From the Division of Infectious Diseases and Program in Global Health, David Geffen School of Medicine, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA
Conflict of interest: None declared.
Correspondence: Jeffrey D. Klausner, MD, MPH, Division of Infectious Diseases and Program in Global Health, David Geffen School of Medicine, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA. E-mail: JDKlausner@mednet.ucla.edu.
Received for publication April 16, 2013, and accepted May 14, 2013.
Male circumcision is highly protective against multiple medical conditions including urinary tract infections, inflammatory conditions of the penis, and sexually transmitted viral diseases such as those caused by human papillomaviruses, herpes simplex virus type 2, and the human immunodeficiency virus (HIV).1,2 In addition, male circumcision significantly reduces the risk of penile cancer and cervical cancer in female partners.3,4 In the United States, newborn male circumcision has been shown to be highly cost-effective and even cost saving.5,6 Importantly, male circumcision was shown to be significantly protective against HIV infection among heterosexual high-risk males in the United States.7 Currently, the American Academy of Pediatrics and the American College of Obstetrics and Gynecology advise that the benefits of newborn male circumcision outweigh the risks and recommend that third-party payers should cover its cost.8
In this issue of Sexually Transmitted Diseases, using data from the National Health and Nutrition Evaluation Survey (NHANES) 2005–2010, officials from the US Centers for Disease Control and Prevention (CDC) demonstrate that the overall prevalence of circumcision in the United States is high (80.5%) but has declined since the 1950s.9 There was a substantial variation in circumcision prevalence by race/ethnicity, with the highest proportion among non-Hispanic whites (90.8%), followed by non-Hispanic blacks (75.7%) and Mexican Americans (44.0%). There were also significant differences by socioeconomic status (83.4% above the poverty index vs. 67.4% at or below the poverty index), which remained significant after controlling for differences in race/ethnicity. The CDC authors also conducted an innovative analysis defining a subpopulation within the NHANES nationally representative sample of men at increased risk for heterosexual acquisition of HIV infection. The CDC defined men at increased risk for HIV acquisition as those with 2 or more sex partners in the preceding 12 months. That subpopulation had a similar proportion of uncircumcised men (19.5%) to that of the national sample, resulting in an estimated 3.3 million men both at increased risk for sexual acquisition of HIV infection caused by sexual risk behavior and lack of circumcision, an unfortunate double-whammy perpetuated by misguided state health policy, and uninformed physicians and parents.
The major findings of the CDC study that circumcision prevalence is declining and that certain subpopulations are less likely to be circumcised and thus fail to realize the multiple medical benefits of circumcision are worrisome. Because insurance coverage like Medicaid for low-income populations is a very strong predictor of circumcision status and varies state by state, the most at-risk populations who are at greatest risk for sexually transmitted diseases are the least likely to be circumcised and thus fall victim to state health policy.10,11 Furthermore, although many believe that the Patient Protection and Affordable Care Act will address gaps in insurance coverage and specifically cover preventive interventions such as newborn medical circumcision—a preventive intervention with outstanding clinical evidence (e.g., 3 randomized controlled trials demonstrating the strong and consistent protective effect of male circumcision for HIV, human papillomavirus, and herpes simplex virus type 2 infections)—newborn circumcision is not currently included or promoted as an essential health benefit in the federally defined core category of maternity and newborn care12–14
Ultimately, essential health benefit packages are left to each state. The essential health benefits are determined based on a current benchmark of health benefits provided by one of the following: (1) the largest health maintenance organization within the state, (2) 1 of the 3 largest small group plans in the state, (3) 1 of the 3 largest state employee health plans, or (4) 1 of the 3 largest federal employee health plan options. Unless states select a benchmark health plan that already includes newborn circumcision or add newborn circumcision as an essential health benefit, it is very unlikely that the millions of at-risk and underinsured individuals will benefit from male circumcision. According to the Patient Protection and Affordable Care Act, another avenue for the introduction of newborn circumcision is a grade A or B recommendation from the US Preventive Services Task Force (USPSTF). Newborn circumcision has not been evaluated by the USPSTF, nor is it under consideration for review.
Given the declining proportions of newborn circumcision and the decreased proportion in those at high risk for sexually transmitted diseases (STDs), it is incumbent upon us to work at multiple levels to ensure the following: (1) policy makers provide access to all newborns to safe, no cost circumcision; (2) providers become educated about the multiple medical benefits and the recent American Academy of Pediatrics and American College of Obstetrics and Gynecology recommendations that support the benefits of newborn circumcision versus the risks; and (3) new parents are taught the early childhood and lifelong health benefits of newborn circumcision so that they may make an informed choice for the heath of their infant and his future sex partners.
Failure to provide parents and guardians information about the benefits of newborn circumcision may make physicians and health systems liable for adverse health outcomes in children of uninformed parents or guardians.15 Because parents and guardians have the legal authority to consent for medical procedures in the best interest of the child, the failure to disclose to parents and guardians the risks of not circumcising a newborn might be considered negligent.
Many of the readers and contributors to the Sexually Transmitted Diseases journal have done much of the work proving the health benefits of circumcision and have been dedicated practitioners of STD prevention and control. Now the hard work must really begin, putting that research into policy and practice. Such efforts must occur state by state and be raised with those at the state level who have authority to define health insurance benefits. In addition, we must work with federal officials to have the USPSTF review newborn circumcision in a timely fashion. Preventing and controlling STDs have never been easy, but when new evidence confronts us demonstrating both the efficacy and need for interventions, we must act. Let us not wait another 5 years when the next analysis of NHANES data might show a further decline in circumcision and increased rates of preventable diseases in the most disadvantaged populations.
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8. American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics 2012; 130: 585–586.
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11. Leibowitz AA, Desmond K, Belin T. Determinants and policy implications of male circumcision in the United States. Am J Public Health 2009; 99: 138–145.