Awareness of Parents About Circumcision: Turkey Data Survey Study

Awareness of Parents About Circumcision: Turkey Data Survey Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Awareness of Parents About Circumcision: Turkey Data Survey Study Mevlüt KELEŞ, Erdal BENLİ, Abdullah ÇIRAKOĞLU, İbrahim YAZICI, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9197492/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 20 You are reading this latest preprint version Abstract Background To evaluate Turkish parents’ perceptions and attitudes regarding the appropriate age for circumcision, practice conditions, and procedural indications across different regions of Turkey. Methods This cross-sectional survey study was conducted between March 2023 and March 2025 across urology and pediatric surgery departments in seven distinct regions of Turkey. A total of 637 literate parents (aged ≥ 18) completed a voluntary 16-question online survey via URL or QR code. Data regarding demographics, circumcision preferences, and information sources were analyzed using descriptive statistics and Chi-square tests. Results The majority of parents (95.1%) considered circumcision necessary, primarily citing religious (77.7%) and medical (63.8%) reasons. Although 76% of participants believed circumcision should ideally occur outside the phallic stage (ages 2–6), a significant discrepancy was observed as 41.1% of children were actually circumcised during this period. Awareness of the non-phallic stage increased significantly with higher parental education levels (p < 0.001). Regarding practice, specialists were preferred (pediatric surgeons 54.4%; pediatric urologists 46.3%), and the operating room was identified as the safest setting by 91.7% of responders. Local anesthesia was the most selected method (51.6%). Conclusion Despite a high general awareness of specialist qualifications and appropriate age ranges, a clear gap exists between parental knowledge and actual practice, particularly regarding the phallic stage. Enhancing clinical guidance and utilizing mass communication effectively are essential to ensure circumcisions are performed under appropriate conditions and to minimize potential psychological trauma. Circumcision male circumcision neonatal circumcision perception psychotrauma phallic stage parental awareness pediatric urology Turkey Figures Figure 1 Background Circumcision is a globally standard surgical procedure, predominantly for religious and cultural reasons [ 1 ]. While a fundamental religious practice in Muslim and Jewish communities, its justification in Western societies often emphasizes prophylactic and therapeutic medical benefits. Circumcision’s medical, psychological, and social implications in male children warrant attention [ 2 ] . Perceptions of circumcision vary globally, influencing timing and method. Modern medicine acknowledges some health benefits, though optimal age and technique remain debated. The American Urological Association (AUA) states that circumcision offers medical benefits like preventing urinary tract infections (UTIs), reducing sexually transmitted diseases (STDs), and decreasing certain penile cancers, with effects varying by developmental stage [ 3 ]. Importantly, circumcision isn’t always essential; parental decisions can be based on cultural and religious factors [ 3 ]. Conversely, the European Association of Urology (EAU) guidelines state that circumcision is necessary only for specific medical conditions and complications like paraphimosis or progressive conditions such as phimosis, balanitis xerotica obliterans, and recurrent UTIs [ 4 ]. The EAU further stresses that qualified physicians should only perform circumcision in sterile operating room conditions to minimize complications and emotional distress. No consensus exists on the ideal age for circumcision regarding psychological and developmental aspects. Some argue that performing circumcision during the phallic stage (PS) (ages 2–6) may negatively impact psychosocial development, advocating avoidance during this period [ 5 ]. While some studies favor neonatal circumcision for faster healing and fewer complications, others suggest circumcision after five years may be psychologically more favorable [ 6 ]. Circumcision under anesthesia after age six is thought to minimize psychological trauma through anterograde amnesia (because of using Midazolam for premedication), preventing memory retention of perioperative pain and distress, thereby reducing anxiety and psychological sequelae [ 7 ]. Some studies align, indicating circumcision performed beyond five years better suits a child’s developmental and psychological status, with anesthesia mitigating conscious apprehension [ 8 ]. However, anesthesia risks and postoperative recovery must also be considered. A recent study reinforces the link between circumcision age and psychological impact, advocating postponement until after age five due to potential developmental trauma from early circumcision [ 9 ]. The psychological effects of circumcision during the PS are not fully understood. While hypothesized to trigger castration anxiety, this lacks conclusive scientific support. For instance, Armagan et al.’s retrospective study on 302 adult men found no significant differences in erectile dysfunction, premature ejaculation, or depression between those circumcised during the phallic period versus later [ 10 ]. Beyond scientific literature, non-medical factors—like religious convictions, ancestral traditions, and community norms—substantially influence circumcision perception and social acceptance. Perception involves interpreting external stimuli into cognitive constructs and is shaped by intertwined biological and psychological factors, significantly influencing individual reactions.[ 11 ] Parents’ perceptions of circumcision, molded by religious beliefs, cultural norms, and medical information, significantly shape their health decisions.[ 12 ] This study aims to assess Turkish parents’ perceptions on the ideal circumcision age and appropriate performance conditions. This study identifies key parental perceptions regarding circumcision, highlighting the specific issues practitioners should clarify to ensure that parents can make well-informed decisions based on accurate clinical guidance. Methods We conducted a cross-sectional survey to assess Turkish parents’ awareness and perceptions on circumcision, exploring its medical, psychological, and cultural aspects, as well as primary information sources. Our study included Turkish parents from varied backgrounds who were literate and completed the voluntary online survey via URL/QR code. The 16-question survey, adapted from literature, assessed demographics, circumcision opinions, and information sources (Appendix). It used a mixed-format (multiple-choice/open-ended) and Likert scale for perceptions on ideal circumcision age and conditions. Ethical approval was obtained from XXX University Clinical Studies Ethic Committee (Decision number:2022/215, Date: 16/09/2022). The study was conducted in accordance with the Declaration of Helsinki. Data were collected online (March 2023-March 2025) via a link shared nationally across seven regions (social media, parent groups, schools). Also, the link was shared with parents consulting the physicians (authors of the manuscript) for pre-circumcision counseling, before receiving information. Physicians at the seven host clinics (designated as authors) distributed the survey by placing QR codes on clinic doors as flyers. Additionally, these codes were shared with parents seeking information about circumcision prior to their clinical briefing, ensuring that responses were collected before any medical counseling was provided. All participants received study information and