Los Angeles Times
August 21, 2012
As circumcision declines, health costs will go up, study projects
By Eryn Brown
A team of researchers estimates that every procedure not
performed could lead to significant increases in lifetime medical
expenses because of STDs.
Declining rates of circumcision among infants will translate into
billions of dollars of unnecessary medical costs in the U.S. as these
boys grow up and become sexually active men, researchers at Johns
Hopkins University warned.
In a study published Monday in the Archives of Pediatric and
Adolescent Medicine, a team of economists and epidemiologists estimated
that every circumcision not performed would lead to significant
increases in lifetime medical expenses to treat sexually transmitted
diseases and related cancers — increases that far surpass the costs
associated with the procedure.
Circumcision is a hotly debated and emotional issue in the U.S.,
where rates have been falling for decades. In the 1970s and 1980s, about
80% of baby boys were routinely circumcised in hospitals or during
religious ceremonies; by 2010, that figure had dropped below 55%,
according to the Centers for Disease Control and Prevention.
Some of that decline is due to shifting attitudes among parents, but
at least part of it can be traced to the decision by many states to
eliminate Medicaid coverage for the procedure in order to save costs.
Today 18 states, including California, do not provide Medicaid coverage
for the procedure, which is considered cosmetic by many physicians.
But in the last decade, studies have increasingly shown that removing
the foreskin of the penis has significant health benefits, said Dr.
Aaron Tobian, senior author of the new study.
Three randomized trials in Africa have demonstrated that circumcision
was associated with a reduced risk of contracting HIV, human
papillomavirus and herpes simplex in men. One of those studies
documented a reduced risk of HPV, bacterial vaginosis and trichomoniasis
in the female partners of men who were circumcised.
Circumcision is believed to prevent STDs by depriving pathogens of a
moist environment where they can thrive. The inner foreskin has been
shown to be highly susceptible to HIV in particular because it contains
large numbers of Langerhans cells, a target for the virus.
Tobian and his colleagues developed a computer-based simulation to
estimate whether declining circumcision rates would lead to more STDs
and thus higher medical costs.
If circumcision rates remained about 50% instead of the higher rates
of years past, the lifetime healthcare costs for all of the babies born
in a single year would probably rise by $211 million, the team
[This has not been the experience of
the rest of the developed world, such as the English-speaking world,
where the experiment of mass circumcision was tried and abandoned.]
If circumcision rates were to fall to 10% — which is typical in
countries where insurance does not cover the procedure — lifetime health
costs for all the babies born in a year would go up by $505 million.
That works out to $313 in added costs for every circumcision that
doesn't happen, the report said.
In this scenario, nearly 80% of the additional projected costs were
because of medical care associated with HIV infection in men, the team
The model includes only direct medical costs such as treatment for
penile and cervical cancer, which are associated with HPV infection. It
doesn't consider nonmedical or indirect costs, such as transportation to
doctors' appointments or lost income.
[Nor does it include costs for revision surgery or other sequelae of botched circumcisions.]
To Tobian, the message is clear: Government efforts to save money by
denying coverage for circumcision are penny-wise but pound-foolish.
"The federal Medicaid program should reclassify circumcision from an optional service to one all states should cover
," he said.
[So much for states' rights.]
That sentiment was echoed in an editorial accompanying the study.
UCLA health economist Arleen Leibowitz wrote that by failing to require
states to cover circumcision in Medicaid plans, the U.S. reinforces
"If we don't give poor parents the opportunity to make this choice,
we're discriminating against their health in the future," she said in an
interview. "If something is better for health and saves money, why
shouldn't we do it? Or at least, why shouldn't we allow parents the
option to choose it?"
Ellen Meara, a researcher at the Dartmouth Institute for Health
Policy and Clinical Practice who was not involved with the study,
praised the researchers for conducting a careful analysis. But she questioned whether data from HIV studies in Africa were generalizable to the U.S. Medicaid population.
Still, it's "the best information we have," she said. "There's nothing better to plug in."
[It's rigged, but it's the only game in
town. No US study has found sufficient evidence of a connection between
circumcision and HIV to justify doing it to babies.]
The analysis comes a week before the American Academy of Pediatrics
is scheduled to release a new policy on circumcision. Since 1999, the
doctors group has taken a neutral stance on the procedure, saying that
"the scientific evidence demonstrates potential medical benefits" but
that it's not strong enough to say that circumcision should be routine.
Some reports have indicated that the new policy will state that the
health benefits of circumcision outweigh the procedure's risks, but will
stop short of recommending it for all baby boys. A spokeswoman for the
academy declined to comment before the policy is formally released
A shift in position could boost support for circumcision, since both
pediatricians and parents look to the academy for guidance, Leibowitz
USC health economist Joel Hay said the new study was inherently flawed
because ethical concerns about the procedure trumped any economic analysis of its potential benefits.
"You're taking an asymptomatic individual and forcing a procedure on him," he said.
Hay also argued that Americans didn't need circumcision to prevent
HIV infection because they had other options, such as using condoms. He
said that just last month the U.S. Food and Drug Administrationapproved
the use of a once-a-day pill called Truvada to reduce the risk of HIV
transmission in high-risk groups.
"There's no reason why people have to engage in this irreversible procedure," he said.