A few weeks after my first daughter was born, I talked to my childhood best friend who was pregnant with her second child and had just found out that she was having a boy. I passed on a tidbit I had learned when I was pregnant; you should have your obstetrician circumcise your baby instead of your pediatrician because the OB is trained a surgeon.
She surprised me by telling me that she was not planning on circumcising her son at all. I wasn’t opposed to that decision, it had just never occurred to me as an option. As a Jewish mother-to-be residing in New York City, everyone, including me, had assumed that if my child were male he would be circumcised and I guess I carried that assumption to my friend even though she was not Jewish and was living in California at the time.
When I was born in the 1970s my assumption would have been a safe one but today there is a major debate raging across the globe over the practice of male circumcision. While public health professionals argue that it has important health benefits and certain religions still require it, a vocal anti-circumcision movement calls the practice cosmetic at best, barbaric at worst, and seeks to outlaw it.
The majority of male infants (80 percent) born in the United States were circumcised as recently as the 1980s, these numbers, however, have been steadily declining in the past couple of decades to just 55 percent in 2010. In Europe, the practice has fallen almost completely out of favor with just 10 percent of male infants circumcised at birth.
This week, the American Academy of Pediatrics (AAP) weighed in on the debate with an opinion that shows strong support for the procedure but stops short of calling for routine circumcision.
How the Guidelines Changed
When the AAP last took on this issue in 1999, it concluded that there were “potential health benefits” but that the scientific research was not sufficient to recommend routine circumcision. It went on to take what could best be called a standoffish stance when it said:
“As in any circumstance in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child.”
The tone of the new opinion suggests more support for the procedure and it has been called a step toward endorsement by some experts. The new statement says:
“Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it.”
This increase in support appears to come from a review of recent research; a 23-page technical report was released along with the policy. The report looked at a number of studies conducted between 1995 and 2010 which found that potential health benefits of circumcision include preventing urinary tract infections, HIV, and penile cancer. Some studies found that circumcision can also prevent the transmission of certain sexually transmitted infections, including the human papillomavirus and genital herpes.
There has been a great deal of research in Africa suggesting that circumcision of adult men can reduce the risk of heterosexually transmitted HIV in men by approximately 60 percent. As a result of this research, the World Health Association (WHO) recommends:
“efficacious intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV, and low male circumcision prevalence.”
A CDC spokesman points out, however, that it’s difficult to predict the impact of male circumcision on the HIV rates in the United States because the current circumcision rates are higher than in the areas studied, the epidemic is different, and there is still a lot we don’t know about the effect of circumcision on male-to-male transmission of HIV.
While the relationship of circumcision and HIV has gotten a lot of attention worldwide, a number of additional studies have suggested other potential health benefits. A 2011 study presented at the American Urological Association meeting, for example, found that the foreskin of uncircumcised males can be a reservoir for HPV. This year, researchers released another study that found that men who are circumcised before they first have sex have lower rates of prostate cancer than those who are uncircumcised or have the procedure after they’ve already been sexually active.
The technical report released along with the opinion also says that the risks are quite low. In fact, major complications from circumcision, including death were “so infrequent” that the academy excluded them from the review. Two hospital-based studies found that the most common risks from circumcision were “bleeding, infection and penile injury.” The report concluded that when done by trained professionals in a sterile environment the procedure is generally well-tolerated by infants (though the opinion does suggests that even infants need more pain management that the sugar-coated pacifier that is standard in some places). The report also noted that the procedure has more risk when done on older men.
Unlikely to Sway Parents
Whether or not a baby is circumcised in this country varies widely across religions, ethnic groups, and geographic regions. Jewish and Muslim children are usually circumcised, Hispanic parents are far less likely to circumcise their children than white or black parents, circumcision is more common in rural and suburban areas than in metropolitan cities, and 75 percent of boys born in the Midwest in 2009 were circumcised compared to just 25 percent in the West. Differences between states are striking–-89 percent of boys born in Michigan in 2009 were circumcised compared to just 15 percent in Washington state–-yet state health officials are unable to completely explain the differences. The most telling determinant may actually be whether the father is circumcised; a Denver study found that 90 percent of males who were circumcised chose to circumcise their sons compared to just 23 percent who were uncircumcised.
Like the previous opinion, this new version says the decision should ultimately be up to the parents. Dr. Marvin Wang, director of newborn nurseries at Mass General Hospital for Children, explains it this way:
“This new policy still puts the decision-making in parents’ hands. But what the AAP says now is, ‘We have enough to say that you can make the decision based on religion, cultural and family issues. But guess what? You can now throw health in as a reason for doing it if you want to.’”
