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RESEARCH AND PRACTICE: Arleen A. Leibowitz, Katherine Desmond, and Thomas Belin Determinants and Policy Implications of Male Circumcision in the United States Am J Public Health 2009; 99: 138-145 [Abstract] [Full text] [PDF]

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Medicaid Coverage of Circumcision Spreads Harm to the Poor

John W Travis, Lawrence W. Green, DrPH, Ryan G. McAllister, PhD, Kent W. Peterson, MD, FACPM   (27 December 2008)

Sixteen States Saving Taxpayer's Dollars

Dan Bollinger   (25 December 2008)

Medicaid Coverage of Circumcision Spreads Harm to the Poor 27 December 2008
John W Travis, Adjunct Professor RMIT University, Melbourne, Australia, Lawrence W. Green, DrPH, Ryan G. McAllister, PhD, Kent W. Peterson, MD, FACPM Send letter to journal: Re: Medicaid Coverage of Circumcision Spreads Harm to the Poor jwtravis{at}mindspring.com John W Travis, et al.	According to data reported by Leibowitz et al., lack of Medicaid coverage (and presumably private insurance) results in lowered circumcision rates (1). We disagree with the authors’ interpretation of these findings and with their concern that poor babies could be deprived of benefits from circumcision. On the contrary, neonatal circumcision places boys at immediate risk for complications (2), methicillin-resistant Staphylococcus aureus (3), and even death. (4). Leibowitz et al. should have concluded that poor children are now at lower risk of neonatal circumcision harm. Further, as the Leibowitz data show, it is clearly not just poor children who are not being circumcised. In some US regions, a majority of male babies from all income brackets remain intact. Although there is no evidence that boys not circumcised at birth are any less healthy than those who are circumcised, there is evidence of the opposite. For example, the HIV rate in America is far higher than in Europe, where males are rarely circumcised (5). The penile cancer is no lower in America than in Europe (6), and a recent study showed that circumcision is associated with higher rates of UTIs (7). A comprehensive cost–utility study found that neonatal circumcision’s complications and consequences increased health care costs 742% beyond the cost of the circumcision itself and therefore is not a justifiable public health measure (8: pp 585, 592). It concludes that if neonatal circumcision were “cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising”(8: p 584). Leibowitz et al. reinforce the overly confident notion, created by the extensive media coverage of 3 African randomized clinical trials, that circumcision is partially effective against HIV. In doing so, they ignore both contradictory evidence and the fact that the trial circumstances are not generalizable in Africa, let alone America (9). Even if male circumcision were somewhat effective in reducing HIV infection among heterosexual adults in certain areas of high HIV prevalence, the leap to recommending population- wide neonatal circumcision in the United States is still unjustifiable (10). With nearly 50 million Americans lacking health insurance, and poor children going without many basic services, it is ethically, morally and perhaps legally inappropriate that any Medicaid program continues to fund an elective and harmful procedure. We applaud the 16 states that have recognized that taxpayers should not be spending money on this unnecessary procedure and the other states that are considering dropping Medicaid coverage. No state should be wasting money on infant circumcision. About the Authors Lawrence W. Green is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Ryan G. McAllister is with the Lombardi Comprehensive Cancer Center, Georgetown Medical Center, Georgetown University, Washington, DC. Kent W. Peterson is a preventive medicine consultant in Charlottesville, VA. John W. Travis is with the Alliance for Transforming the Lives of Children, Asheville, NC, and the Department of Health Sciences, Royal Melbourne Institute of Technology University, Melbourne, Australia. Requests for reprints should be sent to John W. Travis, MD, MPH, Wellness Associates, PO Box 8422, Asheville, NC 28814 (e-mail: jwtravis@internode.on.net). Contributors All authors discussed and helped draft this letter. Acknowledgments The authors greatly appreciate the assistance of research associate Amber Craig, Durham, NC. References Leibowitz AA, Desmond K, Belin T. Determinants and policy implications of male circumcision in the United States. Am J Public Health. 2009;99(1):1–7. Williams N, Kapila L. Complications of circumcision. Br J Surg. 1993;80:1231–1236. Van Howe RS, Robson WLM. The possible role of circumcision in newborn outbreaks of community-associated methicillin-resistant Staphylococcus aureus. Clin Pediatr (Phila). 2007;46(4):356–358. Paediatric Death Review Committee. Office of the Chief Coroner of Ontario. Circumcision: a minor procedure? Paediatr Child Health. 2007;12(4):311–312. UNAIDS/WHO. Annex 2: HIV and AIDS estimates and data 2005 and 2003, 2006 report on the global aids epidemic. Available at: data.unaids.org/pub/GlobalReport/2006/2006_GR_ANN2_en.pdf. Accessed 8 Dec 2008 Frisch M, Friis S, Kjaer SK, Melbye M. Falling incidence of penis cancer in an uncircumcised population (Denmark 1943–90). BMJ. 1995;311:1471. Prais D, Shoov-Furman R, Amir J. Is ritual circumcision a risk factor for neonatal urinary tract infections? Arch Dis Child. Published online first: October 6, 2008. doi:10.1136/adc.2008.144063. Van Howe RS. A cost–utility analysis of neonatal circumcision. Med Decis Making. 2004;24:584–601. Green LW, McAllister RG, Peterson KW, Travis JW. Male circumcision is not the ‘vaccine’ we have been waiting for! Future HIV Ther. 2008;2(3):193– 199. Sidler D, Smith J, Rode H. Neonatal circumcision does not reduce HIV/AIDS infection rates. S Afr Med J. 2008;98(10):762–766.
Sixteen States Saving Taxpayer's Dollars 25 December 2008
Dan Bollinger, Director International Coalition for Genital Integrity Send letter to journal: Re: Sixteen States Saving Taxpayer's Dollars d.bollinger{at}icgi.org Dan Bollinger	Leibowitz et al. discovered that states that do not cover circumcision in the Medicaid programs experience fewer circumcisions being performed. One would expect no less. Leibowitz’s editorializing conclusion failed to mention that states that do not fund circumcision with Medicaid saved hundreds of thousands of dollars that are now being used for life-saving healthcare and not being wasted on a controversial procedure that parents have been saying--for the past two decades--that they don’t want for their boys (and girls). And rightly so. These children do not suffer the pain and trauma of circumcision, and are not at risk for its many complications. Also, they will not have to suffer the lifelong consequences of being deprived of a functional, sexual part of their anatomy.