provided electronic consent. Data were analyzed using SPSS 22 (IBM software, Pointe Claire, Quebec, Canada). Descriptive statistics summarized demographics and perceptions. Chi-square and independent samples t-tests examined group differences; p < 0.05 was considered statistically significant. Results Totally 2300 survey link shared online with parents from seven regions of Turkey. Only 239 of these parents responded. Additionally, 400 parents who were applied the host clinics to gather information about circumcision completed the survey. Two survey responses had structural errors. Totally, data from 637 responders took into consideration. Our study compared totally 637 participants’ maternal and paternal ages, educational levels, and place of residence to identify their approaches on circumcision (Table 1 ). Non phallic circumcision (NPC) indicated that circumcision should not be performed between the ages of 2 and 6. Mothers aged 30–44 had the highest NPC response rate at 78.8% (p = 0.018). For fathers, the 18–29 age group showed the highest NPC response at 86.2% (p = 0.005). NPC answer rates increased with higher educational levels; for instance, 84.6% of mothers and 83.6% of fathers with a university degree demonstrated preferring NPC (p < 0.001). Regarding geographical distribution, no significant clinical variation was observed in circumcision timing between rural and urban populations (p = 0.117). Among participants who considered circumcision necessary, the NPC response rate was 74.8%, while all participants deeming circumcision unnecessary preferred NPC if performed (p = 0.001) (Table 1 ). Table 1 Parents’ socio-demographic characteristics and ideas on circumcision age. Variable n (%) NPC n (%) Test Value p-value Mother’s Age χ²=10.037 0.018 18–29 132 (20.7) 103 (78.0) 30–44 372 (58.4) 293 (78.8) 45–64 123 (19.3) 80 (65.0) 65+ 10 (1.6) 8 (80.0) Father’s Age χ²=13.036 0.005 18–29 58 (9.2) 50 (86.2) 30–44 401 (63.4) 314 (78.3) 45–64 154 (24.4) 105 (68.2) 65+ 19 (3.0) 11 (57.9) Mother’s Education Level χ²=22.882 < 0.001 Primary School 88 (13.8) 61 (69.3) Middle School 75 (11.8) 39 (52.0) High School 149 (23.4) 109 (73.2) University 325 (51.0) 275 (84.6) Father’s Education Level χ²=22.882 < 0.001 Primary School 59 (9.3) 41 (69.5) Middle School 58 (9.1) 36 (62.1) High School 191 (30.0) 132 (69.1) University 329 (51.6) 275 (83.6) Place of Residence χ²=4.287 0.117 Provincial Center 495 (77.7) 376 (76.0) District Center 117 (18.4) 93 (79.5) Village 25 (3.9) 15 (60.0) Is circumcision necessary? χ²=10.301 0.001 Yes 606 (95.1) 453 (74.8) No 31 (4.9) 31 (100.0) Did you research before circumcision? χ²=0 0.994 Yes 404 (63.4) 307 (76.0) No 233 (36.6) 177 (76.0) Total 637 (100.0) 484 (76.0) *NPC: Non-phallic circumcision Many participants (76%) stated that circumcision should occur outside the PS. Fathers aged 18–29 and mothers aged 30–44 showed the highest awareness of appropriate circumcision timing. Interestingly, despite most parents believing circumcision shouldn’t be performed during the PS, 41% of their children were circumcised within this period (Fig. 1 ). Participants were also asked if they considered circumcision necessary and their underlying reasons. Table 3 shows that a vast majority (95.1%) believed it was essential. Religious convictions (77.7%) were the most common justification, followed by medical reasons (63.8%), customs (12.8%), social considerations (7.0%), and psychological factors (6.2%), respectively. Circumcision’s multidimensional impact on individuals is evident, as participants could indicate various reasons (Table 2 ). Table 2 Opinions on circumcision necessity of circumcision and justifications. Category n % Is circumcision necessary? Yes 606 95.1 No 31 4.9 Reasons for considering circumcision necessary* Religious 475 77.7 Medical 390 63.8 Customs and traditions 78 12.8 Social 43 7.0 Psychological 38 6.2 Participants’ opinions on circumcision practices clearly show a preference for medical professionals, with pediatric surgeons (54.4%) and pediatric urologists (46.3%) being most preferred. Local anesthesia (LA) was the most chosen method (51.6%), while 31.1% preferred general anesthesia (GA). The operating room (91.7%) was overwhelmingly considered the safest setting. These results indicate participants favor a professional and sterile approach to circumcision (Table 3 ). Table 3 Parents’ circumcision practice preferences. Aspect Response n % Preferred practitioner for circumcision * Urologist 257 41.6% Pediatric urologist 286 46.3% Pediatric surgeon 336 54.4% General surgeon 80 12.9% Plastic and aesthetic surgeon 44 7.1% General practitioner 8 1.3% Non-physician healthcare personnel 3 0.5% Traditional circumciser 36 5.8% Preferred method of circumcision No anesthesia needed 47 7.4% With general anesthesia 198 31.1% With both general and local anesthesia 63 9.9% With local anesthesia 329 51.6% Preferred setting for circumcision * Operating room 565 91.7% Clinic or doctor’s office 84 13.6% At home 43 7.0% Discussion Circumcision is an ancient and globally standard surgical procedure with diverse justifications. While literature highlights its role in preventing pathologies like UTIs, STDs, and penile cancers, with AUA guidelines supporting these benefits, concerns exist [ 2 , 3 ]. Specifically, circumcision performed during the PS may adversely affect psychosocial development [ 6 ]. Conversely, retrospective analyses of adult males show no significant differences in erectile dysfunction, premature ejaculation, or depression based on whether circumcision occurred during phallic or non-phallic periods [ 10 ]. Our study, addressing the lack of clear consensus on circumcision’s necessity, found that a vast majority of parents (95.1%) considered it necessary, with only 4.9% deeming it unnecessary. Despite this low proportion, it’s significant given Turkey’s strong religious and cultural acceptance of circumcision. Parental attitudes toward circumcision in Turkey are deeply intertwined with both religious values and regional traditions. Given that traditional impact is often more substantial in the Eastern and Southeastern regions, our multicenter approach across all seven regions was designed to capture this sociocultural diversity and identify how these factors influence parental opinions. The appropriate age for circumcision remains debated. While neonatal circumcision is favored for faster healing and fewer complications [ 6 ], circumcision under anesthesia after age six may reduce psychological trauma through anterograde amnesia [ 7 ]. The 2–6 year PS is a point of contention; some studies suggest circumcision during this period might trigger castration anxiety [ 5 ]. Conversely, alternative research indicates that circumcision performed during the PS does not result in significant long-term differences during adulthood compared to later procedures. Specifically, no substantial variations were observed regarding the incidence of erectile dysfunction, premature ejaculation, or depression [ 10 ]. In our study, 76% of parents believed circumcision shouldn’t be performed during the PS. This widespread perception of potential psychological harm persists despite conflicting literature. Subgroup analyses were conducted to explore the factors influencing parental awareness. These analyses revealed that the location of residence, whether urban or rural, had no significant impact on opinions regarding the ideal timing of medical circumcision (p = 0.117). This lack of disparity may be attributed to the widespread accessibility of medical information through the internet and social media platforms. Fathers aged 18–29 and mothers aged 30–44 showed the highest awareness of correct circumcision timing, suggesting greater knowledge among younger parents. Interestingly, prior research on the procedure didn’t significantly influence this awareness. Despite high parental awareness of the appropriate circumcision age, 41% of children in our study were circumcised during the PS. The observed discrepancy between awareness and practice may stem from a demographic bias within the participant pool. Specifically, younger and more informed parents—who correctly identify the non-phallic period as ideal—may not have yet proceeded with the circumcision procedure, potentially leaving the retrospective question ‘At what age did you circumcise your child?’ unanswered. Debates around circumcision also focus on who should perform it, under what conditions, and how. European urology guidelines emphasize that performing circumcision in a sterile operating room reduces infection and complication rates [ 13 ]. The procedure should be done in a well-equipped hospital, if done in an office with local anesthesia. Our results show parents essentially believe physicians should perform circumcision, aligning with current literature. Surprisingly, though rare, some parents consider non-physician healthcare personnel or ‘fenni sünnetçi’ (traditional circumcisers) acceptable. Regarding setting, 91.7% of parents favored an operating room, 13.6% preferred a clinic, and 7% surprisingly believed a home environment was appropriate. While our findings largely align with the literature, the continued acceptance of home circumcisions in the 21st century is thought-provoking. When performing circumcision, general anesthesia, local anesthesia, or a combination are used, with prominence varying across patient populations. Literature generally suggests LA for newborns and GA for older age groups [ 14 ], believing GA minimizes psycho-trauma through anterograde amnesia [ 7 ]. One study reported that circumcision did not result in severe post-traumatic stress disorder (PTSD) symptoms; however, procedures performed under GA were found to have a more negative impact on PTSD symptoms compared to those LA. Furthermore, findings indicated that baseline depression levels served as a significant predictor for subsequent PTSD symptoms. [ 15 ]. The literature evaluates a wide range of local and regional anesthesia techniques for pain management during circumcision. Within this context, caudal block has been proven superior to both dorsal penile nerve block and subcutaneous morphine in the effective prevention of procedural pain [ 16 ]. In our study, 51.6% of parents preferred LA for circumcision, 31.1% preferred GA, and 9.9% favored LA + GA. Despite literature highlighting LA for neonatal circumcision and GA for older groups, most parents in our study still preferred LA for circumcision. Traditions, customs, and religious beliefs significantly shape parental perceptions of circumcision. While both Islam and Judaism recommend circumcision, medical necessity is also a recognized justification [ 17 ]. In modern society, the internet and social media have emerged as prominent information sources for parents on child health, influencing perceptions across all age groups [ 18 ]. Parents deem information from physicians to be most reliable. A recent study noted that most parents (89%) searched online for health information when their children were ill, though some (31%) followed it instead of seeing a doctor. Parents trusting their child’s doctor were more likely to follow medical advice over conflicting online information. Most parents (91%) also sought help from healthcare professionals while searching online [ 19 ]. In Turkey, religious beliefs are often more decisive in parental circumcision decisions [ 5 ]. Our study similarly found parents primarily cited both religious and medical reasons for circumcision, followed by traditions, societal, and psychological factors. These findings align with national data. Conversely, medical benefits are emphasized in Western societies, with religious reasons less influential [ 2 ]. Consistently, many responder parents in our study (63.8%) believed "Circumcision should be performed for medical reasons," aligning our results with national and global data. A recent Turkish study explored perceptions and decision-making regarding circumcision among parents and medical personnel. While it addressed similar aspects to our work, our study’s 637 surveys offer greater generalizability to a larger population. That study uniquely examined grandparental influence on circumcision decisions, a factor relevant in patriarchal societies. While their study’s smaller patient cohort allowed for the inclusion of pediatrician, general practitioner, and parent perspectives (areas our study didn’t cover), our nationwide data on parental attitudes provides superior strength in assessing parental trends. This study has several limitations. First, the sampling method relied solely on online distribution, which may have introduced selection bias by excluding individuals without reliable internet access or digital literacy. Second, due to its cross-sectional design, the study captures only a single time point, limiting the ability to establish causality between variables. Additionally, the survey questionnaire was not prepared using the Delphi consensus. Furthermore, despite not employing a Delphi consensus, our survey questions were developed with input from pediatric urology specialists, a preliminary step not detailed in the other study, highlighting a key strength of our approach. Also, no sensibility and validity test performed for the survey items. An additional limitation of this research is the absence of grandparental influence on the decision-making process regarding circumcision. Given the traditional family structure in Turkey, the role of elders may represent a significant factor that was not captured in the current analysis. Future research should prioritize longitudinal designs to systematically evaluate the long-term psychological and developmental impacts of circumcision performed across different age cohorts. Furthermore, achieving a more holistic understanding of decision-making dynamics necessitates the integration of perspectives from diverse stakeholders, including healthcare providers, religious leaders, and grandparents. Such an inclusive approach is particularly vital within patriarchal cultural frameworks, where familial and community hierarchies significantly influence health outcomes. Finally, further investigation is warranted to assess the burgeoning impact of digital media and internet-based resources. These platforms increasingly shape parental health-seeking behaviors and play a critical role in the contemporary decision-making processes regarding pediatric surgical interventions. Conclusion Circumcision, an ancient and globally standard surgical procedure, still has debated benefits and risks. Parental approaches to this procedure are crucial and influenced by various factors. Our study shows that most parents desire circumcision for both medical and religious reasons. Findings also indicate high parental awareness regarding appropriate circumcision age, practitioner qualifications, and proper environmental settings. Despite this, some parents still believe circumcision can occur at home by unqualified individuals. Therefore, we believe that effectively using mass communication is vital to inform parents about this standard yet risky procedure and to enhance existing circumcision awareness. Abbreviations AUA American Urological Association UTIs Urinary tract infections STDs Sexually transmitted diseases EAU European Association of Urology PS Phallic stage NPC Non phallic circumcision LA Local anesthesia GA General anesthesia PTSD Post-traumatic stress disorder Declarations Conflict Of Interest Statement All authors declare that there are no financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work. Funding All authors declare that no funding source used for this study. Ethics Declaration The study conducted in concordance to the Declaration of Helsinki. Ethics approval from our institutional scientific committee was obtained also (Decision number:2022/215, Date: 16/09/2022). Author Contributions The authors confirm contribution to the paper as follows: Study conception and design: MK, AAA, AÇ, EB, NK, MSS; data collection: MK, AÇ, EB, AAA, NK, İY, MUY, NB, AA; analysis and interpretation of results: HD, AÇ; draft manuscript preparation: MK, MUY, HD, NB, NK, MSS. All authors reviewed the results and manuscript and approved the final version of the manuscript. Data Availibility Statement The datasets (survey response documanet) used and/or analysed during the current study are available from the corresponding author on reasonable request. Artificial Intelligence Statement During the preparation of this work the author(s) used ChatGPT and Google Gemini for language editting and manuscript formatting. After using this tools/services, the author(s) reviewed and edited the content as needed and take full responsibility for the content of the publication. References World Health Organization. UNAIDS. 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University","correspondingAuthor":false,"prefix":"","firstName":"Nurullah","middleName":"","lastName":"KADİM","suffix":""},{"id":617522341,"identity":"23635f6f-205b-4583-be0a-d87da92737e7","order_by":5,"name":"Ahmet Anıl ACET","email":"","orcid":"","institution":"Ordu University","correspondingAuthor":false,"prefix":"","firstName":"Ahmet","middleName":"Anıl","lastName":"ACET","suffix":""},{"id":617522342,"identity":"045ed9ca-be43-4521-ab35-5d5f6e56638c","order_by":6,"name":"Hasan DURMUŞ","email":"","orcid":"","institution":"Erciyes University","correspondingAuthor":false,"prefix":"","firstName":"Hasan","middleName":"","lastName":"DURMUŞ","suffix":""},{"id":617522343,"identity":"233eca74-2bc4-4add-991b-139cdfaceb02","order_by":7,"name":"Mehmet Uğur YILMAZ","email":"","orcid":"","institution":"Bursa Uludağ University","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"Uğur","lastName":"YILMAZ","suffix":""},{"id":617522344,"identity":"1a2dbaa9-e594-48f3-883e-72a741ab5cb6","order_by":8,"name":"Aybegüm KALYONCU AYÇENK","email":"","orcid":"","institution":"Ordu University","correspondingAuthor":false,"prefix":"","firstName":"Aybegüm","middleName":"KALYONCU","lastName":"AYÇENK","suffix":""},{"id":617522346,"identity":"ad8edbcb-a6a0-4866-bebd-21001efc2426","order_by":9,"name":"Numan BAYDİLLİ","email":"","orcid":"","institution":"Erciyes University","correspondingAuthor":false,"prefix":"","firstName":"Numan","middleName":"","lastName":"BAYDİLLİ","suffix":""},{"id":617522348,"identity":"6a06844d-b7bd-430b-95ac-3c296d391038","order_by":10,"name":"Nizamettin KILIÇ","email":"","orcid":"","institution":"Bursa Uludağ University","correspondingAuthor":false,"prefix":"","firstName":"Nizamettin","middleName":"","lastName":"KILIÇ","suffix":""},{"id":617522349,"identity":"dcfbcae2-7dd7-4920-a796-e292404c17af","order_by":11,"name":"Mesrur Selçuk SILAY","email":"","orcid":"","institution":"İstanbul Medipol University","correspondingAuthor":false,"prefix":"","firstName":"Mesrur","middleName":"Selçuk","lastName":"SILAY","suffix":""}],"badges":[],"createdAt":"2026-03-23 08:23:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9197492/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9197492/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106309539,"identity":"2f27e342-162f-4288-8e0b-1fed8645f428","added_by":"auto","created_at":"2026-04-07 10:18:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40971,"visible":true,"origin":"","legend":"\u003cp\u003eCircumcision age distribution status (Responders whose kids were circumcised).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9197492/v1/9f4090846b344573fa235bf8.png"},{"id":106959606,"identity":"94cb91e9-549d-4647-a07f-00d01f1e6107","added_by":"auto","created_at":"2026-04-15 09:12:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":798386,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9197492/v1/64f741c6-db1e-46ea-930e-763ed601bca3.pdf"},{"id":106309538,"identity":"d3dc6f08-83d8-42ac-acd4-dd3698cc3978","added_by":"auto","created_at":"2026-04-07 10:18:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16692,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-9197492/v1/7f25d71395a845bf4f1d2a90.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAwareness of Parents About Circumcision: Turkey Data Survey Study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eCircumcision is a globally standard surgical procedure, predominantly for religious and cultural reasons [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While a fundamental religious practice in Muslim and Jewish communities, its justification in Western societies often emphasizes prophylactic and therapeutic medical benefits. Circumcision\u0026rsquo;s medical, psychological, and social implications in male children warrant attention [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003ePerceptions of circumcision vary globally, influencing timing and method. Modern medicine acknowledges some health benefits, though optimal age and technique remain debated. The American Urological Association (AUA) states that circumcision offers medical benefits like preventing urinary tract infections (UTIs), reducing sexually transmitted diseases (STDs), and decreasing certain penile cancers, with effects varying by developmental stage [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Importantly, circumcision isn\u0026rsquo;t always essential; parental decisions can be based on cultural and religious factors [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConversely, the European Association of Urology (EAU) guidelines state that circumcision is necessary only for specific medical conditions and complications like paraphimosis or progressive conditions such as phimosis, balanitis xerotica obliterans, and recurrent UTIs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The EAU further stresses that qualified physicians should only perform circumcision in sterile operating room conditions to minimize complications and emotional distress.\u003c/p\u003e \u003cp\u003eNo consensus exists on the ideal age for circumcision regarding psychological and developmental aspects. Some argue that performing circumcision during the phallic stage (PS) (ages 2\u0026ndash;6) may negatively impact psychosocial development, advocating avoidance during this period [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While some studies favor neonatal circumcision for faster healing and fewer complications, others suggest circumcision after five years may be psychologically more favorable [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCircumcision under anesthesia after age six is thought to minimize psychological trauma through anterograde amnesia (because of using Midazolam for premedication), preventing memory retention of perioperative pain and distress, thereby reducing anxiety and psychological sequelae [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Some studies align, indicating circumcision performed beyond five years better suits a child\u0026rsquo;s developmental and psychological status, with anesthesia mitigating conscious apprehension [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, anesthesia risks and postoperative recovery must also be considered. A recent study reinforces the link between circumcision age and psychological impact, advocating postponement until after age five due to potential developmental trauma from early circumcision [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe psychological effects of circumcision during the PS are not fully understood. While hypothesized to trigger castration anxiety, this lacks conclusive scientific support. For instance, Armagan et al.