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Study: Declining circumcision rates could lead to increase in health care costs, disease

Published: Thursday, Aug. 23 2012 9:07 p.m. MDT

Nurse Angie Hagen tends to a new born baby boy in the nursery at Denver Health medical facility in Denver on Thursday, June 23, 2011. Colorado will end coverage for routine circumcisions under Medicaid next month, adding to what's become a national debate over the once widely-accepted procedure. The change will take effect July 1. Lawmakers agreed to end funding as part of a package of cuts to balance the budget.

Ed Andrieski, Associated Press

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SALT LAKE CITY — Circumcision rates have been declining during the past 10 years in Utah and the country, and researchers are now saying the trend could result in higher health care costs because of potential medical complications.

The American Academy of Pediatrics, which holds the leading opinion on the matter, has also announced an upcoming change to its decades-old stance on circumcision. An official statement explaining its new position is expected Monday.

The organization has been neutral on the procedure since 1999, saying that while there are some health benefits to the procedure, they don't outweigh the risks and circumcision is considered a cosmetic procedure.

Utah Medicaid stopped covering the procedure in 2003, as a cost-saving measure decided by lawmakers. Unless it is deemed medically necessary, it is not covered. But officials in Utah are now considering potential changes to current benefits as the number of parents choosing to circumcise their children continues to drop.

Approximately 39 percent of infant boys in Utah were circumcised in 2010, according to the latest data available from the Utah Department of Health. That's down from nearly 70 percent of newborn boys in 2000, with the largest decline happening the year Medicaid dropped coverage of the procedure.

Davis County circumcises the largest number of newborn males, at 54.2 percent in 2010, while southwestern Utah performs the procedure on slightly more than 20 percent of babies.

Nationwide, 80 percent of males were circumcised in the 1970s and 1980s, but the number dropped significantly in 1999, to 62 percent, according to the U.S. Centers for Disease Control and Prevention. In 2010, the rate continued to decline, hovering around 55 percent.

Dr. Mark Witt, a pediatrician with Intermountain Healthcare's Holladay Pediatrics clinic, said that while most pediatricians refer patients to the AAP recommendation, the decision is entirely up to the parents of a newborn boy.

"There is a dilemma in that parents know the American Academy of Pediatrics says it is more a cosmetic procedure and I think that causes some anxiety, and rightfully so," he said. "In talking to parents, they feel a little on the fence. They're making a choice for their one- to two-day-old little boy who doesn't have a say in it."

The procedure is generally performed at a hospital, one or two days after birth, or up to about two weeks at a pediatrician's office. After that time period, a urologist at a hospital typically takes over.

For many families, the procedure results from tradition or a desire for sons to be like their fathers, who were also circumcised out of tradition, religious or otherwise.

Acknowledging it is a personal decision for families to make on their own, Marlise Smurthwaite said she studied the pros and cons of both circumcising and not circumcising her newborn sons. Her stepson, she said, had not been circumcised, and "I was in a situation where my sons would either be the same as their father or their brother, so I went back and forth."

Biblically, and according to Judaism, circumcision is a sign of a covenant relationship between God and Abraham, a symbol of cleanliness and a reminder of the generations to come. It is considered religious law for those of the Jewish and Islamic faiths, and barring any sickness, happens on the eighth day after birth, when humans typically form blood-clotting properties.

"It is not just a medical act, it is a connection with our God, symbolizing our devotion to him, and it serves as a reminder of the importance of being moral," said Rabbi Gadi Levy, who lives in Colorado and travels throughout the country as a fully trained mohel, performing circumcisions.

He said that while he believes there are many medical advantages to circumcision, he most enjoys "bringing a child into that relationship with God. It is a privilege, really."

Smurthwaite, who also lives in Colorado, said even though her LDS faith does not require circumcision as a commandment, she felt it reminded her of something more meaningful.

"The religious view helped me to remember that it was something God asked at one time, and therefore, at least for me, I thought of it not as something that was abusive or horrific — because I can't see God requiring something that is inhumane for his children, in their desire to covenant with him," she said.

