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American Academy of Pediatrics. (2012). Male Circumcision: Task force on circumcision. AAP News and Journals. 130(3). Retrieved from http://pediatrics.aappublications.org/content/130/3/e756

American Society for Pain Management Nursing. (2011). Male Infant Circumcision Pain Management. Retrieved from www.aspmn.org/documents/circumcision.pdf

National Institutes of Health. (2007). Routine Circumcision: The opposing view. Canadian Urological Association Journal. 1(4). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2422979/

Intact America. (2018). Circumcision Decision. Retrieved from http://www.intactamerica.org/resources/decision

Journal of Medical Ethics. (2018). Circumcision: A surgeon's perspective. BMJ Journals. 30(3). Retrieved from http://jme.bmj.com/content/30/3/238

Journal of Obstetric Gynecologic and Neonatal Nursing. (1987). Newborn Circumcision. 6(1). Retrieved from http://www.jognn.org/article/S0884-2175(15)32652-6/fulltext

Mayo Clinic. (2018). Circumcision (male). Retrieved from https://www.mayoclinic.org/tests-procedures/circumcision/about/pac-20393550

Nurses for the Rights of the Child. (2017). Non-therapeutic Circumcision of Healthy Boys Unethical and Violation of Children's Rights. Retrieved from http://childrightsnurses.org/

The American College of Obstetricians and Gynecologists. (2017). Newborn Male Circumcision. Retrieved from https://www.acog.org/Patients/FAQs/Newborn-Male-Circumcision

Mothering: The Magazine of Natural Family Living. (2003). The Case Against Circumcision. Retrieved from http://www.cirp.org/news/Mothering1997/#n10

The Circumcision Debate. (2018). Retrieved from http://www.circumcisiondebate.org/debate

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In nursing school we were taught to always be the patient's advocate.  It is of utmost importance to advocate for infants, as they do not have the option to tells us their feelings, thoughts, and opinions.  This has prepared me to take a leadership role because now I understand that my actions, and what I do or do not say, could ultimately affect the child for the rest of his life.  As a nurse dealing with infants and circumcision, it is vital for me to be an advocate and provide leadership, so that the parent's are aware of the decisions they are making, and that the babies are protected.

Another curricular concept learned at SCOHS is the importance of safety.  This goes hand in hand with being the patient's advocate.  If you are not the patient's advocate, you are putting their safety at risk, and if you are not making sure your patient is safe, you are not being an efficient advocate.  With that being said, because they do not have a voice, it is necessary for the nurse to speak for them.  It is another way the nurse takes a leadership role in her scope of practice.  I will show leadership in this instance by making sure I inform everyone involved of the safety concerns related to circumcising and not circumcising.  If the parent's decide to circumcise, the nurse should make sure the baby is not in pain during the course of the procedure.  The nurse should also educate the parent's on how to take care of the baby's penis in either circumstance, such as how to properly clean and avoid infection.

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The nurse can/should:
1. Provide accurate, evidence based knowledge to the parents for both the circumcised and uncircumcised penis. There is a lot of information and opinions about circumcision, so it is necessary that nurses "present accurate information to parents and to help them sort through beliefs and feelings on circumcision" so they can make an educated choice for their baby boy (Newborn Circumcision, 1987).

2. Teach staff about the risks, benefits, and reasons why people choose to get their boys circumcised or not circumcised. Most textbooks and discussions are geared toward information about the circumcised penis, while "information about the foreskin itself is almost always missing from discussions about circumcision" (Mothering: The Magazine of Natural Family Living, 2003). All information about circumcision and not circumcising should be known by the nurse and other medical staff so they can be more aware of the facts and also share that information with the parents.

3. Be the patient's number one advocate, especially in regards to pain management.  Infants feel pain just as well as adults, so their pain should be handled just as well.  Because "infants are considered a vulnerable population"..."under the ethical principle of respect for persons there is a moral duty to protect them" (American Society for Pain Management Nursing, 2011).  Nurses can do this by helping to "establish polices or protocols to make certain no infant undergoes circumcision without appropriate comfort measures, analgesia, and anesthetic" (American Society for Pain Management Nursing, 2011).

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The nurses' role in infant male circumcision is to provide education to the parents before they make their decision, give proper care to the baby boy to promote healing and comfort while in their care, and educate the parents on how to provide care at home, whether the boy is circumcised or uncircumcised. Because circumcision is popular and a routine procedure in the U.S., many parents who decided to have their boys be circumcised were given adequate information on how to care for the circumcised penis, however, "only half of the parents of the uncircumcised child were given information on the care of their son’s penis" (Journal of Obstetric Gynecologic and Neonatal Nursing, 1987). It is important for the nurse to be knowledgeable of both options, so they can properly teach the parents regardless of what they choose for their son.  It is also very important for the nurse to be the baby's advocate, especially when dealing with pain, because the baby cannot speak for himself.

The nurse will be able to help by sharing the correct knowledge to the parents on the risks and benefits of both options.   Whatever choice the parents make, the nurse can then provide further education on how to care for the circumcised or uncircumcised penis to avoid the complications noted in the literature for both choices. This is important as it is a way to decrease infection and further hospital/doctor's visits since circumcision's "complication rate is one in 500" and "pathogenic bacteria such as staphylococcus, Proteus, Pseudomonas, other coliforms, and even tuberculosis can cause infections leading to death" (Mothering: The Magazine of Natural Family Living, 2003).  The nurse's involvement with being an advocate is also extremely important, because if the baby's pain is not managed properly, "some babies go into shock from the pain" and this "severe pain and trauma in infancy can have long-term neurological and psychological consequences" (The Circumcision Debate, 2018).

