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Covering Circumcision* for All: Poor use of healthcare $

*  surgical removal of some, or all, of the foreskin (or prepuce) from the penis; the most
common surgical procedure in the US.
 
The American Academy of Pediatrics published a new policy statement on circumcision
this week In Pediatrics.  If you just read the abstract and the headlines, this jumps out:
Evaluation of current evidence indicates that the health benefits of newborn male
circumcision outweigh the risks and that the procedure’s benefits justify access to this
procedure for families who choose it.  In other words, health plans should cover circumcision.
Private insurance typically covers circumcision, so we’re talking about Medicaid, which covers
41% of births.
 
Circumcision costs $400-600. I have not heard parents clamoring for this service. Have you?
In fact fewer parents have been choosing circumcision. Reported US rates:

1965: 85%,
2006: 56%,
2009 33%. 
 
The Task Force strongly recommends the development of educational materials for providers
to enhance practitioners’ competency in discussing circumcision’s benefits and risks with
parents.  Let’s exercise some critical health literacy skills to consider the content of such
discussions. (How to present the content is another discussion)
 
The Policy Statement refers readers to the Technical Report but there is no bibliography or
list of studies considered. The report simply mentions prevention of urinary tract infections,
acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. 
Let’s look at three of these:
 
Urinary tract infections (UTI) are rare, usually limited to the first year of life (usually the first
month for boys), much more common in girls (but no circumcision is recommended for girls).
While it is may be correct to say that UTIs are 10 times more common in uncircumcised boys,
that is not informative and is misleading. The numbers are tiny; 0.1% - one tenth of one percent
or one in one thousand  circumcised baby boys get a UTI vs. 1.1% of uncircumcised boys. So the
best possible preventive effect is a 1% reduction in risk.  One study estimates it would take 195
circumcisions (about $10,000) to prevent one urinary tract infection, which would be readily
treated with antibiotics. hmmm...
 
HIV  The World Health Organization declared three years ago that circumcision should be part of
any strategy to prevent HIV infection in men in parts of the world where less than 20 percent of
boys are circumcised.  Notably, there are six African countries where men are more likely to be
HIV+ if they've been circumcised.  On the other hand, Scientific American reports 3 randomized
trials in different settings consistently showed  a 55 to 65% reduction in new HIV infections among
newly circumcised African adult males. However, that conclusion relies on the (big) assumption
that all the subjects in different countries, cultures and religions had similar sexual practices; 
and controversy remains over how circumcision protects. It seems logical that if circumcision
was that effective against HIV, the epidemic could not survive as it has in the US.  Also worth
asking: Why does uncircumcised Europe have lower HIV and STD rates than more circumcised
USA? hmmm...

While the policy is not about women, it seems worth mentioning that a randomized controlled
trial into male-to-female transmission showed women were  54% more likely to be infected by
a circumcised man than by an “intact” man.  Circumcised or not, you still have to use a condom!

Penile cancer is rare, even among uncircumcised men. 1570 new cases are expected in 2012,
and 310 deaths. Risks appear a bit lower for men circumcised in childhood and a bit higher
for those circumcised as adults. hmmmm

The American Cancer Society concludes:  In the end, decisions about circumcision are highly
personal and depend more on social and religious factors than on medical evidence.
This is essentially what AAP said; the policy is about covering the cost through health insurance
coverage.

It seems to me this policy presents nothing new for practice, but shores up the industry built
up around circumcision and now waning as fewer parents elect circumcision. That money
would be better spent on primary care for mothers.


Next time.  What to tell Parents?
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