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INTRODUCTION: In 2012, the American Academy of Pediatrics (AAP) guidelines on newborn circumcision stated that although health benefits outweigh risks, the final decision lies with parents in the context of their beliefs. The internet has become an increasingly popular source of healthcare information. Using the DISCERN Plus scale, a validated research tool to judge the quality of medical information online, we analyzed circumcision websites to evaluate their overall quality, detail, accuracy, and bias. Separate analyses were completed for English and Spanish websites to see if a cultural bias existed online. To our knowledge this is the first such analysis of the quality of online information regarding newborn circumcision.
METHODS: In April 2013, we queried both English and Spanish versions of Google, Yahoo!, and Bing with several commonly searched terms related to newborn circumcision. We gathered 214 unique websites listed in the first 2 pages of each search engine’s results, representing over 98% of web-traffic involving those search terms. Two raters analyzed each site utilizing the DISCERN Plus scale for content quality as well as additional study-specific criteria.
RESULTS: We analyzed 214 websites (141 English, 73 Spanish). Interclass correlation coefficient was 0.77, showing excellent agreement between raters. Out of a maximum 75 points, the mean DISCERN score for English and Spanish websites was 50.8 and 52.9, respectively, indicating decent content quality independent of language (p=0.24). Most sites took a neutral position regarding circumcision (53.9% and 58.9% in English and Spanish respectively), with a smaller subset biased against (28.4% and 26.0%) and even smaller toward (17.7% and 15.1%) the procedure. Language did not influence the type and amount of bias (p=0.77). Blogs and personal websites were more likely against circumcision, commercial sites largely for them, and academic websites mostly neutral (p<0.01). Commercial sites and blogs or forum sites were least likely to cite AAP guidelines (p=<0.01). Spanish sites were more likely to give a “good” or “excellent” description of the circumcision procedure than English sites (56% vs. 41%, p=0.04), but were less likely to clearly cite references (33% vs. 65%, p<0.01). While most sites in both languages described risks of circumcision, Spanish sites were more likely to describe the benefits (66% vs. 48%, p=0.02). Regardless of language only 21% of sites mentioned the updated AAP guidelines. Surprisingly the American Urological Association’s (AUA) policy statement on circumcision did not appear in the top results. When searched for specifically, the link to the AUA guidelines did not work.
CONCLUSIONS: Information on the Internet regarding newborn circumcision is of decent quality, but has different characteristics in English and Spanish. The varying types of information conveyed in the different languages may reflect a cultural bias, which may explain the disparate rates of circumcision between different races in the US. The AAP circumcision guidelines were referenced by a minority (20%) of webpages websites. The AUA guidelines were not even part of the top results. The AUA should have a more active role in providing accurate and comprehensive online information to parents regarding circumcision.