Whether to circumcise a newborn male child is not the simple, binary “yes/no” question it appears to be. Rather, the choice is affected by an astonishing array of issues: religion, culture, health and hygiene, sexually transmitted infections, expense, pain and medical recommendations. Some cite ethical concerns regarding usurpation of a child’s free choice. Others claim an equivalency between neonatal male circumcision and the practice of female genital mutilation.

As a practicing physician, I have safely performed dozens of male infant circumcisions and many more on adults. During 30-plus years of emergency medicine, I have encountered nearly every problem an uncircumcised male can encounter: chronic urinary tract infections, refractory problems from medical diseases, the need for emergent surgery due to scarring or pain and even strangulation of the penis’ blood supply. Circumcision eliminates all these conditions.

Additionally, there is compelling evidence that circumcision reduces the risk of obtaining or transmitting serious sexually transmitted infections.

Male circumcision is a simple, safe, and inexpensive procedure. There are no adverse effects to the removal of the foreskin. Circumcision is exceptionally safe when performed in infancy, with complications in fewer than one-half of one percent of cases. Use of anesthetics renders the process virtually painless.

Despite its clear benefits, the rate of circumcision in the U.S. has been steadily declining. It is not a reportable procedure. Therefore, statistics only reflect voluntarily submitted survey information regarding hospital-born infants circumcised before discharge. Not included are males who undergo the procedure later, such as for religious, cultural or reimbursement reasons. But the downward trend is real. A Center for Disease Control (CDC) study found that the average U.S. circumcision rate has fallen from 56% of newborns in 2006 to only 33% in 2009. It is difficult to imagine that only 80 years ago the rate of circumcision in the US was as high as 81% of all baby boys.

Department of Health and Human Services (HHS) information from twenty-six states (1998 – 2006) confirmed this downward trend. The rate of circumcision fell in 11 states, remained unchanged in 11, and rose by 1% in only four. In my home state of Arizona, the rate of circumcision dropped 18% during this time, primarily due to lack of Medicaid reimbursement. One year before the Medicaid provision was cut, 41% of boys born in Arizona were circumcised in a hospital. Two years later, that number had fallen to 26%, with the latest reported information showing only 20% undergoing the procedure.

Statistics from the National Hospital Discharge Survey (NHDS) reflect the distinctly regional rates of circumcision. The NHDS gathers data in four census regions. The lowering non-circumcision rate has been consistent in the Western Region for some time, while the Southern Region now approaches parity of circumcision vs. uncircumcised.

The practice of routine circumcision in the U.S. is beginning to parallel the Northern European and Scandinavian experience of declining rates since World War II.

Why is this?

Youth are more skeptical of the practice. A YouGov survey found only 33% of 18-29 year-olds said that male children should be routinely circumcised, compared to 43% of 30-44 year-olds, 52% of 45-64 year-olds and nearly 66% of seniors. The number of millennials who view circumcision as an individual choice is nearly identical to the number espousing individual choice regarding childhood vaccination.

Not surprisingly, politics play a role. In 2011 San Francisco unsuccessfully attempted to ban the practice. Illegal in South Africa and Sweden, a current similar movement in Iceland is being fiercely resisted. Opponents claim that the intention is more to reduce immigration than circumcision since the Muslim faith requires circumcision.

No major medical organization recommends routine circumcision other than in areas of high HIV prevalence in Africa, where it serves as effective prevention. The Danish College of General Practitioners even calls medically unnecessary circumcision “mutilation.”

Yet no major medical organization in the world calls for banning routine circumcision, either.

Notably, the American Academy of Pediatrics (AAP) holds that the health benefits of circumcision outweigh the risks. This is because of the demonstrated reduction in transmission of sexually transmitted diseases (syphilis, genital herpes) and human papillomavirus (genital warts, penile and cervical cancer) and reduction of infant urinary tract infections. While stopping short of recommending routine circumcision, the AAP recommends third-party reimbursement for the procedure.

Likewise, the CDC does not recommend routine circumcision. However, their studies note its effectiveness in preventing STD and HIV transmission and suggest that routine circumcision would result in cost savings to society. Health experts and economists at Johns Hopkins University School of Medicine warned that if circumcision rates in the United States fall to the same level as in Europe, it could add more than $4 billion in health care costs over a decade.

Due to ethical concerns, should we ban all “unnecessary” childhood interventions, including piercing ears? Of course not. Parents are assumed to have the child’s welfare as a top priority. A thoughtful decision based on the risks and benefits of the procedure are in the child’s best interests.

Delaying the procedure until the individual can decide for themselves is not realistic. Few teens would choose to participate in a discussion about their own circumcision, let alone consider undergoing the procedure. And do teens actually have the capacity to truly understand the impact of the issues involved? Important ethical concerns arise since the complication rate for later circumcision rises ten to twenty-fold. And a harsh reality is that adult circumcision is not reimbursed unless performed for medical necessity.

It is starkly evident that lack of third-party reimbursement is directly related to significantly lower rates of circumcision. The cost of the procedure is insurmountable to many individuals. Insurance company reimbursement appears completely scattershot. Some pay without question. Many follow Medicaid policy and balk paying for a “medically unnecessary” procedure. Others will pay but prefer a deferred office procedure due to decreased expense. UCLA researchers found that at hospitals in the 16 states where the procedure is not covered by Medicaid, circumcision rates were 24 percentage points lower than at hospitals in other states, with lower rates particularly prevalent among Hispanics.

The ultimate question surrounding circumcision is whether the medical benefits outweigh the risks of performing the procedure. If the only benefits were prevention of relatively rare penile cancer or the acquired medical or surgical problems, it might be questionable. However, by adding the prevention of chronic urinary infections and the reduction of STD and HIV transmission, the risk/benefit ratio suddenly tilts heavily toward benefit.

How do we reverse the declining rates of circumcision? The first step is to educate, particularly the skeptical youth, regarding the many positives resulting from circumcision. Secondly, the AAP and CDC already recognize the health benefits. The endorsement of routine circumcision by these influential organizations would generate tremendous inertia toward the goal of universal neonatal circumcision. Lastly, requiring insurance companies and Medicare to provide reimbursement would not only increase circumcision rates but would eliminate any potential disparity in rates of circumcision for those that cannot afford it.

Paul Blackburn is an emergency physician.

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