Declining Circumcision Rates in U.S. Raise Disease Risk

Infant boys in the U.S. are less likely to get circumcised now than in years past, a trend that leaves them vulnerable to sexually transmitted infections and may add billions of dollars to health-care costs, Johns Hopkins University researchers said.

About 55 percent of the 2 million males born each year in America are circumcised, a decrease from 79 percent in the 1980s, according to the report in the Archives of Pediatrics & Adolescent Medicine. The procedure, which removes the foreskin from the tip of the penis where bacteria and viruses accumulate, is linked to fewer cases of HIV, herpes, genital warts and genital cancers among men and their sexual partners.

Circumcision has gathered support from groups such as the Bill & Melinda Gates Foundation for use in Africa and other areas of the world where HIV is widespread as public health officials consider it one of the most effective ways to curb infection. It has gotten less attention in the U.S., where 18 state Medicare programs for the poor dropped coverage of the procedure and private insurers have followed, researchers said.

“If there were a vaccine that reduced HIV infection, genital herpes and warts, penile cancer, cervical cancer and bacterial vaginosis, it would be promoted as a game changing intervention, and all physicians would encourage their patients to get it,” said Aaron Tobian, a health epidemiologist and pathologist at Johns Hopkins and senior researcher on the study. “The difference is this is a surgery with very minor complications, and it also has a cultural tone to it.”

Health Costs

The lack of protection may boost U.S. health-care costs by $4.4 billion if rates plunge in the next decade to levels seen in Europe, where 10 percent of boys are circumcised, according to the analysis by health economists at Johns Hopkins. Each time a circumcision is avoided, $313 is added in direct illness-related expenses, after taking into account the cost of the procedure, Tobian said in a telephone interview.

“All state Medicaid and private insurers should cover male circumcision and we should eliminate all of the current barriers,” he said. “Families should discuss the risks and benefits of the procedure with their physicians and decide what is best for them.”

Tobian criticized the American Academy of Pediatrics, which is reviewing its policy position on infant male circumcision. The academy doesn’t recognize any of the health benefits linked to the procedure, despite overwhelming evidence, he said.

Reduces Burden

“Documentation that male circumcision not only reduces the burden of sexually transmitted infections for both men and women, but also reduces lifetime treatment costs should provide compelling arguments in favor of infant male circumcision,” Arleen A. Leibowitz and Katherine Desmond from the University of California, Los Angeles’ Center for HIV Identification, Prevention and Treatment Services, wrote in an editorial accompanying the study.

Medicaid plans cover two-fifths of all 4 million births each year in the U.S. If they were all to drop coverage of circumcision, just one in three newborn males would get the procedure, according to projections from an earlier study, they wrote. Eliminating coverage creates health disparities that will remain with disadvantaged children into adulthood, they said.

Medicaid is the joint federal-state government health program for the poor.

“States’ efforts to reduce current costs by eliminating Medicaid coverage for male circumcision are penny-wise and pound foolish,” they said. “Investing today in a relatively low-cost procedure will avert greater future treatment costs for cancer, HIV, and other STIs,” they wrote, calling on the federal government to reclassify the procedure as a mandatory service.

“Indeed, the groups that Medicaid covers are precisely those that experience the greatest prevalence of HIV and other STIs, which male circumcision can effectively avert,” Leibowitz and Desmond wrote.

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