Trust in Internet medical information (OR = 6.054, p = 0.047): parents who exhibited greater trust in internet acquired medical information were significantly more likely to undergo surgery. This finding suggests the substantial influence of online health information dissemination, both in terms of content and delivery on parental decision making.

Long term exposure to recommended surgical content (OR = 7.500, p = 0.015): Parental acceptance of circumcision increased significantly with long term exposure to content about the necessity of surgery (e.g., short video recommendations, parental experience sharing, etc.) on social media or search engines (Table 1). This result reflects the critical role of frequency of information exposure in decision making, especially in the context of algorithmic recommendation mechanisms in social media, where parents are prone to develop an “information echo chamber effect”.

Concerns about surgical risks (OR = 0.239, p = 0.044): parents with high perceptions of surgical complications (e.g., scarring, bleeding, infection, insufficient foreskin, etc.) had a significantly lower probability of choosing surgery. This finding suggests that perceived surgical risk serves as a strong deterrent in parental decision-making, and that the way risks are presented in different information channels may influence parental attitudes (Table 1).

Baidu/Academic Database: The content on these platforms is primarily based on medical research and professional guidelines, emphasizing the indications for surgery and postoperative risks (3). Parents searching for information from such sources are usually more inclined to make rational decisions and consider the necessity of surgery.

Co-word analysis is one of the most important tools to reveal research hotspots. By analyzing keywords, abstracts and other citation-related data, a visual knowledge map is generated. In this study, a total of 285 high-frequency keywords were extracted, forming 390 connecting lines. The keyword co-occurrence map (Figures 3, 4) shows that “circumcision” is the most dominant node, followed by “phimosis” and “prepuce.” The thickness and density of the connecting lines indicate the strength of keyword co-occurrence, reflecting the degree of association between different keywords. Early studies focused on techniques such as circumcision, clamping, and CO₂ laser, while recent studies have explored new areas such as day surgery, comprehensive perioperative care, and combined anesthesia. This suggests that future research may increasingly focus on the comprehensive therapeutic efficacy of the procedure and postoperative care.

Keyword cluster analysis provides an intuitive reflection of research hotspots. Based on Cite Space software and the LLR (Log Likelihood Ratio) algorithm, we conducted a cluster analysis of keyword co-occurrence, and the results show that research in this field is predominantly focused on “circumcision”, “nursing” and “circumcision.” The clustering map (Figure 4) shows a network density of 0.0096 and a modularity value (Q) of 0.7921, indicating a strong clustering effect. Besides, the average silhouette value (S) is 0.9412, indicating high homogeneity among the clusters. The top five clusters have an average publication year range from 2010 to 2013, indicating that the topics covered in this period have matured. The largest cluster, “circumcision,” contains 42 keywords, mainly related to circumcision, phimosis, phimosis, psychological care, and the use of compound lidocaine cream (Table 2).

Xiaohongshu, a social media focusing on life experience sharing, exhibits significant user engagement in circumcision-related discussions. These discussions, primarily within parents’ groups, cover a broad range of topics through first-level and second-level comments. Users raised a variety of questions and opinions, covering different stages from childhood to adulthood, including the necessity of surgery, the timing of the operation, and post-surgery recovery. A large number of users shared their personal experiences and opinions through comments and replies. This interaction not only increases the popularity of the post but also creates a small community about circumcision. Since parents often play a leading role in making decisions about children’s health, we hypothesized that the experiences they shared on this platform could provide insights to other parents in informed decision-making.

In this study, the top ten posts related to circumcision on the Xiaohongshu platform were selected as the research objects. The study mainly focuses on the physiological effects (sensitivity, hardness), aesthetic effects, and the credibility of medical information provided to parents. Among them, the post with the highest engagement stands out: it received 14,000 comments, 91,000 likes, 137,000 shares, and 33,000 favorites, which indicates significant social attention and influence within the young parent community. The data collection system was constructed using the Python programming language, and structured data from the comment section was obtained by reverse parsing the encrypted parameters of the platform through Node.js. Sentiment analysis was performed using the SnowNLP module to establish the following classification criteria:

Negative Sentiment: (0, 0.5), Neutral Sentiment: = 0.5, Positive Sentiment: (0.5, 1).

