Declining rates of circumcision in US infant males could add billions to health care costs

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A team of disease experts and health economists at Johns Hopkins warns that steadily declining rates of U.S. infant male circumcision could add more than $4.4 billion in avoidable health care costs if rates over the next decade drop to levels now seen in Europe.

In a report to be published in the Archives of Pediatrics & Adolescent Medicine online, the Johns Hopkins experts say the added expense stems from new cases and higher rates of sexually transmitted infections and related cancers among uncircumcised men and their female partners. 

They say the study is believed to be the first cost analysis to account for increased rates of multiple infectious diseases associated with lower rates of male circumcision, including HIV/AIDS, herpes and genital warts, as well as cervical and penile cancers.  Previous research focused mostly on HIV, the single most costly disease whose risk of infection is decreased by male circumcision, a procedure that removes foreskin at the tip of the penis, hindering the buildup of bacteria and viruses in the penis’ skin folds.

Senior study investigator, health epidemiologist and pathologist Aaron Tobian, M.D., Ph.D., says that roughly 55 percent of the 2 million males born each year in the United States are circumcised, a decline from a high of 79 percent in the 1970s and ‘80s.  Rates in Europe average only 10 percent, and in Denmark, only 1.6 percent of infant males undergo the procedure.

“Our economic evidence is backing up what our medical evidence has already shown to be perfectly clear,” says Tobian, an assistant professor at the Johns Hopkins University School of Medicine. “There are health benefits to infant male circumcision in guarding against illness and disease, and declining male circumcision rates come at a severe price, not just in human suffering, but in billions of health care dollars as well.”

The 20-year decline in the number of American males circumcised at birth has already cost the nation upwards of $2 billion, Tobian and his colleagues estimate.

The Johns Hopkins team’s analysis showed that, on average, each male circumcision passed over and not performed leads to $313 more in illness-related expenses, costs which Tobian says would not have been incurred if these men had undergone the procedure.

According to the team’s analysis, if U.S. male circumcision rates among men born in the same year dropped to European rates, there would be an expected 12 percent increase in men infected with HIV (or 4,843); 29 percent more men infected with human papillomavirus (57,124); a 19 percent increase in men infected with herpes simplex virus (124,767); and a 211 percent jump in the number of infant male urinary tract infections (26,876).  Among their female sex partners, there would be 50 percent more cases each of bacterial vaginosis (538,865) and trichomoniasis (64,585).  The number of new infections with the high-risk form of human papillomavirus, which is closely linked to cervical cancer in women, would increase by 18 percent (33,148 more infections).

Tobian says state funding cuts in Medicaid, the government medical assistance program for the poor, have substantially reduced numbers of U.S. infant male circumcisions, noting that 18 states have stopped paying for the procedure.  “The financial and health consequences of these decisions are becoming worse over time, especially if more states continue on this ill-fated path,” he says.  “State governments need to start recognizing the medical benefits as well as the cost savings from providing insurance coverage for infant male circumcision.”

The problem in the United States is compounded, Tobian says, by the failure of the American Academy of Pediatrics to recognize the medical evidence in support of male circumcision.

The Johns Hopkins team says it plans to share its study findings among state government officials across the United States to help raise awareness of its medical and cost-benefit analysis.

In the study, researchers constructed a novel economic model to predict the cost implications of not circumcising a male newborn.  Included in their forecasting was information from multiple studies and databases that closely tracked the number of overall infections for each sexually transmitted disease, as well as the numbers of new people infected.  Costs were conservatively limited to direct costs for drug treatment, physician visits and hospital care, and did not include indirect costs from work absences and medical travel expenses.

The most recent states to stop Medicaid funding for infant circumcision were Colorado and South Carolina, in 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 stopped funding before 1999.

Funding support for the study was provided by The Johns Hopkins Hospital.  Other Johns Hopkins investigators involved in this research were Seema Kacker, B.S.; Kevin Frick, Ph.D.; and Charlotte Gaydos, M.S., Dr.P.H.

For additional information, go to:

Source: Johns Hopkins Medicine


  1. Stephen Hogan Stephen Hogan Belgium says:

    We are meant to assume that the doctors involved in this study remained completely independent, absent of any personal thinking or value judgment? The assumption by the public at large that doctors and scientists as being wholly objective is misguided. Doctors are people and with an issue such as this conclusions are often backed by data - not the other way around, how else would you explain the exact opposite conclusions by a Dutch study that concluded "There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene" ?

    Circumcision is an antiquated religious ritual based on misguided beliefs and bad science. In the US, the popularity of circumcision dates back 140 years to Dr Lewis Sayre, one of the founders of the American Medical Association who believed that many medical conditions had their root in a dysfunction in the genital area, and that circumcision could be used to treat a wide array of problems, from depression to mental health issues, syphilis and epilepsy. Circumcision was also promoted as a way of discouraging masturbation, and was regarded as clean and hygienic. Sayre's theories have since been debunked.

  2. Hugh Intactive Hugh Intactive New Zealand says:

    Circumcision has always been an intervention looking for an excuse, more recently a "cure" in search of a disease, and nothing has changed, except that its advocates (almost all circumcised men who, like the fox who lost his tale in Aesop's fable, can't bear other men having something they lack) are now working in concert. Tobian is part of this small coterie. (They are not a conspiracy; their names are well known, since they often publish together.)

    Most men in the world, and the vast majority in the developed world, are not circumcised. The rest of the English-speaking world gave up mass-circumcision a generation ago, with no outbreaks of any of the diseases it was supposed to be good against. A new study from Puerto Rico found circumcised men there were MORE likely to have STDS and HIV.  A study in Uganda by Wawer, Gray, et al. (also in the clique) started to find that circumcising men INcreases the risk to women, but that was cut short for no good reason before that could be confirmed. In 10 out of 18 countries for which USAID has figures, more of the circumcised men have HIV than the non-circumcised.

    The current thrust is to restore public funding to male genital cutting, lest the rate fall below the 50% tipping point and the "locker room" argument can be used against it.

    Other US studies have shown circumcision's risk and harm do NOT justify doing it. Why do they not get this level of publicity?

    Infant circumcision is a human rights issue. HIS body, HIS choice.

  3. Mark Lyndon Mark Lyndon United Kingdom says:

    More misinformation by people trying to defend cutting parts off babies' genitals. Despite almost no-one in Europe except for Jewish and Muslim families circumcising, Europe has *lower* rates of HIV.

    Even in Africa (from a USAID report):
    "There appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher."

    It is unclear if circumcised men are more likely to infect women. The only ever randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised.

    Women have "skin folds" too, but we don't cut parts off baby girls. Think how much money we could save by removing their breast buds too (breast cancer affects about 12% of women, and kills about 3%).

The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of News Medical.
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