Unkindest cut: Medicaid won’t cover circumcision in Colorado

Effective July 1, Colorado will join 17 other states in dropping coverage for routine circumcisions under Medicaid. The move was part of a series of budget cuts approved by lawmakers during the recent legislative session.

The decision will save the state’s general fund an estimated $186,500 annually, but it also will nudge Colorado closer toward a debate that has been growing in intensity across the country. In Massachusetts, a bill banning routine circumcision was introduced in the state legislature last year. Bans also have been proposed in Santa Monica, Calif., and San Francisco, where voters will decide in November whether to make the procedure a crime.

Gillian Longley, a registered nurse in Louisville, looks at the change in Medicaid policy as a critical moment for public education surrounding the issue. A member of the National Organization of Circumcision Information Resource Centers (NOCIRC), Longley said that until recently, new parents were remarkably ill-informed of the pros and cons of circumcision.

“Doctors were not giving them the information they needed to make a decision,” she said. “The usual ethical requirements for informed consent were overlooked. Circumcision was a cultural habit that was accepted as normal.”

Circumcision is the most common medical procedure performed on children in the United States, but is far less common around the world. According to data from the World Health Organization, 75 percent of men in the U.S. have been circumcised compared to 30 percent in Canada and 6 percent in the United Kingdom.

As states have dropped coverage for the procedure under Medicaid, circumcision rates have dropped. Researchers from UCLA studied 16 states where circumcision is not covered and found that the rate dropped 24 percent below rates in states where Medicaid covers the cost. The researchers said if Medicaid covered circumcision in all 50 states, the rate for newborns being circumcised would increase to 62.6 percent. If all states dropped the coverage, the rate would decline to 38.5 percent.

No medical justification

Colorado lawmakers had to cut hundreds of millions from state spending to balance the budget this year. Halting Medicaid coverage for circumcision is increasingly common across the country and is a relatively easy choice because there is no medical justification for the procedure.

“The medical reasons are not convincing either way,” said Dr. Susan Pharo, director of Medicaid and External Pediatric Care for Kaiser Permanente.

Research has found a “tiny” benefit in terms of circumcision reducing the frequency of urinary tract infections in the first year of life, Pharo said, “but the numbers are so low it’s not significant.”

Some research has found a slight decrease in the transmission of HIV and sexually transmitted diseases among circumcised men in sub-Saharan Africa, “but that’s not really applicable here,” Pharo said, “and the evidence is not strong either way.”

The risks of the procedure include relatively rare incidence of complications such as bleeding and infection and, more commonly, “poor cosmetic effect,” said Dr. Sarah Pilarowski, pediatrician at Cherry Creek Pediatrics.

“We do have a lot of baby boys going in later for revisions,” she said.

The No. 1 risk is pain. “We try to minimize it,” Pilarowski said, but penile nerve blocks don’t always work and numbing creams “are not 100 percent.”

Since 1999, the American Academy of Pediatrics has not recommended routine circumcision. A task force convened on the issue concluded that the “potential medical benefits … are not sufficient to recommend” it.

Cultural factors still important

The AAP defers the decision to parents, saying that it is “legitimate” to consider “cultural, religious and ethnic traditions, in addition to the medical factors, when making this decision.”

Acceptance of the procedure varies widely across different religious and ethnic populations. It is a culturally important tradition in the Jewish and Muslim communities, but is rare in Europe, most Asian countries and in Hispanic culture. In states with large Hispanic populations, circumcision rates are markedly lower than the national average.

“When asked by a family whether a circumcision should be done, most pediatricians  say unless there is some special reason in the family, they don’t recommend it as a general policy,” said Dr. Donald Schiff, professor emeritus of pediatrics at the University of Colorado School of Medicine.

For some families, however, the procedure is a cherished tradition.

Scott Levin, director of the Mountain States Region Anti-Defamation League, said that circumcision is “among the most sacred of obligations that Jews have” and proposed bans are an extreme affront.

