Declining rates of circumcision among infants will translate into billions of dollars of unnecessary medical costs in the U.S. as these boys grow up and become sexually active men, researchers at Johns Hopkins University warned.

In a study published Monday in the Archives of Pediatric and Adolescent Medicine, a team of economists and epidemiologists estimated that every circumcision not performed would lead to significant increases in lifetime medical expenses to treat sexually transmitted diseases and related cancers — increases that far surpass the costs associated with the procedure.

Circumcision is a hotly debated and emotional issue in the U.S., where rates have been falling for decades. In the 1970s and 1980s, about 80% of baby boys were routinely circumcised in hospitals or during religious ceremonies; by 2010, that figure had dropped below 55%, according to the Centers for Disease Control and Prevention.

Some of that decline is due to shifting attitudes among parents, but at least part of it can be traced to the decision by many states to eliminate Medicaid coverage for the procedure in order to save costs. Today 18 states, including California, do not provide Medicaid coverage for the procedure, which is considered cosmetic by many physicians.

But in the last decade, studies have increasingly shown that removing the foreskin of the penis has significant health benefits, said Dr. Aaron Tobian, senior author of the new study.

Three randomized trials in Africa have demonstrated that circumcision was associated with a reduced risk of contracting HIV, human papillomavirus and herpes simplex in men. One of those studies documented a reduced risk of HPV, bacterial vaginosis and trichomoniasis in the female partners of men who were circumcised.

Circumcision is believed to prevent STDs by depriving pathogens of a moist environment where they can thrive. The inner foreskin has been shown to be highly susceptible to HIV in particular because it contains large numbers of Langerhans cells, a target for the virus.

Tobian and his colleagues developed a computer-based simulation to estimate whether declining circumcision rates would lead to more STDs and thus higher medical costs.

If circumcision rates remained about 50% instead of the higher rates of years past, the lifetime healthcare costs for all of the babies born in a single year would probably rise by $211 million, the team calculated.

If circumcision rates were to fall to 10% — which is typical in countries where insurance does not cover the procedure — lifetime health costs for all the babies born in a year would go up by $505 million. That works out to $313 in added costs for every circumcision that doesn’t happen, the report said.

In this scenario, nearly 80% of the additional projected costs were because of medical care associated with HIV infection in men, the team wrote.

The model includes only direct medical costs such as treatment for penile and cervical cancer, which are associated with HPV infection. It doesn’t consider nonmedical or indirect costs, such as transportation to doctors’ appointments or lost income.

To Tobian, the message is clear: Government efforts to save money by denying coverage for circumcision are penny-wise but pound-foolish.

“The federal Medicaid program should reclassify circumcision from an optional service to one all states should cover,” he said.

That sentiment was echoed in an editorial accompanying the study. UCLA health economist Arleen Leibowitz wrote that by failing to require states to cover circumcision in Medicaid plans, the U.S. reinforces healthcare disparities.

“If we don’t give poor parents the opportunity to make this choice, we’re discriminating against their health in the future,” she said in an interview. “If something is better for health and saves money, why shouldn’t we do it? Or at least, why shouldn’t we allow parents the option to choose it?”

Ellen Meara, a researcher at the Dartmouth Institute for Health Policy and Clinical Practice who was not involved with the study, praised the researchers for conducting a careful analysis. But she questioned whether data from HIV studies in Africa were generalizable to the U.S. Medicaid population.

Still, it’s “the best information we have,” she said. “There’s nothing better to plug in.”

The analysis comes a week before the American Academy of Pediatrics is scheduled to release a new policy on circumcision. Since 1999, the doctors group has taken a neutral stance on the procedure, saying that “the scientific evidence demonstrates potential medical benefits” but that it’s not strong enough to say that circumcision should be routine.

Some reports have indicated that the new policy will state that the health benefits of circumcision outweigh the procedure’s risks, but will stop short of recommending it for all baby boys. A spokeswoman for the academy declined to comment before the policy is formally released Monday.

A shift in position could boost support for circumcision, since both pediatricians and parents look to the academy for guidance, Leibowitz said.

USC health economist Joel Hay said the new study was inherently flawed because ethical concerns about the procedure trumped any economic analysis of its potential benefits.

“You’re taking an asymptomatic individual and forcing a procedure on him,” he said.

Hay also argued that Americans didn’t need circumcision to prevent HIV infection because they had other options, such as using condoms. He said that just last month the U.S. Food and Drug Administration approved the use of a once-a-day pill called Truvada to reduce the risk of HIV transmission in high-risk groups.

“There’s no reason why people have to engage in this irreversible procedure,” he said.

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By Eryn Brown, Los Angeles Times
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