This site does not give medical advice. Consult your physician if you have questions about you or your child's particular situation. Information on this site is strictly for noncommercial, educational research.
What do the AMA and other medical organizations say about circumcisions? Does ANY medical society in the world recommend circumcision at birth?
Not a single medical society recommends this, and some vehemently oppose it. See http://www.circumcision.org/position.htm
Research showing a lessening of AIDS and other disease transmission rates is complex and ongoing, but in any event the eventual outcome of that research is to give men the data needed to make an informed choice. Grown men can make up their own mind whether they want the surgery, and parents with private insurance or paying for it themselves can similarly make their own decisions (although we hope they will make an informed decision, so neither they nor their child will regret the decision later). This site is only concerned with the use of taxpayers' money in the state of Kentucky to have the surgery performed as a prophylactic on children receiving Medicaid benefits. Even as the state's budget situation has gotten more and more dire, and many other states are dropping funding for it, the Kentucky Department for Medicaid has not only continued but greatly expanded funding for this procedure in recent years.
[OLD info] How much does Kentucky pay each year for publicly-funded neonatal circumcisions?
In the fiscal year ending June 30, 2008, it paid about a million dollars, including "repairing" circumcisions that had problems or "lesions."
The Department doesn't separately list treatment for infections, one of the major complications of circumcision. MRSA and other infections that are more common in circumcised infants are not represented under the circumcision category.
[Old info] 2009 Update:
The Department has released its cost figures for the fiscal year ending June 30, 2009:
Procedure code & Description
Paid Amount Count
Paid Amount Count 54150 - Circumcision W/Regionl Block5890347441
589034744154160 - Circumcision, Neonate81696625
8169662554161 - Circum 28 Days Or Older285816964
28581696454162 - Lysis Penil Circumic Lesion44737206
4473720654163 - Repair Of Circumcision54456183
54456183The Department increased overall spending for nontherapeutic circumcision by over 12% (from $934,621 to $1,055,739). The amount spent to repair problem circumcisions increased by over 40%. Total "repairs" of taxpayer-funded circumcisions rose from 138 to 195, giving taxpayer-funded circumcisions a complication rate of at least 2.2% (if we assume the "lysis" category does not include treatment for circumcision-acquired infections) to over 4% (if the lysis category covers such infections). The American Academy of Pediatrics says "Complications occur in 1 in 200 to 1 in 500 circumcised newborn males and are most often minor" or .05% or less, so in Kentucky the rate appears to be at least four times higher than it should be, and possibly higher considering that the complication numbers shown above are those requiring surgical intervention of some sort; the "most often minor" category is probably much larger.
Is circumcision safe and effective? Shouldn't men be able to choose to have it done?
The issue of its safety and effectiveness can be debated a length. Yes, there's data that it has some protective effects but also some significant risks, including amputation of the penis and MRSA. Complications are not rare, but vary widely in their effect on the child. Statistically, of course, you can expect a percentage of infants to die from blood loss or infection. Of course, you should always check with your physician about any medical problem. This site cannot and does not give medical advice about your particular situation.
If you are deciding whether to have a circumcision, or whether to have one done on your son, you owe it to yourself (and him) to find out as much as you can about the procedure. There are numerous videos online showing exactly what happens during the procedure. You may also enjoy Penn & Teller's take on the subject. If you are having your child circumcised, you should also know that he is at a much greater risk for infection with MRSA or another staph infection, see Nguyen et al, Risk Factors for Neonatal Methicillin-Resistant Staphylococcus aureus Infection in a Well-Infant Nursery, Infection Control and Hospital Epidemiology, April 2007, vol. 28, no. 4. You should take extensive precautions both in the hospital or clinic and at home.
What was the complication rate in Kentucky for circumcisions paid for by the state?
The Department doesn''t provide official figures, but from the data obtained via Open Records requests we can get a good idea of how many circumcisions had complications. The typical neonatal circumcision rate nationally is low, usually cited at less than 1%. (See the American Academy of Pediatrics policy statement) In Kentucky, it appears that complications in Medicaid-paid circumcisions are significantly higher: If repairs of circumcisions and removal of scar tissue from circumcisions are compared to the number of circumcisions performed, the complication rate appears to be well above 3% for these taxpayer-funded surgeries. Again, this does not include the cost of treating infections. Also, the exact nature and extent of these complications can't be known because the Department doesn't collect this data--complications could be minor, or life-threatening. Of course, many complications (including infections), could be presented under treatment codes unrelated to circumcision, even though the surgery was the source of the initial problem.
What does state law say about how Medicaid dollars can be spent?
