08.27.12

American Academy of Pediatrics: Circumcise It!

To snip or not to snip? Rates have been sliding for decades. Enter the nation’s top pediatricians, who are now recommending the procedure for the first time. Lizzie Crocker reports.

The nation's most influential pediatricians have given male circumcision a second look, and they like what they see.

In a new policy report published Monday, the American Academy of Pediatrics endorsed the procedure and its medical benefits for the first time, urging third-party insurance providers to cover the cuts. The landmark guidelines come on the heels of a surprising study published last week by Johns Hopkins researchers, which linked declining rates in circumcision in recent years to rising health-care costs—and a measurable spike in sexually-transmitted infections.  

Whether the new findings will reverse a decades-long slump is up for debate. The traditional Jewish practice was culturally ensconced in the U.S. as recently as the 1970s and 80s, when a finely sculpted mushroom top was practically de rigueur and roughly 79 percent of newborn boys had their biologically bestowed foreskins snipped and discarded like toenails. Through the 90s, it seemed, America was averse to foreskin. In one famous Seinfeld episode, Elaine turned her nose up at the thought of an uncircumcised pecker, complaining that it “lacked personality” and “looked like a Martian.”

But rates had begun a freefall in the late 80s, due in part to the growing population of immigrant Hispanics who are less likely to circumcise their children, according to a 2007 CDC study. By 1999, the frequency had dipped to 63 percent—the same year the AAP, in its previous policy report, voiced a neutral stance on the procedure’s health benefits. Eighteen states have since eliminated Medicaid coverage for circumcision, a change that both the AAP and John Hopkins researchers say has largely contributed to an even further dip in the rate of the procedure. Today, fewer than 55 percent of newborn boys go under the knife.

“There’s enough medical evidence to suggest we shouldn’t have been neutral before,” says Dr. Michael Brady, a member of the AAP’s circumcision task force, who allows that by not recognizing procedural health benefits in previous reports, the AAP gave Medicaid the opportunity to decline payment. “Now, we’re clearly stating that third-party payers and Medicaid should cover circumcision so that parents aren’t having the decision made for them.”  

And boy, the newly recognized health benefits are many: for starters, lower risks of men acquiring HIV, genital herpes, HPV, syphilis, penile cancer, and UTIs, in addition to reduced cervical cancers among their female sexual partners. In this respect, the report affirms many national and international scientific studies, including one in 2005 by French and South African researchers who found that male circumcision cuts the risk of HIV infection by up to 60 percent.  

“The medical benefits of circumcision are already abundantly clear,” concurs Dr. Aaron Tobian, a senior author on the Johns Hopkins study, which analyzed the cost implications of declining circumcision rates in the U.S. If circumcision rates were to be trimmed down to 10 percent—the average in Europe, where the procedure is not routinely covered and sometimes even outlawed—the country’s annual net increase in medical costs would amount to roughly $500 million dollars, according to the study.  

“I remember how uncircumcised kids were treated in the locker room.”

Doctors’ advice aside, parents—especially those born during the golden age of circumcision—tend to point out that the decision to snip or not snip is ultimately a cultural one.  “A lot of it has to do with whether you’re circumcised yourself,” says Austin Olney, 32, whose two boys had their genitalia scalpelled shortly after birth.

The cultural standard is evident among Latin Americans in the U.S., who generally keep their elongated foreskins. For the few who would choose to circumcise their sons, Tobian warns that decreasing Medicaid coverage may stymie their efforts and exaggerate the country’s racial and socioeconomic disparities. “Some populations likely to qualify for Medicaid have the lowest rates of male circumcision and the highest risks of STIs,” he says. “In the end I think we should remove all the barriers to the procedure, at which point parents can discuss the risks and benefits with their physician and make an informed decision.”

Sure, but what’s the likelihood that state legislatures, which set Medicaid guidelines, will reverse their coverage policies? “Getting them excited about adding a health benefit with new costs to Medicaid is not going to happen easily,” admits Brady.

Nor will virulent opposition from those who think the procedure is barbaric won’t make the process any easier.

“The research is conducted by circumcised men, it’s reviewed by circumcised men, and it completely ignores the functions of the foreskin,” Dr. Ronald Goldman, executive director of the Circumcision Resource Center in Boston, tells The Daily Beast. “On average, the adult foreskin is 12 inches of highly erogenous tissue,” says Goldman, author of Circumcision: The Hidden Trauma and Questioning Circumcision: A Jewish Perspective. A 2006 study published in the British Journal of Urology concluded that “circumcision ablates the most sensitive parts of the penis,” therefore making sex less pleasurable. “We’re talking about a double layer of skin with specialized nerves that is completely foreign to circumcised men,” says Goldman, himself a circumcised Jew. “They literally don’t know what they’re missing.”  

Goldman is outspoken about the supposed harmful psychological effects of having one’s foreskin sliced off, which he compares to PTSD and even rape. “It’s a psychological issue that is being disguised as a medical issue,” he says, claiming that a growing number of Jewish people in the U.S. and abroad are not circumcising their sons. “Unfortunately there’s very little political will to come up with the money to study the harm of circumcision. Culturally, we don’t want to hear about it.”

The AAP’s new report refutes the theory that circumcision decreases sexual pleasure, citing one study in which a group of sexually active African men underwent the procedure as adults. The majority didn’t notice a difference during sex afterwards, but among those who did notice a difference, the majority said it made sex better. “Even if we weren’t going to routinely recommend circumcision, we could tell parents the risks and benefits and be confident that we weren’t subjecting their child to a lifelong change he would be uncomfortable with,” says Brady.   

Despite the health benefits confirmed by the AAP, tradition and culture continue to have the final say on both sides of the debate. For Olney, ensuring that his kids fit in was ultimately the deciding factor. “I remember how uncircumcised kids were treated in the locker room,” he says. “At the end of the day, you’re not basing your decision on what the AAP says.”