A dramatic decline in the number of circumcisions of boys born in the United States may lead to a surge in the rate of sexually transmitted diseases, a new study contends. The cost of those infections could top $4.4 billion (R36.4 billion) over the course of a decade, according to a study in Archives of Pediatrics & Adolescent Medicine.
Rates of male circumcision - the surgical removal of foreskin from a penis - have plummeted from 79% in the 1970s and 1980s to about 55% in 2010, according to the study.
One reason for the decline is that more states (18 to date) refuse to cover the procedure under their Medicaid programs, said Arleen Leibowitz, author of an accompanying journal editorial and a professor of public policy at University of California, Los Angeles, Luskin School of Public Affairs.
In addition to cost-cutting measures, opposition to neonatal male circumcision on moral or ethical grounds likely accounts for part of the decrease, Leibowitz added. Some people believe clipping an infant's penile foreskin is a form of mutilation.
Study senior author Dr Aaron Tobian said evidence supporting the medical benefits of male circumcision continues to mount. Included are declines in HIV, genital herpes and penile and cervical cancers, which are caused by sexually transmitted human papillomavirus (HPV).
"States that are trying to look for cost savings should also look at this study and see in the long term that eliminating male circumcision coverage is not advantageous," said Tobian, an assistant professor of pathology, medicine and epidemiology at Johns Hopkins School of Medicine and Bloomberg School of Public Health in Baltimore.
Sexually transmitted diseases (STDs), including HIV and HPV, already cost the United States $17 billion each year in direct medical costs alone, the study authors stated. For the study, Tobian and his colleagues devised a computer model to estimate the cost of STDs should the US neonatal circumcision rate decline to 10%, the rate seen in Europe, where the procedure is not routinely covered by insurance.
The model predicted that health-care spending will increase by $313 for each circumcision not performed. Cases of HIV, the Aids-causing virus, would account for almost 80% of the increased costs, the authors said.
HIV infections to increase by 12%
Over a male's lifespan, HIV infections would increase by about 12%; HPV by roughly 29%; herpes by nearly 20% and infant urinary tract infections would more than double, the researchers determined. In females, high-risk HPV would increase by more than 18%, and bacterial vaginosis and trichomoniasis would increase by 51%.
The estimates are "extremely conservative," said Tobian, because the study only included direct medical costs, not indirect costs such as patient transportation and patient and caregiver productivity loss. "I believe the federal Medicaid program should reclassify male circumcision from an optional service to one that all Medicaid insurance plans should cover," Tobian added.
However, he said, he is "not mandating every individual should be circumcised. This should be a parental decision." In 1999, the American Academy of Pediatrics issued a policy statement stating that the available evidence was not compelling enough to recommend circumcision as a routine procedure.
But Leibowitz believes the evidence has changed appreciably since then."I would hope that [the AAP] would look at the available evidence, which really nails it down, and make the appropriate public health recommendation," she said.
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