During the data cleaning process, emoticons, irrelevant characters, and off-topic content (e.g., “What’s a circumcision ring?” “What do I do?” etc.) were excluded. A total of 7112 valid primary and secondary comments were obtained.

Medical risks are one of the most immediate concerns for parents, mainly including surgical complications and anesthesia risks. Although modern surgical techniques have significantly reduced the risks related to circumcision, parents may still be concerned about possible side effects of the procedure.

Common postoperative complications include infection, bleeding, postoperative pain, scarring, and urethral stricture (1). Although this surgery is usually considered a low-risk surgery, some parents remain cautious due to possible postoperative recovery issues.

Anesthesia, whether general or local, may trigger allergic reactions, respiratory depression, and other adverse effects (4). Although such risks are extremely rare, parental concerns about anesthesia safety may influence their decision to refuse surgery.

Socioeconomic status plays an important role in medical decision-making, and the cost and recovery period of circumcision may pose a greater challenge for low-income families.

Financial burden: Although Medicare-covered surgery is available in public hospitals in some areas, surgery costs can be significantly higher in the private sector, especially for elective surgeries (3). As a result, low-income families may be hesitant about surgery.

Time investment: The recovery from surgery usually takes days to weeks, which may disrupt a child’s schooling or the family’s daily routines. Parents need to weigh the short-term inconvenience of recovery against the potential long-term health benefits of the procedure.

Parents’ perception of risk and the way they receive information may lead to an overestimation of the necessity for surgery and an underestimation of the likelihood of natural remission of a physiologic prepuce. This bias is closely related to the sociocultural tendency toward “preventive medicine”.

Risk magnification effect: Some parents believe that not undergoing circumcision may lead to urinary tract infections, reproductive health issues, and other complications. However, under normal circumstances, the foreskin covering the glans does not pose significant health risks (3).

Herd mentality: Parents may be influenced by others to adopt the belief that “the majority choice of surgery is the right choice,” a socially normative perception that may undermine rational decision-making.

Parents’ decision to opt for unnecessary surgical procedures can be understood through behavioral science theories. On one hand, this phenomenon relates to cognitive biases (5), while medical decisions should ideally be based on an accurate understanding of potential risks, parental risk perception is often distorted by cognitive biases and irrelevant information (6). On the other hand, the principle of risk aversion suggests that when confronted with uncertain future outcomes, parents may prefer to accept a certain, immediate cost (e.g., the surgery) to avoid a perceived, larger future risk (e.g., reproductive health issues) (7). Social media content may exploit this psychological tendency by amplifying the perceived risks associated with not undergoing circumcision, thereby aligning the choice of surgery with parents’ protective instincts.

The platform’s recommendation algorithm favors content with high interaction rates, leading to the dominance of specific views in the information stream. This study found that pro-surgery comments on the Xiaohongshu platform were more frequently exposed than opposing views. The interactivity of posts amplifies the effect, as the sharing of surgical experiences and before-and-after comparison photos holds stronger visual appeal and emotional resonance, making them more likely to be liked and shared.

As a result, the information becomes skewed, and platform algorithms may inadvertently amplify particular points of view, exposing users to more homogenous information and overshadowing more objective medical advice.

When parents view relevant content on social media, they are more likely to join discussion groups that share similar views, leading to a polarization of group opinions. This phenomenon, known as the “opinion vortex,” is particularly evident on social media platforms such as Xiaohongshu. The pro-surgery group is more active, with more than half of the popular posts analyzed in this study being pro-surgery. This is nearly 30% higher than the percentage of surgery recommendations outlined in medical guidelines. While negative comments about surgery account for around 28% of the responses, they have a relatively low reach and interaction, weakening their influence on parental decision-making.

The study found that when parents search for circumcision information on social media, the algorithm tends to push similar content, creating an “information cocoon” phenomenon. As the algorithm continues to push content aligned with their initial perceptions, parents are less likely to encounter contrary viewpoints. Longer exposure to a single perspective can strengthen their decision-making stance and amplify cognitive biases, even when these views diverge from professional medical guidelines (8).

