The U.S. government is justifiably proud of its leadership abroad funding male circumcision as a way to prevent HIV infections. The president’s AIDS relief program boasts of having provided more than 1 million circumcisions in 14 African countries.
The record of government support for male circumcision within the U.S., however, is nothing to crow about. More and more states (18 so far) are dropping Medicaid coverage for routine infant male circumcision, contributing to a decline in rates from 79 percent throughout the 1970s to 55 percent in 2010. This has occurred even as evidence of the medical benefits of the procedure has stacked up.
The Medicaid cutbacks are driven by budget pressure, which has also caused some private insurers to stop coverage. These are penny-wise, pound-foolish decisions. In an analysis published Monday, researchers at the Johns Hopkins University School of Medicine conclude that every infant circumcision that is not performed results in $313 in extra health care expenses even after accounting for the procedure’s cost of about $291.
This is a conservative figure that does not include the cost of procedures for the 10 percent to 15 percent of men who, uncircumcised as babies, will require the surgery later in life, at greater cost, for medical conditions such as phimosis, a tightening of the foreskin that can close the opening of the penis. The risks of complications are about seven times greater for adult than infant circumcisions.
Male circumcision is an ancient practice that appeared independently in a number of disparate cultures. Only in recent decades have its medical benefits been known. It has been established for years that circumcising baby boys reduces their incidence of urinary tract infections when they are infants. Evidence was strong that the practice protected against penile cancer.
More recently, three randomized controlled trials in Africa demonstrated that circumcision reduces a man’s chances of becoming infected with HIV, herpes and human papillomavirus (HPV), which causes penile cancer in men. In one study, female partners of circumcised men had a lower risk of HPV, which causes cervical cancer in women, and two other sexually transmitted diseases.
Activists opposed to circumcision argue that it constitutes mutilation. They had a point when the procedure served only ritualistic purposes. The evidence is overwhelming now, however, that the surgery has medical benefits, making it not so different from removal of a worrisome mole.
Opponents also claim circumcision reduces sexual function and satisfaction. Until the trials in Africa, in which mature boys and men were circumcised, no one had tested that proposition scientifically. In the Kenyan trial, 64 percent of the circumcised men reported their penis was “much more sensitive” and 54 percent said they had a “much” easier time achieving orgasm. In the Ugandan trial, 57 percent of female partners of circumcised men reported no change in sexual satisfaction and 40 percent reported an improvement.
Of course, parents should not be coerced to circumcise their sons, but the procedure should at least be covered by insurance, including Medicaid, which pays for a third of circumcisions done in U.S. hospitals. When a procedure isn’t covered, a layperson will often assume there’s no medical benefit and forgo it. Federal Medicaid regulations should be amended to include infant circumcision among the services state plans must cover.
Physicians should also encourage infant circumcision. The American Academy of Pediatrics, which is reconsidering its position, could play a positive role. The group recommended against circumcision in 1971 because of a lack of sufficient evidence of benefit at the time. As that research began to emerge, the group in 1999 adopted a position of neither support nor discouragement, which it reaffirmed in 2005. Since then, the data have clearly made the case for support. The academy needs to update its stand accordingly.
