Data suggesting that circumcision rates in neonates have declined in recent years have prompted a renewed call for universal Medicaid coverage for the procedure and inclusion of circumcision as part of public health policy, according to a report published online in the April 2 issue of Mayo Clinic Proceedings.
A review examining trends in U.S. male circumcision rates and the impact of the 2012 American Academy of Pediatrics policy has found that the overall rate of circumcision in the United States declined from 83% in 1960-1969 to 77% by 2010.
Dr. Brian J. Morris
Brian Morris, Ph.D., of the University of Sydney and his colleagues suggested that the decline was partly the result of demographic changes, such as the increase in the proportion of Hispanic people, who are traditionally noncircumcising, but also was likely influenced by the withdrawal of Medicaid coverage for circumcision in 18 states.
The review was prompted by a recent report from the Centers for Disease Control and Prevention, which used data from the National Health and Nutrition Examination Surveys to estimate that total circumcision prevalence had risen from 79% to 81% over the past decade, with increases to 90.8% in non-Hispanic white, 75.7% in non-Hispanic black, and 44.0% in Mexican American males.
"Because these data are for males aged 14 to 59 years – and most circumcisions in the United States take place during the neonatal period – they largely reflect past practice," Dr. Morris and his associates wrote.
Instead, they used hospital discharge data, corrected for so-called unreported circumcisions that take place after neonates are discharged from the hospital, to reveal the six percentage point decline since the 1960s.
The authors also conducted a risk-benefit analysis of circumcision, finding that the benefits – such as a reduced risk of urinary tract infection, human papillomavirus, herpes simplex, and HIV infections – exceeded the risks by at least 100 to 1 (Mayo Clin. Proc. 2014 Apr. 2 [doi:10.1016/j.mayocp.2014.01.001]).
They concluded that, over the course of a lifetime, around one in two uncircumcised men would require treatment for some medical condition associated with retention of the foreskin.
"It would be unethical for medical practitioners not to recommend circumcision for a baby boy," Dr. Morris said in an interview. "That’s what the AAP says, and it recommends that parents be educated about the benefits and also the risks early in the pregnancy so they’ve got plenty of time to make up their minds should they have a baby boy."
The most common risk associated with circumcision was local bruising at the site of the local anesthetic injection, affecting approximately one-quarter of individuals. More serious adverse effects such as infection, bleeding, or loss of the penis were extremely rare.
Commenting on the often-quoted risk of reduced penile sensitivity and enjoyment of sex, Dr. Morris said that the overwhelming majority of studies, including those conducted in adult men undergoing circumcision, showed no difference or even an improvement in sexual pleasure.
The reviewers also argued that circumcision was extremely cost effective, citing one study of infant urinary tract infections and sexually transmitted infections suggesting that, if male circumcision rates declined to those seen in Europe – around 10% – it would result in additional medical costs exceeding $4.4 billion.
"When considered together with ethical and human rights arguments, neonatal circumcision should logically be strongly supported and encouraged as an important evidence-based intervention akin to childhood vaccination," the authors wrote.
No conflicts of interest were disclosed.