Under 907 KAR 3:130, Medicaid expenditures must be "medically necessary." Further, it must be "based on an individualized assessment of the recipient’s medical needs" and be "required to identify, diagnose, treat, correct, cure, palliate, or prevent a disease, illness, injury, disability, or other medical condition" and "provided for medical reasons rather than primarily for the convenience of the individual, the individual's caregiver, or the health care provider, or for cosmetic reasons." Since an intact infant has no "medical condition", and this surgery is done because a small (but unknowable) percentage of children may eventually have problems, it is not really "individualized" but is basically a social experiment based on statistics about what will happen to some small percentage of these children at some time in their lives..
Does the Department require doctors to ask whether parents are choosing the surgery for cultural or cosmetic reasons (to "look like Dad") rather than medical reasons.
No, the Department does not require that parents be told anything, nor does it track why parents choose the procedure.
What does the Department say about paying for routine neonatal circumcision?
The Medical Director is in favor of public funding for this procedure and refuses to permit any hearings on the matter. In the Department's view, as long as a doctor is willing to perform the surgery, the state will pay for it with no questions asked. No prior authorization is required. The state does not require that the parents be told that circumcision is an elective procedure, nor does the state require that the infant receive an anesthetic. No hygienic or follow-up care is recommended or required. No complication rate is reported back to the Department.
Here is the text of the Department's official policy on funding for this procedure, as announced by its Medical Director in 2008. You may also find interesting the Department's official policy on why it pays for nontherapeutic circumcisions (comparing it to paying for a "runny nose" doctor visit). Note that one of the main reasons cited for funding the procedure is reduction of urinary tract infections. The Department has more recently been presented with an analysis that using surgery as a prophylactic against UTIs works out to a cost of well over $7000 for every UTI avoided in this way. Further, more recent research suggests that circumcised infants are up to twelve times more susceptible to MRSA-type staph infections than intact males. (<---Warning: Graphic images on this link!) The Department so far has not considered this new research and has denied requests to have this funding issue brought up in any public hearing. The Medical Director's decision is considered final.
The main reasons for the Department's position upholding taxpayer funding in Kentucky are avoidance of urinary tract infections, penile cancer, and avoidance of HIV. The Department does not weigh the risks of surgery against the purported benefits nor does it consider the relative risk of each of these. The American Academy of Pediatrics does weigh these, as follows:
Although studies show the relative risk of developing a urinary tract infection (UTI) in the first year of life is higher for baby boys who are uncircumcised, the AAP policy concludes that their absolute risk of developing one is low - at most approximately 1 percent. Research indicates that during the first year of life an uncircumcised male infant has at most about a 1 in 100 chance of developing a UTI, while a circumcised male has about a 1 in 1000 chance. Studies conclude that the risk of an uncircumcised man developing penile cancer is more than three-fold that of a circumcised man. However, the AAP policy notes that in the United States only 9 to 10 cases of this rare disease are diagnosed per year per 1 million men, indicating that while the risk is higher for uncircumcised men, their overall risk is extremely low. Some research suggests that circumcised men may be at a reduced risk for developing syphilis and HIV infections. However, the AAP policy states that behavioral factors continue to be far more important in determining a person's risk of contracting sexually transmitted diseases than circumcision status.
ScienceDaily. Retrieved September 28, 2009, from http://www.sciencedaily.com /releases/1999/03/990302063210.htm
If fewer than 1 in 100 uncircumcised males will get a UTI, logically the Department would have to fund over 100 circumcisions to prevent a cingle infection. That's over $7000 per avoided infection. Also, circumcising male infants now would only prevent a cost-savings to the Department if they remained on public assistance decades from now when they might acquire HIV or another STD/STI.
Does the state monitor what circumcisions it pays for? Does it require the doctor to infiorm the parents of the risks and benefits of the surgery? Has it investigated statistically high complication rates? Does it discuss this funding in committee meetings open to the public? Has it discussed discontinuing this expenditure in light of the budget crisis?
No.
“I have a grave fear that a cliff is out there somewhere for us on Medicaid.”
Rep. Jimmie Lee, Medicaid Oversight and Advisory Committee
We asked the Medical Director, Dr. Thomas Badgett, as well as members of the legislative Medicaid Advisory reveiw Committee to comment on why the state has not updated its policy statements, why the taxpayer-funded complication rate is so high, and why the state would pay over $7000 to avoid an infection treated in other states with a $4 antibiotic. Here is the reply:
The Cabinet for Health and Family Services recently eliminated funding for sexual abuse coordinators at the state's 14 community mental health centers as well as staff members who assess and treat adult sex offenders. Social workers are being laid off. Security for state workers is being slashed. The Cabinet is cutting home health for the disabled. Rep. Jimmie Lee of Elizabethtown, chairman of
the House Subcommittee on Human Resources, says a shrinking state budget will make it difficult to find funding to bolster domestic
violence programs, including community shelters that serve as refuges for battered spouses.Why is neonatal circumcision still being funded when dozens of other states have dropped it as unaffordable? Ask your senator or representative; maybe they can get an answer where mere parents like us cannot.
