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Hospital Discharge Data Underestimate Circumcision Rates


Sexually Transmitted Diseases: August 2007 - Volume 34 - Issue 8 - p 624
doi: 10.1097/OLQ.0b013e3180de2120
Letter to the Editor

Circumcision Independent Reference and Commentary Service Radcliffe, Manchester, UK

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To the Editor:

Using a national sample of males aged between 14 and 59, Xu et al. recently published figures for the prevalence of circumcision in the United States.1 Before the publication of this study, data from national samples were available for neonatal circumcision rates2 and the prevalence in older males (e.g., Laumann et al., cited in Ref. 1 and Slaby and Drizd3), but not for the same birth cohort. Now that Xu et al. have published their findings, the relationship between the prevalence of circumcision in adolescents and young adults may be compared with neonatal circumcision rates from the National Hospital Discharge Survey (NHDS).2

Xu et al. report that 84% of males born in the 1980s were circumcised by the time of the survey.1 In the same period, the proportion of newborn males circumcised in short-stay hospitals was approximately 64%.2 From these figures, we may estimate a postneonatal circumcision rate of approximately 56%. Data from other sources, however, indicate that typical postneonatal circumcision rates include 7.1% (Finland) and 9.6% (California).4 It is doubtful that the 56% figure is correct. We must, therefore, consider whether the data in each survey is reliable.

Although the National Health and Nutrition Examination Survey used self-reported circumcision status, it is unlikely that this would introduce significant errors, especially when visual aids were used to assist participants. Moreover, the data are similar to those published elsewhere in the literature for overlapping time periods. The NHDS figure, however, represents only those circumcisions performed in short-stay hospitals and coded accordingly.5 The figures do not include infants who were circumcised after hospital discharge, perhaps as an office procedure, or whose circumcisions were not coded.5 Thus, NHDS data may be reasonably expected to underestimate the true rate of neonatal circumcision.

On the basis of a realistic 10% postneonatal circumcision rate, we may estimate the true neonatal circumcision rate for the 1980s at 82%. This figure is similar to those from local samples reported in the literature (surveyed by Schoen in Ref. 5). Researchers should be aware that infant circumcision rates are likely to be significantly higher than hospital discharge data might suggest.

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1. Xu F, Markowitz LE, Sternberg MR, et al. Prevalence of circumcision and herpes simplex virus type 2 infection in men in the United States: The National Health and Nutrition Examination Survey (NHANES), 1999–2004. Sex Transm Dis. In press.
2. National Center for Health Statistics. Percent of newborn males with circumcision performed in short-stay hospitals by race. Available at: Accessed April 5, 2007.
3. Slaby AR, Drizd TD. Circumcision in the United States. Am J Public Health 1985;75:878–880.
4. Schoen EJ, Colby CJ, To TT. Cost analysis of neonatal circumcision in a large health maintenance organization. J Urol 2006;175(3, Pt 1):1111–1115.
5. Schoen EJ. Ignoring evidence of circumcision benefits. Pediatrics 2006;118:385–387.
© Copyright 2007 American Sexually Transmitted Diseases Association