\u0026rsquo;s retrospective study on 302 adult men found no significant differences in erectile dysfunction, premature ejaculation, or depression between those circumcised during the phallic period versus later [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBeyond scientific literature, non-medical factors\u0026mdash;like religious convictions, ancestral traditions, and community norms\u0026mdash;substantially influence circumcision perception and social acceptance. Perception involves interpreting external stimuli into cognitive constructs and is shaped by intertwined biological and psychological factors, significantly influencing individual reactions.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Parents\u0026rsquo; perceptions of circumcision, molded by religious beliefs, cultural norms, and medical information, significantly shape their health decisions.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis study aims to assess Turkish parents\u0026rsquo; perceptions on the ideal circumcision age and appropriate performance conditions. This study identifies key parental perceptions regarding circumcision, highlighting the specific issues practitioners should clarify to ensure that parents can make well-informed decisions based on accurate clinical guidance.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a cross-sectional survey to assess Turkish parents\u0026rsquo; awareness and perceptions on circumcision, exploring its medical, psychological, and cultural aspects, as well as primary information sources.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study included Turkish parents from varied backgrounds who were literate and completed the voluntary online survey via URL/QR code. The 16-question survey, adapted from literature, assessed demographics, circumcision opinions, and information sources (Appendix). It used a mixed-format (multiple-choice/open-ended) and Likert scale for perceptions on ideal circumcision age and conditions.\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from XXX University Clinical Studies Ethic Committee (Decision number:2022/215, Date: 16/09/2022). The study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eData were collected online (March 2023-March 2025) via a link shared nationally across seven regions (social media, parent groups, schools). Also, the link was shared with parents consulting the physicians (authors of the manuscript) for pre-circumcision counseling, before receiving information. Physicians at the seven host clinics (designated as authors) distributed the survey by placing QR codes on clinic doors as flyers. Additionally, these codes were shared with parents seeking information about circumcision prior to their clinical briefing, ensuring that responses were collected before any medical counseling was provided. All participants received study information and provided electronic consent.\u003c/p\u003e\n\u003cp\u003eData were analyzed using SPSS 22 (IBM software, Pointe Claire, Quebec, Canada). Descriptive statistics summarized demographics and perceptions. Chi-square and independent samples t-tests examined group differences; p \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTotally 2300 survey link shared online with parents from seven regions of Turkey. Only 239 of these parents responded. Additionally, 400 parents who were applied the host clinics to gather information about circumcision completed the survey. Two survey responses had structural errors. Totally, data from 637 responders took into consideration. Our study compared totally 637 participants\u0026rsquo; maternal and paternal ages, educational levels, and place of residence to identify their approaches on circumcision (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Non phallic circumcision (NPC) indicated that circumcision should not be performed between the ages of 2 and 6.\u003c/p\u003e \u003cp\u003eMothers aged 30\u0026ndash;44 had the highest NPC response rate at 78.8% (p\u0026thinsp;=\u0026thinsp;0.018). For fathers, the 18\u0026ndash;29 age group showed the highest NPC response at 86.2% (p\u0026thinsp;=\u0026thinsp;0.005). NPC answer rates increased with higher educational levels; for instance, 84.6% of mothers and 83.6% of fathers with a university degree demonstrated preferring NPC (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Regarding geographical distribution, no significant clinical variation was observed in circumcision timing between rural and urban populations (p\u0026thinsp;=\u0026thinsp;0.117). Among participants who considered circumcision necessary, the NPC response rate was 74.8%, while all participants deeming circumcision unnecessary preferred NPC if performed (p\u0026thinsp;=\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParents\u0026rsquo; socio-demographic characteristics and ideas on circumcision age.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNPC n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMother\u0026rsquo;s Age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2;=10.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e132 (20.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e103 (78.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e372 (58.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e293 (78.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026ndash;64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e123 (19.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80 (65.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e65+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFather\u0026rsquo;s Age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2;=13.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58 (9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50 (86.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e401 (63.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e314 (78.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026ndash;64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e154 (24.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e105 (68.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e65+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (57.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMother\u0026rsquo;s Education Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2;=22.882\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e88 (13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61 (69.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (52.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e149 (23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e109 (73.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e325 (51.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e275 (84.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFather\u0026rsquo;s Education Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2;=22.882\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41 (69.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36 (62.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e191 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e132 (69.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e329 (51.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e275 (83.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlace of Residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2;=4.287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProvincial Center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e495 (77.