To circumcise or not to circumcise? Continued US debate on the benefits of infant male circumcision as an STI prevention tool

Last month saw two further developments in the ongoing US debate over infant male circumcision (MC).  European readers may be surprised to discover that infant MC has traditionally been widely practised in the US – for complex historical reasons (http://blogs.bmj.com/sti/2011/10/15/to-circumcise-or-not-to-circumcise/?preview=true&preview_id=509&preview_nonce=9ecb80c216 ).  MC has shown a sharp decline in the US from around 79% some twenty years ago to 56% as of 2008, with the doubts widely expressed as to its medical justification, and insurance cover withdrawn in 18 US states; yet some paediatricians are making a last-ditch effort to halt the trend, drawing attention to medical benefits of MC as a prevention tool that have been highlighted by recent African studies (e.g. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60313-4/abstract).

At the end of August came first, on the 20th, the publication in the Archives of Pediatrics and Adolescent Medicine of an editorial and associated paper seeking to place a speculative figure on the potential health cost to the US of infant MC declining to European levels of 10% (http://archpedi.jamanetwork.com.libproxy.ucl.ac.uk/issue.aspx): then, on the 27th, a long-awaited policy statement on infant MC by the American Association of Paediatrics (http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Newborn-Male-Circumcision.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token).

The paper (Kacker and Tobian) takes into account the health costs not only of increased heterosexual HIV, but of other STI problems in men and women (HPV, HSV-2, bacterial vaginosis) as well as infant male UTIs.  Their model claims to demonstrate a net increased health expenditure of $313 per forgone MC procedure, amounting to a net additional annual health care cost of $505 million, largely driven by male HIV, infant UTIs and high-risk HPV in women.  An associated editorial (http://archpedi.jamanetwork.com.libproxy.ucl.ac.uk/article.aspx?articleid=1352168) reminds us that State Medicaid plans have covered two fifths of infant MCs in the past, but are currently in the process of dropping their coverage.  It also argues that the sectors of US society most affected by the abandonment of insurance cover for MC are precisely the sectors that experience highest levels of STIs and are most likely to benefit from MC.

The policy statement by the AAP, however, declares that, while the benefits of infant MC outweigh the risks, those benefits are not “great enough to recommend universal male newborn circumcision”.  What are we to make of the apparent discrepancy between the conclusions of Kacker & Tobian and the recommendations of the AAP?

The probable role of male circumcision in limiting HIV transmission in African contexts has been recognized (http://sti.bmj.com/content/87/7/640.abstract?sid=3c2776bf-91df-4443-b45c-d91cccd67208), along with its preventative benefits where other STIs are concerned (e.g. chancroid and syphilis (http://sti.bmj.com/content/82/2/101.abstract?sid=4e861499-e57a-40b3-833f-1c3a03449ee8); trichomonas (http://sti.bmj.com/content/85/2/116.abstract?sid=4e861499-e57a-40b3-833f-1c3a03449ee8).  Its effectiveness and acceptability as a prevention tool have been positively evaluated in some cultural contexts (http://sti.bmj.comcontent/79/3/214.abstract?sid=4e861499-e57a-40b3-833f-1c3a03449ee8; http://sti.bmj.com/content/87/Suppl_1/A319.1.abstract?sid=4e861499-e57a-40b3-833f-1c3a03449ee8). In others, however, a link between circumcision and reduced HIV prevalence is not evident, and MC would not be acceptable (http://sti.bmj.com/content/84/1/49.abstract?sid=4e861499-e57a-40b3-833f-1c3a03449ee8 and http://sti.bmj.com/content/86/5/404.abstract?sid=4e861499-e57a-40b3-833f-1c3a03449ee8).

Clearly the feasibility of MC as a prevention tool is highly culture-specific.  This aspect may be  undervalued by Kacker & Tobian, who, in reference to European contexts,  assume a link between low rates of MC and the absence of insurance cover for the procedure – as though, but for insurance, a practice of infant MC would be universally adopted by everybody in the interests of sexual health!  This makes light of the element of culture and tradition.  From an outsider perspective, history would appear to have delivered the US, the shape of infant MS, a fortuitous cultural advantage which it would seem all the more misguided to squander, as it is not something that any rationally-directed health strategy could have delivered to order.  This perspective, which seems a very persuasive one, is as absent from Kacker & Tobian’s paper as it from the AAP recommendation that the authorities proceed on the basis of a calculation of individual benefit and risk.