How many state-funded circumcisions were done for religious, cosmetic or cultural reasons?
The Medicaid Department does not ask this question of its providers or recipients, and does not perform any statistical analysis on the subject, so it does not know. It pays for any circumcision a doctor is willing to perform on a Medicaid-recipient child. If the doctor does the surgery, the Department pays for it, period.
If we don't pay for this procedure for poor kids, won't we be making them "look different" based on their income level?
Circumcision rates are low in most of the world, and are plummeting in the U.S. In many areas of the country it's the circumcised boys who "look different." In any event, state law does not permit payments for cosmetic surgeries. Interestingly, the International Statistical Classification of Diseases and Related Health Problems (ICD) classifies routine circumcision (in the absence of any medical indication) in the same category as ear piercing, facelifts, and hair transplants.
Don't other states cover this procedure in their Medicaid systems?
Some do, but many have dropped this coverage, and the overwhelming trend is not to fund them, since this is elective surgery with potential benefits that may not show up for decades, if at all. Just in the past few years Florida, North Carolina, Missouri, Michigan, Arizona, and many other states have dropped this coverage as not giving much "bang" for the health dollar buck.
Don't circumcised boys get fewer urinary tract infections (UTIs)?
Slightly, yes, although the science is murky. In any event, since less than one in 100 boys would get a UTI, at least 100 boys would have to be circumcised to prevent a single UTI. At $70 per circumcision, we're spending $7000 for every UTI we prevent via prophylactic surgery. Add in the potential complications of surgery (including MRSA and other nasty bugs), and the figure skyrockets. By comparison, most states treat UTIs in Medicaid kids just fine with a $4 antibiotic.
How do you know how much Kentucky spends on this? Can I get a copy of the data?
Of course. A lawsuit a few years ago forced the Medicaid Department to reveal how much it pays to whom for what services. You can get a complete copy of the Medicaid Provider and Procedure database using this form. It will cost you $15 and will be delivered to you on a CD. You'll then need to "import" the data in Microsoft Access or another database system in order to see the data (unless the Department sends it to you already in Access format, as they have done in recent years--although they are not required to do so). It will be broken down by provider and procedure. The main CPT code governing routine neonatal circumcisions is 54150, but the database will also have a plain-language entry for each procedure. If you have trouble getting this data from the Department, please let us know. Remember, this data can only be used for noncommercial purposes!
Why can't Kentucky afford this benefit?
The Medicaid budget is doing much worse than anticipated. As one recent story put it, "For agencies that receive Medicaid benefits, like Cedar Lake Lodge and Residences in Louisville, funding has been stagnant for the last few years, while costs continue to rise. 'We are actually eroding away any quality components and enhancements that once existed in the program,' says Cedar Lake President Jim Richardson. “We are down to bare bones.” State senator Julie Denton, chair of the Senate Health and Welfare Committee and is on the Medicaid Oversight and Advisory Committee, says, "You’ve got to look at potentially cutting programs,” she says, “it may be some real pain and some real tough things that are going to have to happen if we can’t get an infusion of cash and we can’t figure out a smarter way to make these dollars stretch.” More Kentuckians are facing unemployment, so more are signing up for Medicaid benefits therefore a $232-million shortfall is growing.
One critical issue is that in order to keep paying for this procedure the Cabinet for Health Services has understaffed its social worker positions. In Fayette County, for example, as of August 2008, there are only half the recommended number of investigators. (Lexington Herald-Leader, August 30, 2008.) Chief Fayette Family Court Judge Jo Ann Wise said "It's just come to the point where we have to say something. We're worried that a child may be hurt or killed." The remaining workers reportedly often fear for their safety, as security positions have also been eliminated. Rep. Tom Burch, D-Louisville, said the Cabinet blamed its "lean" budget. "This is the worst budget in my 34 years. We bear a lot of responsibility for what's happening, and we can't escape it." At $40,000 per position, eliminating routine neonatal circumcision would allow close to full staffing at the Fayette Office, funding 25 additional positions.
We didn't have my son circumcised at birth. His foreskin isn't yet fully retractable. Is he normal?
