Lower circumcision rates mean higher health costs, US study says

BMJ 2012; 345 doi: (Published 28 August 2012) Cite this as: BMJ 2012;345:e5776
  1. Janice Hopkins Tanne
  1. 1New York

Circumcision rates for male newborns are decreasing in the United States and will lead to higher health costs and more sexually transmitted diseases, according to a study from Johns Hopkins Medical Institutions published in Archives of Pediatric and Adolescent Medicine.1

The study says lower circumcision rates will increase lifetime healthcare costs for men and women in the US, because of increased infections, including HIV. The 20 year decline in circumcisions has already cost the US $2bn (£1.3bn; €1.6bn), says senior study investigator Aaron Tobian.

“Our economic evidence is backing up what our medical evidence has shown to be perfectly clear. There are health benefits to infant male circumcision in guarding against illness and disease, and declining male circumcision comes at a severe price, not just in human suffering, but in billions of healthcare dollars,” Tobian said.

According to the study, the three main drivers of increased costs from lack of circumcision are male HIV infections (78.9%), followed by urinary tract infections in male infants (6.3%), and female papillomavirus infections with both high risk and low risk strains (6.8%).

Circumcision rates for US newborn boys have dropped from 79% in the 1970s and 1980s to 55% in 2010. The rate continues to decrease “despite growing evidence of medical benefit,” the study says.

In the UK the circumcision rate is about 16% and in Denmark it is less than 2%.

If the US circumcision rate dropped to 10%, the level in countries where it is not covered by insurance, direct medical costs would increase by $505m annually and lifetime medical costs for treating infections that would have been prevented by circumcision would increase by $407 for each man and $43 for each woman, the study says.

The main reason for the US decline in circumcisions is that Medicaid, the joint federal-state health insurance programme that covers many pregnant women and the poor, no longer pays for circumcision in 18 of the 50 states, Seema Kacker, lead author of the paper, told the BMJ.

Male circumcision lowers the risk of acquiring HIV infection, both low risk and high risk papillomavirus infections, and herpes simplex virus type 2 infection, according to three randomised controlled trials in Africa, the study says. One of the trials also showed that the female partners of circumcised men had a reduced risk of both high and low risk papillomavirus infections, bacterial vaginosis, and trichomoniasis.

In an accompanying editorial, two doctors at the University of California, Los Angeles, advocate for circumcision but say, “Public policies are moving in the opposite direction. State Medicaid plans, which currently provide insurance for two fifths of all births, have been attempting to control ballooning costs by dropping insurance coverage for routine male circumcision . . . pennywise and pound foolish because investing today in a relatively low-cost procedure will avert greater future treatment costs for cancer, HIV, and other sexually transmitted diseases . . . .The groups that Medicaid covers are precisely those that experience the greatest prevalence of HIV and other sexually transmitted diseases, which male circumcision can effectively avert.”2

The American Academy of Pediatrics said [27 August] that the benefits of circumcision in preventing infections such as HIV outweigh the risks, reversing its previous position against circumcision. However, the academy said that parents should make their own informed decisions.


Cite this as: BMJ 2012;345:e5776