Efforts to Defund Or Ban Infant Male Circumcision Are Unfounded and Potentially Harmful

Johns Hopkins infectious disease experts say the medical benefits for male circumcision are clear and that efforts in an increasing number of states (currently 18) to not provide Medicaid insurance coverage for male circumcision, as well as an attempted ballot initiative in San Francisco earlier this year to ban male circumcision in newborns and young boys, are unwarranted. Moreover, they say these actions ignore the last decade of medical evidence that the procedure can substantially protect men and their female partners from certain sexually transmitted infections.

The Johns Hopkins experts argue that implementing policy or financial barriers to safe circumcision could potentially disadvantage people most in need of publicly financed services to improve their health. These groups include minorities and the poor, among whom sexually transmitted infection rates are often the highest.

Critics of infant or childhood circumcision claim, among other things, that the procedure should not be considered until males can give legal informed consent at age 18.

In an editorial to be published in the Journal of the American Medical Association online Oct. 5, Johns Hopkins health epidemiologist and pathologist Aaron Tobian, M.D., Ph.D., and health epidemiologist Ronald Gray, M.D., highlight the most recent medical research showing the considerable life-long health benefits of circumcision performed during infancy and the potential disadvantages associated with waiting until adulthood before undergoing the procedure. The experts point out that there are medical benefits during childhood, as many young men are already sexually active before age 18, and at greater risk of infection from sexually transmitted infections. Circumcision at older ages is also associated with more complications and cost than having the minimal surgery in infancy.

“Our goal is to encourage all parents to make fully informed decisions on whether to circumcise their infant boys based on medical evidence and not conjecture or misinformation put out by anti-circumcision advocates,” says Tobian, an assistant professor at the Johns Hopkins University School of Medicine.

Among the research cited by Tobian and Gray, a professor at the University’s Bloomberg School of Public Health, are multiple studies conducted within the last five years showing that in heterosexuals, circumcision reduced HIV infection risk by 60 percent, genital herpes by 30 percent and cancer-causing human papillomavirus (HPV) by 35 percent in men. Females benefit from a 40 percent or greater reduced risk of bacterial vaginosis or parasitic trichomonas spread during sex, as well as HPV infection, which causes cervical cancer.

In addition, the experts say the data clearly show that having the procedure in infancy reduces the risk of urinary tract infections, as well as inflammation in the opening or head region of the penis. Risk of infection from surgically removing the foreskin, considered a minimal and simple surgery, is already low overall but even lower during infancy, at between 0.2 percent and 0.6 percent. In adults, infection and complication rates are higher, between 1.5 percent and 3.8 percent.

In contrast to what circumcision’s opponents claim, Tobian and Gray say that research shows no reduction in sexual satisfaction or male performance. Indeed, they add, circumcised men in the trials, the gold standard of medical evidence, reported no difference or even increased penile sensitivity during intercourse and enhanced orgasms compared to uncircumcised men. The majority of female partners also reported either no change or increased sexual satisfaction, largely because of improved hygiene.

The Johns Hopkins experts argue that delaying circumcision until adulthood, when young men can legally decide for themselves, not only carries added risk of infection, but also challenges the long-held rights and responsibilities of many parents to make decisions about the long-term health of their children, including vaccinating them against hepatitis B, measles, polio, whooping cough and influenza. The proposed ban or delays also counter the religious rights for parents who observe Jewish and Muslim faiths, in which infant male circumcision is a prescribed religious obligation.

In the editorial, Tobian and Gray conclude that if a vaccine comparable in disease-prevention benefits to male circumcision was available, with the same disease-preventing benefits, “the medical community would rally behind the immunization, and it would be promoted as a game-changing public health intervention.” They say that banning male circumcision would be “ethically questionable.”

Tobian and Gray say Medicaid and other insurers should cover male circumcision costs if parents opt for the procedure, and that leading medical groups, such as the American Academy of Pediatrics and the U.S. Centers for Disease Control, need to recognize the health benefits of male circumcision and do more to educate parents and physicians about them.

More than 500 U.S. and international observational studies and 13 studies from randomized trials, Tobian says, have been published in the most influential medical journals, including the New England Journal of Medicine and the Lancet, in the past decade – reaffirming the benefits of male circumcision in preventing sexually transmitted infections.

However, the Academy’s policy on male circumcision, last issued in 1999 and re-affirmed in 2005, is ambiguous with respect to medical benefits. The CDC's policy also takes no firm position on the medical benefits of male circumcision, but that policy is expected to be updated shortly.

“In light of the latest medical evidence, the medical community and government officials at all levels would do well to revisit their policies on male circumcision, so as best to counsel parents on the potential health benefits to their children well into adulthood,” says Gray.

Jewish and other community groups successfully challenged the San Francisco ballot initiative in court, and in July, the male circumcision ban was taken off the city’s November ballot because of a legal technicality. The most recent states to stop Medicaid funding for infant circumcision are Colorado in June, and South Carolina, in February 2011. States that already had funding bans in place include Louisiana, Idaho and Minnesota, all since 2005; Maine, since 2004; Montana, Utah and Florida, since 2003; and Missouri, Arizona and North Carolina, since 2002. California, North Dakota, Oregon, Mississippi, Nevada and Washington – all had stopped funding before 1999.