MEDICAID COVERAGE OF NEWBORN CIRCUMCISION: A HEALTH PARITY RIGHT OF THE POOR

We applaud Leibowitz et al. for describing the adverse impact on public health of the withdrawal by 16 states of Medicaid coverage for male circumcision.¹ However, we are alarmed by a subsequent letter by anticircumcision lobbyists, in which the evidence regarding circumcision is thoroughly misrepresented.²

Their claims flatly contradict the bulk of the legitimate medical literature demonstrating that male circumcision protects against urinary tract infections, HIV, HSV-2, syphilis, chancroid, thrush, bacterial accumulation, human papillomavirus, penile (and possibly prostate) cancer, local inflammation (balanitis), phimosis, paraphimosis, sexual problems with age, and, in female partners, human papillomavirus, cervical cancer, HSV-2, chlamydia, and bacterial vaginosis.³ The evidence for several of these conditions now includes data from randomized controlled trials and rigorous meta-analyses. Two recent randomized controlled trials also show no adverse effect on sensitivity, sexual function, or satisfaction.⁴

Risks associated with medical circumcision of infants are extremely low (0.3%–0.6%) and the majority of complications are minor and easily treated.³ Moreover, this procedure remains as popular as ever in the United States, with the majority of male infants being circumcised.

Green et al. display a disturbing lack of understanding of basic epidemiology. A valid test of whether circumcision protects against HIV infection or penile cancer is not by comparing rates between different countries! Moreover, the flaws in their arguments denying circumcision's protection against HIV infection have been exposed previously in a detailed 48-author commentary.⁵ In contrast to their claim about applicability of data from Africa to the United States, the degree of protection that circumcision affords against heterosexual HIV infection confirmed in 3 large randomized controlled trials is now observed in heterosexual men in the United States.⁶ This protection probably extends, moreover, to insertive anal intercourse.⁷

Circumcision also protects against urinary tract infections throughout life.⁸ The accumulated lifetime prevalence in US men is up to 14%.⁹ But the highest rate (1%–4%) is during infancy, where circumcision affords a 10-fold protective effect.³ This is observed consistently in the literature.

Properly conducted cost-benefit analyses have indicated that, over a man's lifetime, infant circumcision provides a positive cost benefit, especially when diseases and medical problems in female partners are also considered.¹⁰

In this new political era in the United States, with its hope for better health care generally, Medicaid coverage for circumcision is a health care parity right of the poor. It must be retained by the majority of states, and must be reinstated by those states that have previously withdrawn it.