterial infection (Fleiss et al., 1998). Langerhans cells are
immunoactive cells found in the skin and certain mucous membrane surfaces, including the
foreskin and vagina. Recent research on human tissue samples has shown that these cells
produce a protein called Langerin that helps to scavenge viruses from the environment and
transport them elsewhere in the cell for destruction (de Witte et al., 2007). While some
authors have claimed that Langerhans cells in the foreskin are a portal for HIV infection
(Szabo & Short, 2000), and have used this claim to argue for circumcision as a way to
prevent HIV, de Witte et al. (2007) conclude, in contrast:
Langerin is a natural barrier to HIV-1 infection, and strategies to combat
infection must enhance, preserve or, at the very least, not interfere with
Langerin expression and function (p. 367).

Finally, like the vagina, the foreskin has its own internal ecology of bacterial flora
(Fleiss et al., 1998). It is known that excessive use of soap under the prepuce can disturb the
floral balance, and contribute to inflammation of the foreskin and glans (balanoposthitis)
(Birley, Luzzi, & Bell, 1993; Fleiss et ah, 1998).
Anatomical Factors Relating to the Foreskins Sexual Functions
Most of the scientific understanding of the sexual functionality of the foreskin has
developed since the late 1990s. Following is a review of some of the anatomical features of
the foreskin that are indicative of its sexual function.
Mucocutaneous junctions are specialized areas of tissue that constitute the primary
erogenous zones of the body (Winkelmann, 1959). A mucocutaneous junction (L. cutis =
skin) is a region of tissue where the regular skin transitions into mucous membrane. The rim
of the preputial fold is one such region, where the external penile skin transitions into the
mucous membrane surface of the inner foreskin. Besides the foreskin, mucocutaneous
junctions are found elsewhere in the body, such as the lips, anus, nipples, and vulva. The
chief characteristic of these areas is that they typically display an increased quantity and
specialization of nerves endings, allowing for heightened touch sensitivity and erogenous
sensation (Winkelmann, 1959).
As with other mucous membrane surfaces in the body, the inner layer of the foreskin
tends toward more acute sensation than the outer layer (Sorrells et al., 2007). This is because
the mucous membrane epithelium is thinner than the keratinized external skin, and because
the networks of nerves rise closer to the surface in mucous membrane surfaces than they do

in regular skin (Winkelmann, 1959). The mucosa of the prepuce is divided into two zones,
the ridged mucosa and the smooth mucosa (J. R. Taylor et al., 1996). A mucosal band of 10-
12 small ridges, totaling about 1 cm. wide, loops just within the mucocutaneous junction of
the preputial opening. It merges bilaterally downward into the frenulum, a web of tissue that
tethers the inner foreskin to the underside of the glans. The smooth mucosa comprises the
remainder of the inner prepuce, attaching to the shaft behind the corona. While the inner
foreskin layer is normally shielded against the glans in the flaccid state, with erection, in the
adult, the penile shaft elongates out of the preputial fold, causing the inner mucosal layer of
the foreskin to evert along the shaft of the penis (see Figure 2.2).
Figure 2.2: Eversion of the Foreskin, Showing the Ridged Band.
Adapted from Figure 4, p. 16, in The Anatomy and Physiology of the Prepuce by Steve Scott. Male
and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice. Edited
by G.C. Denniston, F.M. Flodges, and M.F. Milos. Kluwer Academic/Plenum Publishers, NY. 1999.
With kind permission from Springer Science and Business Media.

An anatomical study by J. R. Taylor et al. (1996) of the prepuces of 22 adult males
obtained on autopsy, found that the inner foreskin contained high concentrations of
Meissners corpuscles, the type of nerve ending that is responsible for fine-touch sensitivity,
for example, the extreme tactile sensitivity of the fingertips and the lips. The Meissners
corpuscles were found to be particularly densely concentrated in the ridged band of the inner
foreskin of the samples studied, where they were found to cluster on the crests of the
mucosal ridges, but were not found in the valleys between the ridges. This distribution,
putting the concentrations of Meissners corpuscles in contact with adjacent structures,
strongly suggests the sensory function of the ridged mucosal band. In contrast to the
foreskin, the glans has few Meissners corpuscles approximately 10 times fewer than the
foreskin instead containing predominantly free nerve endings (Halata & Munger, 1986),
whose function is the detection of more primitive and poorly localized sensory input, such as
pain, heat, cold, and extreme deep pressure
A recent study by Sorrells et al. (2007) on the fine-touch sensitivity of the adult
penis, conducted on 68 intact men and 91 circumcised men, confirms Taylor et al.s
anatomical findings (see abbreviated set of results in Figure 2.3). Using Semmes-Weinstein
monofilament testing, the authors mapped fine-touch pressure thresholds at 19 penile
locations, 8 present only in the intact male, and 2 present only in the circumcised male (the
dorsal and ventral scar lines). In both circumcised and intact men, the glans was found to be
the least fine-touch sensitive location on the penis, with the glans of the circumcised penis
significantly less sensitive than the glans of the intact penis (P = 0.040). The corona of the
glans was found to be the most sensitive part of the glans, although still of a relatively low
sensitivity. Of all the penile locations tested, the preputial orifice rim (the mucocutaneous

