Published January 4, 2020
Updated June 3, 2023
Circumcision opponents often tell each other that not only are they on the right side of history, but they are winning the fight to end the procedure. [1] While groups like Intact America and the Blood Stained Men make a lot of noise and get a lot of publicity, are they actually reducing the number of circumcised boys? Are they actually changing a significant number of minds? As we are at the beginning of a new decade, it makes sense to take a look back at events of the past decade.
MEDICAL ASSOCIATION POLICY STATEMENTS
In its 2012 policy statement the American Academy of Pediatrics declared that "Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it." [2] This assessment is more supportive of the procedure than the previous 1999 AAP policy statement, which merely stated that "existing ... data are not sufficient to recommend routine neonatal circumcision. [3] The AAP policy statement has been quite influential, as government agencies have cited the AAP statement when formulating policy decisions.
In 2018 the U.S. Centers for Disease Control published a statement largely in agreement with the AAP. Not only did the CDC support parental choice and insurance coverage for the procedure, the federal agency went a step further. The CDC recommended that medical professionals inform all uncircumcised adult men and teenage boys that circumcision protects against HIV and other sexually transmitted infections. [4]
Policy statements by the Royal Australasian College of Physicians and the Canadian Paediatric Society also support parental choice. The 2010 RACP statement declared, "it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons... Parental choice should be respected." [5] The 2015 CPS statement affirmed several of the medical benefits cited by the AAP, and agreed that medical professionals "should provide parents with the most up-to-date, unbiased and personalized medical information available so that they can weigh the specific risks and benefits of circumcising their son in the context of familial, religious and cultural beliefs". [6]
The World Health Organization published a comprehensive 140-page manual on infant circumcision. The preface states, "There are significant benefits in performing male circumcision in early infancy, and programmes that promote early infant male circumcision are likely to have lower morbidity rates and lower costs than programmes targeting adolescent boys and men." [7]
INSURANCE COVERAGE
At the time that the AAP policy statement was issued, Medicaid covered newborn circumcision in 33 states. [8] [9] Since 2014 at least five states have added or reinstated circumcision coverage. They include Florida, [10] Missouri, [11] Colorado, [12] North Carolina, [13] and South Carolina. [14] There are conflicting reports about whether Medicaid covers circumcision in Louisiana [15])
Intactivist attempts to end medicaid coverage for the procedure have been in vain. This statement by a Texas agency responding to a letter is typical. State health agencies are responsible to follow sound recommendations of leading medical associations, rather than partisan fanatics educated by social media.
"After careful consideration HHSC is continuing existing coverage for this benefit based on findings related to the prospective medical benefits and associated potential public health implications of male circumcision recognized by the American Academy of Pediatrics (AAP), the American Urological Association (AUA), the U.S. Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO).” [16]
LEGAL ACTIONS
In 2011 activists in two California cities collected signatures for municipal ballot measures that would have banned elective circumcision of all boys under 18. The sponsor of the Santa Monica measure voluntarily abandoned her effort. [17] While the San Francisco measure received enough signatures to qualify for the ballot, a judge removed the measure before the election because it violated state policy that precludes cities and counties from regulating medical procedures.
In response to the ballot measures, the California legislature swiftly and unanimously passed a law that makes explicit the prohibition against municipal restrictions. The law declares that "male circumcision has a wide array of health and affiliative benefits". [18] Concurrently Congressman Brad Sherman of California introduced a federal bill that would have prohibited such restrictions nationwide. [19] Sherman's bill died in committee.