Some challenges the nurse may have is if they strongly agree with one choice and the parent's decide to go with the opposite choice. This could affect the information the nurse decides to share with the parents, and how the nurse takes care of the baby boy.  This deals with ethical and social reasons.  The nurse may feel it is fundamentally wrong to circumcise boys, or the nurse may feel it is socially unacceptable to not circumcise.  In the situation where the nurse or nurses feel it is wrong to circumcise, they may keep it to themselves if they fear for their job if they were to speak out against it, and if they do speak out against it, other health care professionals may become frustrated and feel disrupted. One nurse from Santa Fe, New Mexico stated "circumcision became so intolerable that five of us wrote a letter saying that ethically we could no longer assist" and "when we were getting ready to present the letter, other nurses came out of the woodwork and asked to sign it: Out of about 50 nurses, 24 signed it" (Nurses for the Rights of the Child, 2017).  This is a great way to create change in the medical field if a nurse believes circumcision to be ethically wrong.

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While infant male circumcision is one of the most common procedures performed in the U.S., some literature suggests the benefits of circumcision outweigh the risks, while other literature suggests the risks for not being uncircumcised are not high enough to perform elective circumcision.  The benefits of circumcision may include "easier hygiene, decreased risk of urinary tract infections, decreased risk of sexually transmitted infections, prevention of penile problems, and decreased risk or penile cancer", yet on the other hand, the same article goes on to say that "the risks of not being circumcised, however, are not only rare, but avoidable with proper care of the penis" (Mayo Clinic, 2018).  One article suggests infant circumcision is not only unnecessary, but "denudes, desensitizes, disables, disfigures, disrupts blood circulation, harms the developing brain, is unhygienic, and always risky" (Mothering: The Magazine of Natural Family Living, 2003). The American College of Obstetricians and Gynecologists states, "some research shows that circumcision may decrease the risk of a man getting human immunodeficiency virus (HIV) from an infected female partner" (The American College of Obstetricians and Gynecologists , 2017). However, "the United States has the highest rate of HIV and also the highest rate of infant circumcision", which "casts doubt on the utility of routine circumcision in preventing HIV infection in developed countries" (National Institutes of Health, 2007). The research regarded preventing HIV also does not apply to homosexual men, and it does not fully protect against acquiring the virus, so it is recommended that it should not be the only prevention strategy used to prevent acquiring HIV.

In regards to ethics, some people are against male circumcision because they believe it is ethically wrong to perform an irreversible procedure on a person without their consent that isn't medically necessary, especially when it is dealing with sexual organs and is painful.  Intact America discusses how "it is unethical to circumcise babies or children, because they cannot consent to it, and because it is not medically necessary" (Intact America, 2018). Also, there is a misconception that infants do not feel pain, or they are not concerned with a child's pain, therefore the infants are not provided the necessary pain management.  In the Journal of Medical Ethics, one article explains how there are many places around the world who do not use any analgesics whatsoever during circumcision, which "is physically cruel and potentially dangerous and must leave major psychological scars" (Journal of Medical Ethics, 2018).  One medical doctor explains in his journal how the pain from "circumcision is followed by prolonged, unrestful non-REM (rapid-eye-movement) sleep" and "in response to the lengthy bombardment of their neural pathways with unbearable pain, the circumcised babies withdrew into a kind of semicoma that lasted days or even weeks" (The Case Against Circumcision, 2003).

Some religions/cultures perform male circumcision on their infants because it is the common practice.  The Journal of Medical Ethics states how "circumcision is a major part of the ritual for such religions as Judaism, Christianity, and Islam, and it is probably no accident that all of these arose in the Middle East", where "circumcision is likely to have arisen as an early public health measure for preventing recurrent balanitis, caused by sand accumulating under the foreskin" (Journal of Medical Ethics, 2018). It was also started as it: was believed to allow one to "receive divine benefits of health and prosperity", "was promoted as preventing masturbation in boys and as a “cure” for “hysteria” in women", and was "wish[ed] to bring about a decrease in sexual intercourse and a weakening of the organ in question" (The Circumcision Debate, 2018). But even though circumcision started out in this way, "fewer than one percent of newborn circumcisions are carried out in the United States as a religious ritual", and "the other ninety-nine percent are performed in hospitals by doctors, and have no spiritual significance" (The Circumcision Debate, 2018). Some may argue that not allowing the choice to perform elective infant circumcision takes away their right to express their religious and individual preferences, however, others argue performing the procedure denies the infant the right to choose his own religious and individual choices.

Personal preference plays a role on whether parents decide to circumcise their boys or not, such as with family tradition.  Parents are much more likely to circumcise their infant boys if the father is circumcised, and vice versa. It has been found in Australia that "the commonest reason for requesting circumcision is the father’s desire for the baby to look like himself" (Journal of Medical Ethics, 2018).  While this may be the case for why many boys are circumcised, others believe this reasoning is not more important than the risks and ethical infringement of circumcising infant boys.

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Infant male circumcision, which is "the surgical removal of some, or all, of the foreskin (or prepuce) from the penis", is a quite controversial topic in the United States (American Academy of Pediatrics, 2012).  While many believe the procedure to be necessary and beneficial, others believe it to be hurtful and unwarranted.  It is estimated around 55% of baby boys in the United States are circumcised soon after birth (Intact America, 2018).  Medical risks/benefits, ethics, religion/culture, and personal preferences are all factors in why parents choose to circumcise or not circumcise their infant boys.

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Infant Male Circumcision: Helpful or Harmful?

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Infant Male Circumcision: Helpful or Harmful?