MEDICAID COVERAGE OF CIRCUMCISION SPREADS HARM TO THE POOR

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 their 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 do not undergo circumcision.

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 rate is no lower in America than it is in Europe.⁶ A recent study showed that urinary tract infections occurred in 6 of 24 infants circumcised by a physician (25%) and in 42 of 87 infants circumcised by a religious circumciser; the calculated odds ratio for contracting a urinary tract infection were 2.8 (95% confidence interval = 1, 9.4).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 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(p584)

Leibowitz et al. reinforce the overly confident notion, created by the extensive media coverage of 3 randomized clinical trials in Africa, 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 to 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.