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e376 (76.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistrict Center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e117 (18.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e93 (79.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVillage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIs circumcision necessary?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2;=10.301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e606 (95.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e453 (74.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDid you research before circumcision?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2;=0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.994\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e404 (63.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e307 (76.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e233 (36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e177 (76.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e637 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e484 (76.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*NPC: Non-phallic circumcision\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMany participants (76%) stated that circumcision should occur outside the PS. Fathers aged 18\u0026ndash;29 and mothers aged 30\u0026ndash;44 showed the highest awareness of appropriate circumcision timing. Interestingly, despite most parents believing circumcision shouldn\u0026rsquo;t be performed during the PS, 41% of their children were circumcised within this period (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eParticipants were also asked if they considered circumcision necessary and their underlying reasons. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows that a vast majority (95.1%) believed it was essential. Religious convictions (77.7%) were the most common justification, followed by medical reasons (63.8%), customs (12.8%), social considerations (7.0%), and psychological factors (6.2%), respectively. Circumcision\u0026rsquo;s multidimensional impact on individuals is evident, as participants could indicate various reasons (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOpinions on circumcision necessity of circumcision and justifications.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIs circumcision necessary?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e606\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReasons for considering circumcision necessary*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e475\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e390\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCustoms and traditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eParticipants\u0026rsquo; opinions on circumcision practices clearly show a preference for medical professionals, with pediatric surgeons (54.4%) and pediatric urologists (46.3%) being most preferred. Local anesthesia (LA) was the most chosen method (51.6%), while 31.1% preferred general anesthesia (GA). The operating room (91.7%) was overwhelmingly considered the safest setting. These results indicate participants favor a professional and sterile approach to circumcision (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParents\u0026rsquo; circumcision practice preferences.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreferred practitioner for circumcision\u003c/b\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePediatric urologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePediatric surgeon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral surgeon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlastic and aesthetic surgeon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-physician healthcare personnel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraditional circumciser\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreferred method of circumcision\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo anesthesia needed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith general anesthesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith both general and local anesthesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith local anesthesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreferred setting for circumcision\u003c/b\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOperating room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e565\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinic or doctor\u0026rsquo;s office\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCircumcision is an ancient and globally standard surgical procedure with diverse justifications. While literature highlights its role in preventing pathologies like UTIs, STDs, and penile cancers, with AUA guidelines supporting these benefits, concerns exist\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Specifically, circumcision performed during the PS may adversely affect psychosocial development [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Conversely, retrospective analyses of adult males show no significant differences in erectile dysfunction, premature ejaculation, or depression based on whether circumcision occurred during phallic or non-phallic periods [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study, addressing the lack of clear consensus on circumcision\u0026rsquo;s necessity, found that a vast majority of parents (95.1%) considered it necessary, with only 4.9% deeming it unnecessary. Despite this low proportion, it\u0026rsquo;s significant given Turkey\u0026rsquo;s strong religious and cultural acceptance of circumcision. Parental attitudes toward circumcision in Turkey are deeply intertwined with both religious values and regional traditions. Given that traditional impact is often more substantial in the Eastern and Southeastern regions, our multicenter approach across all seven regions was designed to capture this sociocultural diversity and identify how these factors influence parental opinions.\u003c/p\u003e \u003cp\u003eThe appropriate age for circumcision remains debated. While neonatal circumcision is favored for faster healing and fewer complications [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], circumcision under anesthesia after age six may reduce psychological trauma through anterograde amnesia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The 2\u0026ndash;6 year PS is a point of contention; some studies suggest circumcision during this period might trigger castration anxiety [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Conversely, alternative research indicates that circumcision performed during the PS does not result in significant long-term differences during adulthood compared to later procedures. Specifically, no substantial variations were observed regarding the incidence of erectile dysfunction, premature ejaculation, or depression [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, 76% of parents believed circumcision shouldn\u0026rsquo;t be performed during the PS. This widespread perception of potential psychological harm persists despite conflicting literature. Subgroup analyses were conducted to explore the factors influencing parental awareness. These analyses revealed that the location of residence, whether urban or rural, had no significant impact on opinions regarding the ideal timing of medical circumcision (p\u0026thinsp;=\u0026thinsp;0.117). This lack of disparity may be attributed to the widespread accessibility of medical information through the internet and social media platforms. Fathers aged 18\u0026ndash;29 and mothers aged 30\u0026ndash;44 showed the highest awareness of correct circumcision timing, suggesting greater knowledge among younger parents. Interestingly, prior research on the procedure didn\u0026rsquo;t significantly influence this awareness.