junction) was the most sensitive to fine touch, approximately twelve times more sensitive
than the glans. Five locations present only on the intact penis (i.e. which are removed with
circumcision) were found to be more sensitive to fine touch than the most sensitive location
on the circumcised penis, the ventral circumcision scar (P < 0.0001). The authors concluded
that circumcision removes the most sensitive parts of the penis (Sorrells et al., 2007).
Figure 2.3: Fine-touch Sensitivity of the Circumcised Versus the Intact Penis.
Adapted by Dan Bollinger from data found in Sorrells et al., 2007. Used with permission.
Several other groups of investigators that have performed sensory studies comparing
the circumcised and the intact penis have concluded that there is no significant difference
between the sensitivity of the two. However, two of these studies did not examine the
sensitivity of the foreskin, testing only single points on the glans and shaft of the penis
Comparative Penile Sensitivity

(Masters & Johnson, 1966; Payne, Thaler, Kukkonen, Carrier, & Binik, 2007). A third study
tested a single point on the dorsal midline of the outer foreskin (the least sensitive area on
the foreskin, according to Sorrells et al.s data), in addition to testing the glans and shaft
(Bleustein, Fogarty, Eckholdt, Arezzo, & Melman, 2005). Sorrells et al.s study is the only
one to date to map the comparative sensitivity of the circumcised and intact penis over
multiple points, including multiple points on the foreskin.
Sexual Functions of the Foreskin
The evidence on the sexual functionality of the foreskin comes not only from
anatomical and touch-testing studies such as those discussed above, but also from surveys of
adult men before and after circumcision (Collins, Upshaw, Rutchik, Ortenberg, & Albertsen,
2002; Coursey et al., 2001; Fink, Carson, & DeVellis, 2002; Kigozi et al., 2008; Kim &
Pang, 2007; Masood et al., 2005; Senkul et al., 2004; Shen, Chen, Zhu, Wan, & Chen, 2004;
Solinis & Yiannaki, 2007); a survey on the sexual experiences of women with circumcised
versus intact partners (O'Hara & O'Hara, 1999); studies of effects on lubrication and
intromission (Bensley & Boyle, 2001; Bensley & Boyle, 2003; O'Hara & O'Hara, 1999;
Taves, 2002); and anecdotal reports from men who have non-surgically restored their
foreskins, thereby regaining coverage of the glans and mobility of the penile skin (National
Organization of Restoring Men (NORM), 1999-2006; Bigelow, 1998).
Results from studies of mens sexual satisfaction and performance before and after
circumcision have produced mixed results. While some have shown no differences (Collins
et al., 2002; Kigozi et al., 2008), others have indicated problems with erection (Fink et al.,

2002; Shen et al., 2004), ejaculation (Senkul et al., 2004; Shen et al., 2004; Solinis &
Yiannaki, 2007), penile sensation (Fink et al., 2002), and masturbatory ease and pleasure
(Kim & Pang, 2007). Overall, a worsening in sex life has been reported in about one third of
cases (Dalton, 2008). Before and after studies are, however, subject to multiple
methodological problems that make them unreliable or difficult to interpret (Silverberg,
2008; Sorrells et al., 2007). A full analysis of these studies is beyond the scope of this paper,
and they will not be considered in the following discussion on the foreskins sexual
Based on what is known of the foreskins sensory capacities and mechanical
properties alone, the foreskin can be understood to have a variety of sexual functions that
affect the pleasure and comfort of both partners. Figure 2.4 shows the mechanics of
intercourse with an intact penis, to illustrate the following discussion. The sexual functions
of the foreskin include at least the following:
1) The penis elongates by at least 50% with erection (Wessells, Lue, & McAninch,
1996). The slack in the penile skin afforded by the preputial fold provides comfortable
coverage of the shaft as it expands with erection, while still allowing for skin mobility. In
contrast, the skin of the circumcised penis is generally relatively taut and immobile with
erection, with the expansion of the organ restricted by a significantly reduced skin
complement. Some circumcised men report experiencing such tightness with erection as to
produce pain or even tearing of the skin (Hammond, 1999).