Wang, however, does not expect that the committee will sway many parents’ decision. In 2010, he released the results of a study he conducted in which parents of newborn males were shown both the AAP’s 1999 opinion and summaries of new research on HIV/HPV and circumcision. Neither made much of an impact on what parents chose to do. As Wang put it:
“Nothing was going to change their mind. What they come into it with is what they go out of it with.”
Paying for the Procedure
Where this new opinion may make a big difference, however, is with insurers. As Douglas Diekema, a member of the AAP’s circumcision task force, explains:
“… it recognizes that there are clear medical benefits that outweigh the risks of the procedure, and that those benefits are sufficient to justify coverage by insurance.”
According to the CDC, the procedure costs between $200 and 600 dollars and coverage varies widely among private insurers. Moreover, at least 18 state Medicaid programs have recently stopped covering it.
Arizona, for example, stopped paying for the procedure in 2002 apparently as part of an effort to trim one billion dollars from the budget. (Cutting circumcision saved the state 400,000 dollars a year.) The year before this change was made, 41 percent of male infants in the state were circumcised, two years later that number was down to 21 percent. Indeed, coverage for the procedure seems to be a strong predictor of whether or not parents choose it; according to a report by the Health & Human Services Department’s Healthcare Cost & Utilization Project, circumcision rates are 24 percent higher in states where Medicaid covers the procedure.
A new study, published in this month’s Archives of Pediatric and Adolescent Medicine, suggests changes to coverage like the one Arizona made may be short-sighted when it comes to saving money. The study was conducted by public health experts and economists at Johns Hopkins University School of Medicine and found that if circumcision rates in the United States were to fall to the same levels as in Europe, we could face more than four billion dollars in increased health care costs over a decade to pay for treatment of urinary tract infections, syphilis, herpes, penile cancer, and HIV.
Probably Not the Last Word
As always when I write about this topic, I feel it necessary to say that my great-grandfather, Abraham Ravich, wrote about many of the same health benefits noted in the technical report in his book Preventing V.D. and Cancer through Circumcision. The book, which was published in 1974, was based on his experiences as a urologist in primarily Jewish neighborhoods in Brooklyn from the 1930s, 40s, and 50s. Having mentioned him before, though, I know that Poppy Abe was considered by many to be a zealot and that there is a very vocal community who still do not believe these health benefits.
In advance of the statement’s release, Georganne Chapin, founding executive director of the anti-circumcision advocacy group Intact America accused the AAP committee of “scientific blindness.” She said of the committee:
“They also appear to be totally ignoring the fact that their European colleagues are not only unimpressed by the supposed ‘benefits’ of cutting up baby boys’ penises but are actually considering whether child circumcision should be banned on the basis that it violates children’s rights.”
Ronald Goldman, the head of another opposition group, expands on these complaints saying that studies show circumcision causes loss of sexual satisfaction and can be psychologically harmful but the AAP says the research does not support these claims. Both Goldman and Chapin call the new statement “out of step” with what is going on in the rest of the world where many are calling for a complete ban on the procedure.
In Germany, for example, a regional court ruled in June that circumcision amounts to “irreversible interference in the integrity of the human body” because the procedure is performed on non-consenting minors who cannot object. (Jewish and Muslim leaders are protesting this verdict.) This decision was spurred by the case of a four-year-old Muslim boy who suffered a great loss of blood as a result of a botched circumcision. According to the Jewish Daily Forward, this case has led to debates about the ethics of what many see as an unnecessary procedure not just in Germany but in Switzerland, Austria, Denmark, and Norway. In fact, the move to ban circumcision entirely recently came to the United States when both San Francisco and Santa Monica entertained the possibility of ballot initiatives to prevent the practice within city limits.
Such bans, however, instantly raise questions of religious freedom, and some have gone as far as to call them anti-Semitic and liken them to bans on circumcision that existed in Soviet-era Russia and Eastern Europe and in ancient Roman and Greek times. Moreover, bans seem to fly in the face of mounting public health evidence about the potential value of circumcision. California’s governor, Jerry Brown, agreed signing legislation in October 2011 that makes such bans illegal in his state and effectively killed the two that had been proposed.
The AAP’s new opinion is not quite that decisive. Even its co-author says the opinion should not be considered the “verdict from on high” and that everyone needs to decide for themselves. Still he adds, “but from a medical standpoint, circumcision’s benefits in reducing risk of disease outweigh its small risks.”
In the 30 years since Poppy Abe died, public opinion and professional opinions on this topic have swung back and forth many times. While I doubt this newest statement from the AAP will cement it in either direction, I do believe my great-grandfather would consider it a step in the right direction.