\u003c/p\u003e \u003cp\u003eDespite high parental awareness of the appropriate circumcision age, 41% of children in our study were circumcised during the PS. The observed discrepancy between awareness and practice may stem from a demographic bias within the participant pool. Specifically, younger and more informed parents\u0026mdash;who correctly identify the non-phallic period as ideal\u0026mdash;may not have yet proceeded with the circumcision procedure, potentially leaving the retrospective question \u0026lsquo;At what age did you circumcise your child?\u0026rsquo; unanswered.\u003c/p\u003e \u003cp\u003eDebates around circumcision also focus on who should perform it, under what conditions, and how. European urology guidelines emphasize that performing circumcision in a sterile operating room reduces infection and complication rates [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The procedure should be done in a well-equipped hospital, if done in an office with local anesthesia.\u003c/p\u003e \u003cp\u003eOur results show parents essentially believe physicians should perform circumcision, aligning with current literature. Surprisingly, though rare, some parents consider non-physician healthcare personnel or \u0026lsquo;fenni s\u0026uuml;nnet\u0026ccedil;i\u0026rsquo; (traditional circumcisers) acceptable. Regarding setting, 91.7% of parents favored an operating room, 13.6% preferred a clinic, and 7% surprisingly believed a home environment was appropriate. While our findings largely align with the literature, the continued acceptance of home circumcisions in the 21st century is thought-provoking.\u003c/p\u003e \u003cp\u003eWhen performing circumcision, general anesthesia, local anesthesia, or a combination are used, with prominence varying across patient populations. Literature generally suggests LA for newborns and GA for older age groups [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], believing GA minimizes psycho-trauma through anterograde amnesia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. One study reported that circumcision did not result in severe post-traumatic stress disorder (PTSD) symptoms; however, procedures performed under GA were found to have a more negative impact on PTSD symptoms compared to those LA. Furthermore, findings indicated that baseline depression levels served as a significant predictor for subsequent PTSD symptoms. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe literature evaluates a wide range of local and regional anesthesia techniques for pain management during circumcision. Within this context, caudal block has been proven superior to both dorsal penile nerve block and subcutaneous morphine in the effective prevention of procedural pain [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In our study, 51.6% of parents preferred LA for circumcision, 31.1% preferred GA, and 9.9% favored LA\u0026thinsp;+\u0026thinsp;GA. Despite literature highlighting LA for neonatal circumcision and GA for older groups, most parents in our study still preferred LA for circumcision.\u003c/p\u003e \u003cp\u003eTraditions, customs, and religious beliefs significantly shape parental perceptions of circumcision. While both Islam and Judaism recommend circumcision, medical necessity is also a recognized justification [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In modern society, the internet and social media have emerged as prominent information sources for parents on child health, influencing perceptions across all age groups [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParents deem information from physicians to be most reliable. A recent study noted that most parents (89%) searched online for health information when their children were ill, though some (31%) followed it instead of seeing a doctor. Parents trusting their child\u0026rsquo;s doctor were more likely to follow medical advice over conflicting online information. Most parents (91%) also sought help from healthcare professionals while searching online [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In Turkey, religious beliefs are often more decisive in parental circumcision decisions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Our study similarly found parents primarily cited both religious and medical reasons for circumcision, followed by traditions, societal, and psychological factors. These findings align with national data. Conversely, medical benefits are emphasized in Western societies, with religious reasons less influential [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Consistently, many responder parents in our study (63.8%) believed \"Circumcision should be performed for medical reasons,\" aligning our results with national and global data.\u003c/p\u003e \u003cp\u003eA recent Turkish study explored perceptions and decision-making regarding circumcision among parents and medical personnel. While it addressed similar aspects to our work, our study\u0026rsquo;s 637 surveys offer greater generalizability to a larger population. That study uniquely examined grandparental influence on circumcision decisions, a factor relevant in patriarchal societies. While their study\u0026rsquo;s smaller patient cohort allowed for the inclusion of pediatrician, general practitioner, and parent perspectives (areas our study didn\u0026rsquo;t cover), our nationwide data on parental attitudes provides superior strength in assessing parental trends.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the sampling method relied solely on online distribution, which may have introduced selection bias by excluding individuals without reliable internet access or digital literacy. Second, due to its cross-sectional design, the study captures only a single time point, limiting the ability to establish causality between variables. Additionally, the survey questionnaire was not prepared using the Delphi consensus. Furthermore, despite not employing a Delphi consensus, our survey questions were developed with input from pediatric urology specialists, a preliminary step not detailed in the other study, highlighting a key strength of our approach. Also, no sensibility and validity test performed for the survey items. An additional limitation of this research is the absence of grandparental influence on the decision-making process regarding circumcision. Given the traditional family structure in Turkey, the role of elders may represent a significant factor that was not captured in the current analysis.\u003c/p\u003e \u003cp\u003eFuture research should prioritize longitudinal designs to systematically evaluate the long-term psychological and developmental impacts of circumcision performed across different age cohorts. Furthermore, achieving a more holistic understanding of decision-making dynamics necessitates the integration of perspectives from diverse stakeholders, including healthcare providers, religious leaders, and grandparents. Such an inclusive approach is particularly vital within patriarchal cultural frameworks, where familial and community hierarchies significantly influence health outcomes. Finally, further investigation is warranted to assess the burgeoning impact of digital media and internet-based resources. These platforms increasingly shape parental health-seeking behaviors and play a critical role in the contemporary decision-making processes regarding pediatric surgical interventions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCircumcision, an ancient and globally standard surgical procedure, still has debated benefits and risks. Parental approaches to this procedure are crucial and influenced by various factors. Our study shows that most parents desire circumcision for both medical and religious reasons. Findings also indicate high parental awareness regarding appropriate circumcision age, practitioner qualifications, and proper environmental settings. Despite this, some parents still believe circumcision can occur at home by unqualified individuals. Therefore, we believe that effectively using mass communication is vital to inform parents about this standard yet risky procedure and to enhance existing circumcision awareness.