For both her sons, and others in her extended family, a mohel was invited to perform the circumcision. Smurthwaite said the procedure was done at her home and was accomplished more quickly than the traditional hospital method and with less obvious pain and suffering to her baby boys.

Levy said that the method used by mohels employs the Mogen clamp or shield. The ritual causes some bleeding, but he said it is well-controlled.

In a report published Monday in the Archives of Pediatrics & Adolescent Medicine journal, experts with Johns Hopkins University School of Medicine claim that with fewer circumcisions comes a higher incidence of sexually transmitted infections, including human papilloma virus and HIV, and related cancers in men and their female partners.

An increase in such conditions has the potential to add more than $4 billion in "avoidable health care costs" if circumcision rates continue to drop, the research states.

"Our economic evidence is backing up what our medical evidence has already shown to be perfectly clear," Dr. Aaron Tobian, a health epidemiologist and co-author of the Johns Hopkins study, said in a written statement. "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."

But a growing number of families are choosing not to have it done.

Certified nurse midwife Rebecca McInnis, at the Birth Center in Murray, said most of her clients will choose to immunize and administer vitamin K for added infant health, but the majority will not have their sons circumcised.

"Studies don't support it as a useful surgery," she said.

Becca Bingham, of Clinton, watched one of her young sons go through it.

"I just assumed everybody had it done and had I had my babies myself, I would have checked the box to have it done. There would've been no question, just for tradition, I guess," she said. Bingham is an adoptive mother of four children, two of whom are boys.

Neither of her sons had been circumcised when they arrived under her care and doctors told them one was likely too old to have it done comfortably, yet the youngest would stand to benefit medically from circumcision.

The procedure, Bingham said, was "traumatic" for the 4-month-old and ended up changing her mind on circumcision altogether.

"You're basically choosing a cosmetic surgery for your kids because of tradition," she said, adding that there has been little difference between the associated anatomy of her two sons.

"Knowing what I know now, I would not have done it," Bingham said. "Unless it was deemed medically necessary."

Non-circumcised males, according to Johns Hopkins' research, could potentially contribute to an increased rate of various diseases.

The research states that if U.S. male circumcision rates declined to the approximate 10 percent rate in Europe, there would be an expected 12 percent increase in men infected with HIV, 29 percent more with HPV, a 19 percent increase in herpes simplex virus, and a 211 percent jump in the number of male urinary tract infections. In addition, the research indicates that female sex partners of non-circumcised males would also experience a higher incidence of HPV and bacterial vaginal infections.

The 20-year decline in the number of American males circumcised at birth, Tobian said, has already cost the nation more than $2 billion. He blames funding cuts in Medicaid programs across the country for the decline.

The most recent states to stop Medicaid funding for infant circumcision were Colorado and South Carolina, in 2011. They followed Louisiana, Idaho and Montana, which quit covering the $300 to $600 procedure in 2005; Maine, in 2004; Utah, Montana and Florida in 2003; Missouri, Arizona and North Carolina in 2002; and California, North Dakota, Oregon, Mississippi, Nevada and Washington before 1999.

Tobian said the states are on an "ill-fated path." Problems are compounded, he said, by the fact that the AAP does not yet recognize medical evidence in support of circumcision, a change he hopes the new research persuades.

It will be difficult, however, to change minds outside of the U.S., as several European countries are considering banning the practice altogether. Just this week, a rabbi in Germany was criminally charged for performing circumcisions.

"It is a debate that will continue forever … as long as there is a free democratic society," Levy said, adding that the Jewish tradition has been the same for 3,824 years, when Jews believe Abraham entered the covenant of circumcision with God.

For parents faced with the decision outside of religion, Bingham said she hopes they educate themselves before having a baby.

"I think you wouldn't cut off your finger unless you had to," she said.

In addition to educating parents, Bingham said parents should counsel their sons on proper cleaning and avoiding the potential for unwanted infection, specifically living a chaste life.

"I don't believe that choosing to or not choosing to will have a harmful or significant impact on boys," Smurthwaite said. "There are things to consider with each choice, but I think it is important to consider the boy, not just what our opinions may be, but a good decision based on the information we gather."

Email: wleonard@desnews.com Twitter: wendyleonards

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