Health-care organizations have partnered with popular science bloggers to popularize the necessity of surgery through short videos and social media, integrating surgery into the concept of “scientific legitimacy.” Surgery videos posted by doctor accounts on platforms such as Shakeology are often highly credible, making parents more receptive to surgical recommendations.

Commercialized platforms, such as Baidu’s bidding rankings, may prioritize content from healthcare providers with a profit-making agenda, which can lead to the overgeneralization of the procedure’s indications. Some hospitals exaggerate the necessity of circumcision in their marketing, leading parents to perceive it as a necessary medical practice (9).

This study found that 78% of the parents interviewed stated they “follow the advice of Netflix doctors,” reflecting how individual decision-making is gradually being hostage to systemic discourse in the age of social media. This phenomenon shows a profound change in power relations in the dissemination of medical knowledge in the Internet era.

Labeling of sources: Social media platforms should be required to label medical content with sources, such as “certified by a tertiary hospital” or “recommended by an authoritative medical guide,” to increase the credibility of the information. Drawing on (10) approach to HIV popularization, this measure would help reduce misleading labels for non-professional users and limit the sharing of non-professional experiences.

Providers can introduce visualization tools (e.g., risk/benefit comparison modules for surgery) and develop decision aids to help parents make more scientific decisions (2).

It is crucial to strengthen the regulation of misleading information by including misleading medical propaganda under the scope of penalties outlined in the Advertising Law, and adhere to the strict indication criteria for male circumcision as recommended by the WHO (4).

This study reveals two central paradoxes in the decision-making process of Chinese parents regarding circumcision for their children aged 6–12 years: (1) information overload is inversely related to the quality of decision-making. Although the Internet provides unprecedented access to medical information, algorithmic recommendation mechanisms (e.g., likes and dislikes, personalized tweets) led parents to rely more on lay sources (e.g., social media experience sharing) than on clinical guidelines. This “visibility bias” increases the exposure of emotional and polarizing content, creating an information cocoon that ultimately undermines rational decision-making. Despite the vast amount of information available, parents found themselves in the paradox of “the more they searched, the more anxious they became” due to cognitive biases (e.g., confirmation bias, herd effect), and the quality of their decision-making did not improve with the amount of information; and (2) there is a conflict between medical norms and social discourse. International clinical guidelines generally recommend conservative treatment for physiological prepuce (1), but online narratives - through short videos and user comments - have framed the surgery as a “standard of scientific parenting” and even positioned it as a preventive health measure. This discursive power permeates through the media platforms, allowing parents to view surgery as a ‘necessary option’ rather than one based on individual medical assessment. A Foucaultian analysis of power shows that capital-driven medical marketing, algorithmic recommendation mechanisms, and parental risk aversion reinforce this trend.

The novelty of this study lies in its interdisciplinary integration of medical science and communication studies, demonstrating how digital media ecosystems directly influence decision-making regarding a specific pediatric surgical procedure in China. This research provides a critical theoretical foundation for enhancing the quality of online health information and fostering a more authoritative medical communication environment.

This study has several limitations. Most notably, the generalizability of the quantitative findings from the parent questionnaire is limited by the relatively small sample size. Although the mixed-methods approach provides rich contextual insights, the statistical power of the regression models is constrained. Consequently, the identified risk factors should be regarded as preliminary hypotheses, necessitating future large-scale, multi-center, and nationally representative surveys to validate these associations and establish more stable effect estimates. Secondly, the cross-sectional survey design employed in this study, while capable of revealing associations between factors, cannot establish the direction of causality. Therefore, future research should focus on three points: (1) Policy intervention: establish a quality certification system for online medical popularization, limit the dissemination of misleading content, and encourage authoritative organizations (e.g., pediatric medical societies) to engage with social platforms to implement the strategy of “replacing authoritative sources”; (2) Clinical practice: strengthen doctor-patient communication and correct parents’ perceptions through decision-making tools (e.g., visualization charts); (3) Expansion of the study: this study’s limitations, particularly its reliance on single-center data, call for future research that incorporates urban-rural and economic stratification and tracks the long-term effects of policy interventions. The absence of publicly available, systematic national statistics on circumcision rates in China underscores the critical need to establish such databases to facilitate more robust epidemiological surveillance and evidence-based policy formulation.