Yes, it may take several years. Of course, you should always check with your physician about any medical problem. The American Academy of Pediatrics puts it this way: "In the first several years your son's foreskin will separate from the tip of the penis. Some foreskins separate soon after birth or even before birth, but this is rare. When it happens is different for every child. It may take a few weeks, months, or years. Once this happens, the foreskin can be pulled back away from the tip of the penis. This is called foreskin retraction. Most boys will be able to retract their foreskins by the time they are 5 years old, yet others will not be able to until the teen years. As a boy becomes more aware of his body, he will most likely discover how to retract his own foreskin. But foreskin retraction should never be forced. Until the foreskin fully separates, do not try to pull it back. Forcing the foreskin to retract before it is ready can cause severe pain, bleeding, and tears in the skin." Check with your doctor, and make sure he or she is aware of the AAP and AMA guidelines for normal child development. If he or she is not familiar with these, or attempts to forcibly retract the foreskin, you may wish to find a physician with more current knowledge. You may also find helpful information online
His doctor says my son has "phimosis" and needs a circumcision. Is that necessary?
This is between you and your doctor and son, but many cases of "phimosis" either clear up on their own, see this material from Mothering magazine, or the foreskin can be made retractable with the application of a topical steroid, see, e.g., Orsala, et al, Conservative treatment of phimosis in children using a topical steroid, UROLOGY, Volume 56, Number 2: Pages 307-310, August 2000 (90% success rate in curing phimosis without surgery). The most tragic result of a phimosis diagnosis is here.
Isn't the foreskin just a useless piece of skin?
Far from it. While most circumcised men get along fine without it, the typical foreskin comprises over twelve square inches of the most sensitive, nerve-filled tissue in the human body. See http://www.angelfire.com/ca5/intact/foreskin.html In fact, many circumcised men are attempting to recover the benefits of having one, see http://en.wikipedia.org/wiki/Foreskin_restoration
Aren't most men in the world circumcised?
No, only about one in 3. The percentage is higher in the US, but has still fallen sharply in recent decades. See http://en.wikipedia.org/wiki/Prevalence_of_circumcision#United_States The influx of Hispanic families (which do tend not to circumcise) to the US has been one factor in lowering the overall average. Another factor is that since 2000 sixteen states have stopped using public funds for the surgery, in the absence of some medical problem. Worldwide, circumcisions performed for medical (rather than religious or cultural) reasons, are probably well below 10%, but still much higher in the US.
If I want to let me elected representative know I don't think this is a wise use of my tax dollars, how can I do that?
Dr. Thomas Badgett's office can be reached at (502) 564-4321. E-mail intended for him can be sent via
vanessa.petrey@ky.gov (If possible, cc us on your efforts.)
The Department has indicated it has no current plans to reconsider this funding, so legislative action may be required. You can find and contact your legislator at http://www.lrc.state.ky.us/Legislators.htm
You can also contact us at nocircky@gmail.com
No reply has been received from the Director or anyone else in response to our repeated inquiries beginning in the fall of 2008. We will post here any statement they care to make.
Updated
December 17, 2011
News: The Kentucky Department for Medicaid Services has released detailed payment records for the fiscal year ending June 30, 2011. Kentucky Medicaid-paid totals for circumcision that FY: $1,038,028
CPT code & DescriptionMedicad CostNumber of procedures
Medicad CostNumber of procedures54150 - Circumcision W/Regionl Block5996557634
599655763454160 - Circumcision Neonate77470629
7747062954161 - Circum 28 Days Or Older245943 885
245943 88554162 - Lysis Penil Circumic Lesion46427215
4642721554163 - Repair Of Circumcision68531251
68531251Analysis: The total number of publicly-funded neonatal circumcisions has stayed flat since 2009, when there were 625. Fewer adults and non-neonates are choosing circs, as that number has dropped from 964 in 2009. However, the number of circumcisions needing repair has skyrocketed from 183 in 2009 to 251, above, a complication rate several times higher than should be expected according to the AMA. Are Kentucky Medicaid patients getting poor care? Also, these numbers reflect only circs needing surgical intervention and does not account for MRSA or other infections. Huge Medicaid cost increases are coming, e.g., http://www.pbs.org/newshour/multimedia/state-medicaid/15.html so why is the state paying anything for elective surgery?
The Medicaid Cost Containment Task Force met throughout 2010 and early 2011 and received dozens of inquiries about defunding circumcision in Kentucky. Number of replies received?: Zero. Nada. None.
The Kentucky Medicaid system--millions of dollars in the red and getting worse--won't even respond to inquiries. You can reach your state Senator at http://www.lrc.ky.gov/Legislators.htm Ask why Kentucky pays more public money for this procedure than Florida, Michigan, Arizona, North Carolina, Oregon, Washington, Utah, North Dakota, Montana, and Missouri combined.
Over $1,000,000 of your tax dollars are spent each year for circumcision on healthy infants in Kentucky