The 114th U.S. Congress passed the Frank N. Wolf International Religious Freedom Act. One provision identifies circumcision as a religious freedom. The U.S. State Department is authorized to use diplomatic measures to protect religious freedom on a global basis. President Obama signed the act into law on December 17, 2016. [20]
In 2018 a federal judge declared the 1996 Female Genital Mutilation Act unconstitutional. The ruling was based on the scope of the Constitution's interstate commerce clause and was unrelated to the legal status of circumcision. [21] In response the executive and legislative branches passed a replacement bill to satisfy the interstate commence clause. President Trump signed the bill on January 5, 2021. [22]
Across the Atlantic a prosecutor in Germany charged a doctor with physical mistreatment following the hospitalization of a 4 year-old boy with bleeding two days after a circumcision. In 2012 a regional court in Cologne ruled that the surgery, performed for religious reasons, constituted bodily injury. [23] The ruling was contested by a union of Muslim, Jewish, and Christian groups. Later that year the national legislature overwhelmingly passed a law that overturned the court ruling and protected parental choice throughout Germany. [24]
Despite the fact that circumcision in Iceland is rare, [25] in 2018 the Iceland parliament was poised to criminalize circumcision of minor boys. The proposed legislation would have imposed a penalty of six years in prison for anyone performing a circumcision for non-medical reasons. ”Sources are conflicted as to whether the bill was dismissed [26] or simply tabled for later review. [27] With no update in the past nineteen months, it's likely that elected leaders have backed down from a ban.
In August 2020 a parliament member introduced similar legislation in Denmark. [28] Despite having expressed support for a ban many years earlier, Prime Minister Mette Frederiksen publicly opposed the bill, citing the history of Jews in Denmark. [29] The head of the anti-circumcision organization Intact Denmark accused the U.S. and Israeli governments of trying to "interfere in Danish domestic politics." However intactivists from around the world also tried to influence the vote via an email campaign, and some Danish leaders admitted that the lobbying efforts were within the normal bounds of diplomatic influence. [30] In May 2021 the proposed ban was rejected by a 62-32 vote. [31]
Circumcision remains legal in every country on earth.
OTHER INTERNATIONAL DEVELOPMENTS
Since 2004 the U.S. President's Emergency Plan For AIDS Relief (PEPFAR) has supported the circumcision of nearly 23 million males in developing countries, including nearly 4 million during 2019. [32] [33] A study surprisingly showed that the rate of newborn circumcision complications was higher than the rate of adolescent complications, which in turn was higher than the rate of adult complications. Based on the study results PEPFAR announced a temporary halt in circumcisions for boys under age 15. A draft plan stated that PEPFAR may reevalute the role of infant circumcision once additional data is available, including data on the safety of the ShangRing devise (see below) for young adolescents. [34]
Circumcision opponents have trumpeted headlines announcing that more and more Jewish parents are choosing against circumcision - even in Israel, the most circumcision-friendly country on earth. However media reports have featured mere anecdotes, not scientific evidence. [35] [36] In reality, a 2017 survey of 501 Israeli Jewish parents found that 98% circumcised their sons. [37][38] This figure represents an improbable one percent increase over the previous decade. [39]
ShangRing, a relatively new device, has been used in China since 2005. Tests show that the ShangRing is quick, safe, and effective for circumcision of adolescent and adult males. [40] Based on the results of trials, the device may support the widespread circumcision of men in Africa for HIV prevention.
A union of Chinese hospitals reported that hospitals in Beijing are training university doctors to perform circumcision via ShangRing. Training includes educating the participants about the importance of circumcision as part of a program to prevent HIV. As of April 2019 more than 5,000 circumcisions had been performed. [41]
CONCLUSION
Intact America was created in 2009 with a million dollar endowment. The group has more than 50,000 Facebook fans, and the executive director is often interviewed for circumcision related stories. The Blood Stained Men formed in 2012; they have held more than 350 protests in the past seven years. These two have been the most prominent groups in terms of media coverage over the past decade. While intactivists have had moderate success at getting media attention, their attempts to influence medical authorities and end third-party coverage have been complete failures. If historical trends continue, based on the AAP and CDC statements in support of circumcision and the addition of states offering Medicaid coverage, the circumcision rate in the United States is likely on the rise.
Globally the WHO estimated in 2007 that about 30% of males were circumcised. [42] A 2016 estimate by pro circumcision researchers offered an approximation of 37.7%. [43] If China - home to 20% of the world's population - goes for circumcision, then at some point in this century, circumcised men will be in the majority.
[1] See for example: Georganne Chapin; "Working to Outlaw Infant and Child Circumcision – A Wise Strategy, or Not?"; Intact America blog; December 2, 2011. "The other side is afraid, because they know we are winning, and that their professed right to cut the genitals of babies is being challenged as never before." J Steven Svoboda; "Message From the Executive Director"; Attorneys for the Rights of the Child newsletter; April 17, 2019. "In short, we are winning. Soon, we will have won." Kenneth Hopkins (a.k.a. "Brother K"); "Grassroots Intactivism"; Blood Stained Men & Their Friends Facebook post; June 22, 2019. "We are winning."