“This is really about the free exercise of religion, something that is guaranteed to everyone in the United States under the First Amendment,” Levin said.

An effort to place a circumcision ban on the ballot in Santa Monica resulted in charges of anti-Semitism from Jewish groups. The author of the measure, Matthew Hess, refers to circumcision as “male genital mutilation” and ridicules the procedure in his online comic “Foreskin Man.”

The ADL issued a statement criticizing Hess’ tactics.

“This is an advocacy campaign taken to a new low,” it said in a written statement. “This is a sensitive, serious issue where good people can disagree and which the Jewish community feels is an assault on its values and traditions going back thousands of years and centered in the Hebrew Bible.  …  ‘Foreskin Man,’ with its grotesque anti-Semitic imagery and themes, reaches a new low and is disrespectful and deeply offensive.”

Hess, who is founder and president of MGMbill.org, said the ADL is “just trying to redirect the argument.

“Any time you challenge a tradition that is thousands of years old and this entrenched, you’re going to stir up fierce opposition,” he said. “Rather than address the human rights abuse of forced circumcision, they have attacked me. It’s pretty standard tactics.”

Ban written for Colorado

Hess said a bill outlawing circumcision in Colorado has been written and is awaiting a legislative sponsor. The measure would amend the existing law outlawing female genital mutilation, extending the same protections to males.

Longley said Colorado’s NOCIRC activists are not associated with Hess.

“One benefit we see in putting these measures on the ballot is that it results in a lot of public discourse about circumcision,” said Longley. “Our culture is ignorant and blind on this issue.”

In arguing against routine circumcision, Longley compared it to laws outlawing female genital mutilation. “Boys need equal protection,” she said. “We consider this a human rights issue.”

She cites the value of the foreskin in its role in male sexual function and female satisfaction. “We’ve lost the knowledge and the value of normalcy in our culture,” she said.

Schiff said evidence on the role of foreskin in sexual function is scarce and “very anecdotal. There’s nothing objective about that kind of research.”

Hess insists that male and female circumcision are exactly the same.

“You can argue about which one is more damaging or traumatizing, but the bottom line is both practices remove healthy functioning sexual tissue from an unconsenting minor.”

While he has no formal polling to cite, Hess said he believes the movement to ban circumcision is growing across the country. “Requests for interviews come in daily,” and he said traffic to his website and relevant Facebook and YouTube sites has increased dramatically.

Dr. Pharo said she has seen no evidence of a decline in support for circumcision in Colorado in her three decades as a pediatrician. “I don’t think as a society our culture has really changed very much.”

That’s not surprising to Dr. Pilarowski. Outside of religious traditions, she said, the overriding factor influencing parents’ decisions about circumcision is whether the father was circumcised.

“Men want their little boys to look like them. They say, ‘I don’t know how to care for it. I don’t know how to counsel them,’” she said. “There’s a comfort level in the father and son being alike.”

If it was up to the mothers, the pediatricians said, far fewer newborn boys would be circumcised because the moms would rather not subject their new babies to unnecessary pain and risk.

Real savings questioned

Some pediatricians and family practice physicians are concerned that the Medicaid cut will result in pressure on doctors to perform circumcisions on baby boys later when the procedure is more complicated and costly. Parents who feel strongly that their sons should be circumcised could try to urge physicians to claim that it is a medical necessity at six months in order to have the procedure qualify for Medicaid reimbursement.

If even 30 or 40 such cases occurred in a year, the savings to the state would likely be obliterated.

Another concern is that with every cut in Medicaid reimbursements, more physicians reduce the number of Medicaid patients they will accept into their practices.

Pilarowski speculates that the changes in Medicaid policies will spark changes in private insurance coverage.

“Everyone is looking to cut costs,” she said. “It’s very possible other insurance companies will follow suit.”

That would be considered a victory for the anti-circumcision activists.

“This is a normal body part,” said Longley. “We are doing our sons a favor to support them to stay whole.”

Sasha Dillavou contributed to this report.