Circumcision policy should be revisited, according to commentary in JAMA

October 13, 2011

At a time when 18 states are seeking to eliminate Medicaid coverage for circumcision of newborn males and at least 1 city sought to ban the practice, an editorial published in a leading medical journal says that such efforts are wrongheaded and that more should be done to promote the procedure. The authors maintain that hundreds of studies in the last 5 years document the benefits of circumcision. What did those studies find, and should neutral pediatric guidelines be changed?

At a time when 18 states are seeking to eliminate Medicaid coverage for circumcision of newborn males, commentary in the Journal of the American Medical Association says that such efforts are wrongheaded and that more should be done to promote the procedure because of its documented health benefits.

Noting that “evidence for the long-term public health benefits of male circumcision has increased substantially during the past 5 years,” health epidemiologist and pathologist Aaron Tobian, MD, PhD, and health epidemiologist Ronald Gray, MD, MSc, both of Johns Hopkins University, argue that the American Academy of Pediatrics (AAP) and the national Centers for Disease Control and Prevention (CDC) should revisit their essentially neutral policies and do more to inform parents and physicians about circumcision’s value.

In addition to state Medicaid actions, an attempt recently was made to ban circumcision in the city of San Francisco, but a federal judge blocked the ballot initiative, saying that power lies with the state, not municipalities. Groups representing Jews and Muslims, for whom circumcision is a religious tradition, also opposed the initiative on First Amendment grounds.

“If a vaccine were available that reduced HIV risk by 60%, genital herpes risk by 30%, and HR-HPV risk by 35%, the medical community would rally behind the immunization and it would be promoted as a game-changing public health intervention,” Tobian and Gray write, saying that depriving parents of that information is “ethically questionable.”

Denying Medicaid coverage for circumcision creates the greatest disadvantage to minorities and the poor, where sexually transmitted infection rates are often the highest, the commentary states. The CDC reported recently that circumcision rates have dropped between 5% and 6% from 2001 to 2008.

Hospitals in states where Medicaid covers routine male circumcision have rates 24% higher than hospitals in states without such coverage. Even before this year, 17 states did not provide full Medicaid coverage for the procedure.

Opponents of circumcision call it “male genital mutilation” and argue that, at the very least, the procedure should not be performed until males can give legal informed consent at age 18.

Tobian and Gray, however, say that the procedure has lifelong benefits-such as reducing the risk of urinary tract infections and inflammation in the head region of the penis-as well as benefits once men become sexually active, including a lessened risk of infection from sexually transmitted disease. Furthermore, they say, circumcision in adults creates more complications and is much more costly than performing the procedure in infants. Risk of infection is between 0.2% and 0.6% in infants but between 1.5% and 3.8% in adults, according to the authors.

In addition, they state, parents have long-held rights and responsibilities to make decisions to ensure their children’s health, including vaccinating them against illnesses such as the human papillomavirus (HPV), measles, polio, pertussis, and influenza.

“Our goal is to encourage all parents to make fully informed decisions on whether to circumcise their infant boys based on medical evidence and not conjecture or misinformation put out by anti-circumcision advocates,” Tobian said.

The commentary states that the benefits of circumcision have been found in more than 500 studies. Those studies found that, in heterosexual men, circumcision reduces HIV infection risk by 60%; genital herpes by 30%; and HPV, which can cause cancer, by 35%.

Women who have sex with circumcised men have a 40% or greater reduced risk of bacterial vaginosis or parasitic trichomonas spread during sex, as well as HPV infection, according to the commentary.

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