[2] Susan Blank MD et al; Circumcision Policy Statement - Task Force on Circumcision; Pediatrics; September 2012
[3] Carole M. Lannon MD et al; Circumcision Policy Statement - Task Force on Circumcision; Pediatrics; March 1999
[4] "Information for Providers to Share with Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV Infection, Sexually Transmitted Infections, and other Health Outcomes"; Centers for Disease Control and Prevention; August 2018
[5] "Circumcision of infant males": Royal Australasian College of Physicians; September 2010
[6] S Todd Sorokan et al; "Position Statement - newborn male circumcision"; Canadian Paediatric Society; September 8, 2015; Reaffirmed February 28, 2018
[7] "Manual for early infant male circumcision under local anesthesia"; World Health Organization; February 2011
[8] Some anti-circumcision websites have indicated that Nevada does not cover the procedure. In fact Medicaid covers circumcision in Clark County (Las Vegas) and Washoe County (Reno), which represents 88% of the state's population. "Medicaid managed care plans in two urban areas cover routine newborn male circumcision." (Source - footnote [14], p 69)
[9] The United Healthcare Services website confirms that newborn circumcisions are included in a list of covered benefits. (Accessed December 28, 2019)
[10] Florida reinstated coverage in 2014. "Florida Managed Medical Assistance Program 2013-2014 Financial Annual Report", p. 13; Florida Agency for Health Care Administration. "The following is a list of the expanded services offered by the capitated Reform health plans of which the over-the-counter drug benefits and adult preventive benefits were the most frequently offered: ... Circumcisions for male newborns"
[11] Missouri reinstated coverage in 2014. Provider Bulletin; Missouri Department of Social Services; Volume 36, Number 31; June 12, 2014. "Effective June 15, 2014, MO HealthNet will pay for elective circumcisions for all newborn infants less than 28 days old using Current Procedural Terminology (CPT) codes 54150 and 54160.
[12] Colorado reinstated coverage in 2017. Provider Bulletin; Colorado Department of Health Care Policy & Financing; September 2017. "Beginning July 1, 2017, circumcision is a benefit of the Colorado Medicaid program. The following procedure codes are covered services and can be reimbursed: 54150, 54160 or 54161. There are no prior authorization requirements for this service."
[13] North Carolina reinstated coverage in 2021. "Clinical Policy 1A-22, Medically Necessary Circumcision Revised"; North Carolina Department of Health and Human Services; December 29, 2020. "Effective Jan. 1, 2021, providers billing for medically necessary circumcisions performed for the prevention of disease [including HIV] for newborn and non-newborn male beneficiaries should submit diagnosis Z29.8 (encounter of other specified prophylactic measures) and an appropriate circumcision procedure code."
[14] South Carolina reinstated coverage in 2021. SCDHHS Policy Updates for July 1, 2021 - Coverage for Newborn Circumcisions; South Carolina Deoartment of Health and Human Services; June 3, 2021. "SCDHHS will provide coverage for routine newborn circumcisions without the necessity for prior approval effective for dates of service on or after July 1, 2021. This policy change affects male newborns whose birth is covered by fee-for-service Healthy Connections Medicaid. Routine male circumcision is already a covered benefit for Healthy Connections Medicaid members who are enrolled in a managed care organization (MCO). This policy change does not affect coverage for newborns who are covered by an MCO but is being made to ensure comprehensive care and promote consistency across the array of covered benefits. Coverage will include services rendered under CPT codes 54150 and 54160 for those 28 days old and younger."
[15] We have found conflicting information about Medicaid coverage in Louisiana. We have reached out to the Louisiana Department of Health and will update this post when we receive clarification.
