To circumcise or not to circumcise?

Against the background of recent legislation by 18 states of the US to eliminate Medicaid Insurance for male circumcision, an editorial in the latest issue of the Journal of the American Medical Association (JAMA) argues the case for circumcision largely on the basis of evidence from African trials of its benefit in reducing HIV transmission.

In marked contrast with other predominantly white English-speaking nations where the practice of infant circumcision is rare or has steeply declined, in the US circumcision remains the norm (57% of males).  This latest drawing of the battle lines is the most recent phase in a US debate around the practice that has been going on for some time, and may now be reaching a decisive point.

The opponents of circumcision seem to view it, like the abusive tonsillectomy, or the cosmetic total dental extraction, as a practice of dubious medical benefit testifying to the doctrinaire medical interventionism of a bygone era.  They may be right.  One convincing explanation attributes the normalization of circumcision largely to the comprehensive medicalization of childbirth in the US (1% homebirths by 1955) at a time when infant circumcision was being most enthusiastically promoted by health professionals.  Circumcision would appear to have been well entrenched in American custom before more sceptical voices came to be raised.  Today’s sceptics argue that the relevance to the US of African trials purporting to prove the efficacy of circumcision as a preventative tool against HIV is, to the say least, unclear.  Preventative effects of circumcision have been demonstrated – if they have been demonstrated at all – only in relation to heterosexual transmission of HIV, and that, is of course not the predominant mode of HIV transmission in the US.

So what do the editors of JAMA have to say in response?  Potential benefits, they claim, are in three areas.  First, heterosexual transmission of HIV is an important mode of transmission for certain populations – including, significantly, many of those most likely to be affected by the withdrawal of Medicaid for circumcision, e.g. black and Hispanic populations.  Second, male circumcision may turn out to have preventative effects for homosexual as well as heterosexual transmission (though this is yet to be proved).  Third, circumcision has been demonstrated to have considerable preventative efficacy against other STIs, notably a 28%-34% reduction in the risk of acquiring genital herpes and a 32% reduction for oncogenic HPV.  It has also been shown to have a protective effect for the female partner, notably:  reductions of 28%, 40%, and 48% for ongenic HPV, vaginosis, and trichomoniasis, respectively.

In support of their claims the editors of JAMA refer to a recent cost-effectiveness study (Sansom, Prabhu & Hutchinson).  The latter claims to demonstrate that newborn circumcision in the US results in savings in costs and quality-adjusted life-years for all males, and especially for black and Hispanic males.  The number of circumcisions needed to prevent one HIV infection is calculated at 298 for all males and 65 for black males.  Given the relative cheapness of newborn circumcision, and the high cost of HIV, the cost-effectiveness of the intervention seems evident.  In the case of white males, at 1,231 circumcisions per one HIV infection, the economic argument for circumcision is less clear-cut.  The cost works out at $87,792 for each QALY saved.  This is at the borderline of cost effectiveness:  the traditional US cost-effectiveness threshold has been $50,000 per QALY saved, while the WHO recommends a threshold of three times per capita gross domestic product – which would give $140,000 per QALY.

Clearly, no one would nowadays advocate newly introducing newborn circumcision as a prevention measure in the US, if it didn’t already have a place in American tradition (though the benefits for STI prevention seem hugely more substantial than those envisaged by its original promoters).  Yet, given it does have such a place, it seems a shame not to take advantage of the potential public health benefits it can bring.

Aaron A. R. Tobian and Ronald H. Gray, “The medical benefits of male circumcision”, Editorial, Journal of the American Medical Association, 2011;306(13: 1479-1480

Samsom S.I., Prabhu V.S, Hutchinson A.B., et al “ Cost-effectiveness of newborn circumcision in reducing lifetime HIV risk among US males, PLoS One, 20105(1) e8723

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