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAUA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Urological Association\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUTIs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUrinary tract infections\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTDs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexually transmitted diseases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEAU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEuropean Association of Urology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePhallic stage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNPC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon phallic circumcision\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLocal anesthesia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral anesthesia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePost-traumatic stress disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict Of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that there are no financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that no funding source used for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study conducted in concordance to the Declaration of Helsinki. Ethics approval from our institutional scientific committee was obtained also (Decision number:2022/215, Date: 16/09/2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm contribution to the paper as follows: Study conception and design: MK, AAA, A\u0026Ccedil;, EB, NK, MSS; data collection: \u0026nbsp;MK, A\u0026Ccedil;, EB, AAA, NK, İY, MUY, NB, AA; analysis and interpretation of results: HD, A\u0026Ccedil;; draft manuscript preparation: MK, MUY, HD, NB, NK, MSS. All authors reviewed the results and manuscript and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availibility Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets (survey response documanet) used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eArtificial Intelligence Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this work the author(s) used ChatGPT and Google Gemini for language editting and manuscript formatting. After using this tools/services, the author(s) reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. UNAIDS. 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PubMed PMID: 37139377; PubMed Central PMCID: PMC10149846.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Circumcision, male circumcision, neonatal circumcision, perception, psychotrauma, phallic stage, parental awareness, pediatric urology, Turkey","lastPublishedDoi":"10.21203/rs.3.rs-9197492/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9197492/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTo evaluate Turkish parents\u0026rsquo; perceptions and attitudes regarding the appropriate age for circumcision, practice conditions, and procedural indications across different regions of Turkey.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional survey study was conducted between March 2023 and March 2025 across urology and pediatric surgery departments in seven distinct regions of Turkey. A total of 637 literate parents (aged\u0026thinsp;\u0026ge;\u0026thinsp;18) completed a voluntary 16-question online survey via URL or QR code. Data regarding demographics, circumcision preferences, and information sources were analyzed using descriptive statistics and Chi-square tests.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe majority of parents (95.1%) considered circumcision necessary, primarily citing religious (77.7%) and medical (63.8%) reasons. Although 76% of participants believed circumcision should ideally occur outside the phallic stage (ages 2\u0026ndash;6), a significant discrepancy was observed as 41.1% of children were actually circumcised during this period. Awareness of the non-phallic stage increased significantly with higher parental education levels (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Regarding practice, specialists were preferred (pediatric surgeons 54.4%; pediatric urologists 46.3%), and the operating room was identified as the safest setting by 91.7% of responders. Local anesthesia was the most selected method (51.6%).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDespite a high general awareness of specialist qualifications and appropriate age ranges, a clear gap exists between parental knowledge and actual practice, particularly regarding the phallic stage. Enhancing clinical guidance and utilizing mass communication effectively are essential to ensure circumcisions are performed under appropriate conditions and to minimize potential psychological trauma.\u003c/p\u003e","manuscriptTitle":"Awareness of Parents About Circumcision: Turkey Data Survey Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-07 10:18:12","doi":"10.21203/rs.3.rs-9197492/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-06T08:39:46+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2026-04-04T12:01:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-04T11:32:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-04T09:54:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337590650623895391364989321664592891412","date":"2026-04-04T09:34:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"72994714604342474010088718309816896494","date":"2026-04-04T08:13:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323953902711912832960096679055059328805","date":"2026-04-03T20:01:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65762615279741433093403956598683206821","date":"2026-04-03T13:16:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"230255294178551767169181505328744280938","date":"2026-04-02T16:33:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48274639396964994538705101469318289351","date":"2026-04-02T09:15:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T08:04:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317377377849845197459313803967090255754","date":"2026-04-01T14:29:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315842465080426094846268359352699449578","date":"2026-04-01T14:13:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68575027843058666440917012463455834525","date":"2026-04-01T10:54:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"206224056152884754528965923581023023376","date":"2026-04-01T09:10:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-01T08:39:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-24T08:01:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-24T07:43:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-24T07:43:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2026-03-23T08:06:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bc1c990f-64c4-41d2-a3db-d96a46c2fd33","owner":[],"postedDate":"April 7th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T17:10:15+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-07 10:18:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9197492","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9197492","identity":"rs-9197492","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}