[16] Executive Director Courtney N. Philips; letter to Ms. Bannister; Texas Health and Human Services Commission; October 25, 2019
[17] Jennifer Medina; "In Santa Monica, Circumcision Opponent Abandons Efforts"; New York Times; June 7, 2011
[18] "States do not allow "just anyone" to perform a circumcision"; Circumcision Choice; April 22, 2019
[19] Madeleine Morganstern; "Calif. congressman to introduce bill to protect circumcision"; Jewish Telegraphic Agency; June 14, 2011
[20] "H.R.1150 - Frank R. Wolf International Religious Freedom Act"; Congress.gov
[21] "Intactivist scholar misunderstands FGM ruling"; Circumcision Choice; November 27, 2018
[22] Hollie McKay; "Trump signs anti-female genital mutilation law that increases punishment of perpetrators"; Fox News; January 6, 2021
[23] Barbara Hans; "Muslims and Jews Outraged by Circumcision Ruling"; Spiegel Online; June 27, 2012
[24] Madeline Chambers; "Circumcision ban overturned in Germany"; Globe and Mail; December 12, 2012
[25] Saphora Smith; Iceland's proposed ban on circumcision rattles Jews, Muslims; NBC News; September 21, 2018. "The practice is uncommon in Iceland. The country's Directorate of Health said its records showed a total of 21 males under the age of 18 have been circumcised at hospitals or private clinics since 2006. It cautioned that its records on circumcision were patchy as some specialists refuse to submit their data. It could not say how many were for religious reasons. [One Jewish resident] said that the effect of such a ban on people living in Iceland who are neither Jewish nor Muslims would be 'basically zero.'"
[26] Alice Demurtas; "Ban On Circumcision In Iceland To Be Dismissed In Parliament"; Reykjavík Grapevine; April 26, 2018
[27] Zelda Caldwell; "Bill to criminalize male circumcision is still alive in Iceland"; Aleteia; May 29, 2018. "
[28] Cnaan Liphshiz; "Danish lawmakers to mull circumcision ban, sparking protest"; Times of Israel; September 7, 2020
[29] Cnaan Liphshipz; "Danish PM opposes bill banning circumcision, cites her promise to Jews"; Jerusalem Post; September 12, 2020
[30] Lena Hunter; "Foreign interference? Evidence points at US and Israeli meddling in Danish circumcision debate"; CPH Post Online; April 20, 2021
[31] "Danish parliament rejects ban on boys' circumcision"; Christian Network Europe; May 19, 2021
[32] The figure is for the federal fiscal year 2019, which covers October 1, 2018-September 30, 2019.
[33] Netta Ahituv; "Even in Israel, More and More Parents Choose Not to Circumcise Their Sons"; Haaretz; June 14, 2012. "Because no systematic record is kept of the number of circumcisions performed in the country ... there are no exact data. Indeed, the Health Ministry itself has no figures regarding this at all. However, according to most estimates, between 1 to 2 percent of Jewish males born in Israel in the past decade were not circumcised."
[34] "Draft PEPFAR 2020 Operational Plan: Guidance for all PEPFAR Countries"; U.S. President's Emergency Plan for AIDS Relief ; November 2019
[35] Linda Gradstein; "Circumcision Rates are Slipping - Even in Israel"; Forward; January 15, 2018. "While exact statistics are not available, it seems clear that the decision to forgo circumcision is becoming more acceptable, at least in secular Israeli circles."
[36] "Survey: 98% of Jewish baby boys in Israel are circumcised"; Arutz Sheva; December 27, 2017
[37] David Israel; "The Forward Misinforms Readers to Promote Anti-Circumcision Agenda"; Jewish Press; January 15, 2018. "The first survey, in 2007, found that 97% of the Israeli public will circumcise their sons..."
[38] Zvika Klein; "UTJ's coalition demands will have opposite effect from what it intends - analysis"; Jerusalem Post; December 13, 2022
[39] X Wu et al; "A report of 918 cases of circumcision with the Shang Ring: comparison between children and adults"; Urology; May 2013
[40] Yue Cheng MD et al; "Chinese Shang Ring Male Circumcision: A Review"; Urologia Internationalis; 2018
[41] Yang Wanli; "Circumcision to be promoted at Beijing universities"; China Daily; April 26, 2019
[42] "Male circumcision Global trends and determinants of prevalence, safety and acceptability"; World Health Organization; 2007
[43] Brian J. Morris et al; "Estimation of country-specific and global prevalence of male circumcision"; Popular Health Metrics; March 1, 2016