In their comments regarding our article, Green et al. do not dispute our article's conclusion that a lack of Medicaid coverage for infant male circumcision discourages the use of this procedure. However, they differ sharply with us in their interpretation of whether this lack of coverage potentially impairs the health of poor infants. In an editorial published earlier this year,1 the same 4 individuals argued that the circumcision of infant males in Africa is unethical. Accordingly, when they argue that we “should have concluded that poor children are now at lower risk of neonatal circumcision harm,” we find it difficult to disentangle what might be read as a scientific claim from the value judgments they have espoused elsewhere. The fact that 48 physicians, public health professionals, and HIV/AIDS researchers joined in a rebuttal2 to Green et al.'s editorial, citing analyses that it is unethical to deny male circumcision in areas of high HIV prevalence,3,4 underscores that there are many people whose value judgments diverge from those of Green et al. We stand by our statements about the policy implications regarding states that do not offer Medicaid coverage for male circumcision, but rather than engaging in a policy debate, in what follows we highlight the scientific foundation for our conclusions. The peer-reviewed literature concerning the long-term health effects of male circumcision points to lower rates of urinary tract infections (UTIs),5 lower rates of penile human papillomavirus infection,6 lower rates of penile cancer,7,8 and a lower risk of chancroid and syphilis.9 A joint World Health Organization and United Nations Programme on HIV/AIDS (UNAIDS) report reviewed 86 randomized controlled trials, systematic reviews, and meta-analyses and found a consistent, protective effect of MC against penile infections.10 Three recent randomized controlled trials provide evidence that circumcising adult men substantially reduces their risk of HIV infection from a female partner.11–13 Regarding the risk of complications of the procedure itself, a thorough review of the literature conducted for the World Health Organization and UNAIDS states, “Neonatal circumcision is a simpler procedure than adult circumcision and very low rates of complications (0.2%–0.4%) have been consistently reported in large series of neonatal circumcision in the United States and Israel.”10(p17) Green et al. base their case that male circumcision is “associated with higher rates of UTIs” in the neonatal period partly on a study conducted in Israel14 in which all of the infants in the study were circumcised and UTI rates were compared between those circumcised by a physician and those circumcised by a religious authority. Although the UTI rate was higher in the traditionally circumcised group, the rate of UTIs in Israel (a country in which nearly all boys are circumcised) remains lower, particularly for boys circumcised by a physician, than the rate among uncircumcised male infants in the United States.14 Similar inferential pitfalls can be found in the claims related to HIV and penile cancer rates in the United States and Europe based on comparisons that fail to control for other relevant variables. The randomized controlled trials in Africa, by contrast, provide compelling evidence that male circumcision protects against infection by HIV, because randomization balances the other factors that may affect the likelihood of infection between the circumcised and the control groups. Readers will have to arrive at conclusions through the prism of their own value judgments, but we are comfortable recommending that public health would be advanced if states were to cover medical circumcision through their Medicaid programs.
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Nov 19, 2009
Rebeca M Plank + 8
Open Access
