Analysis Sexual Health

Circumcision Rates Down 10 Percent Over Past Three Decades. Why?

Martha Kempner

New research shows that the practice of newborn circumcision is falling out of favor, despite the fact that the data suggests the benefits of the procedure far outweigh the costs.

A recently released report from the Centers for Disease Control and Prevention’s National Center for Health Statistics finds that the rate of newborn male circumcision has varied over the past three decades but that overall it’s down by about 10 percent. The report does not posit reasons for this trend, but public health experts have suggested it may be a result of changes in medical opinions, public opinions, and insurance coverage.

The report is based on data collected from 450 hospitals across the country between 1979 and 2010. It found that in 2010, 58.3 percent of newborn males were circumcised in the hospital compared to 64.5 percent of newborn males in 1979. Circumcision rates were highest in 1981, at 64.9 percent, and lowest in 2007, at 55.4 percent.

It is important to note that the report only includes those circumcisions that were performed during an infant’s newborn stay in the hospital. It does not include any procedures conducted by pediatricians or clinic staff after the baby is released from the hospital, nor does it include any circumcisions performed as part of religious ceremonies, which are common in both the Jewish and Muslim communities. Some experts suggest that the numbers in the report may be lower than the actual rates because as hospital stays after birth have become shorter, offsite circumcisions are more common. Douglas Diekema of the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Research Institute told USA Today, “Often they’re going home within 24 hours, so in some places, these procedures are increasingly being done by the pediatrician during the follow-up period in the doctor’s office or clinic as opposed to the hospital.”

The authors of the report did not try to explain the trends but did note that the rates may correspond with the official medical recommendations from the American Academy of Pediatrics (AAP), which have changed five times in the last 32 years. In 1971, an AAP task force released a report saying there was no evidence that routine circumcision of newborn males was necessary. A 1975 report came to a similar conclusion. But the AAP began revising its opinion in 1989 when it published a report citing some health benefits of the procedure. A 1999 report again concluded that there was evidence of health benefits—including lower rates of urinary tract infections and sexually transmitted diseases—but seemed hesitant to even appear to be promoting the procedure. The authors of that report wrote, “As in any circumstance in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child.”

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The AAP did not revisit the issue until August of 2012, when it again compiled the current evidence about health benefits of circumcision. In a 23-page report, the task force examined a number of studies conducted between 1995 and 2010, which found that circumcision could prevent urinary tract infections, HIV, human papillomavirus (HPV), genital herpes, and penile cancer. This most recent opinion is much more supportive of circumcision. As Rewire reported at the time, some even called it an endorsement of the procedure. Still, the AAP stopped short of recommending routine circumcision for newborn males, saying instead, “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.”

Parents may be following this medical advice or they be swayed by public opinion and standard practice in their area. The data also shows wide variations between regions in the United States. Newborn circumcision rates were flat in the Northeast, where they were at their highest in 1994 (69.6 percent) and lowest in 2007 (60.7 percent), but fell by more than 37 percent in the West, where only 40.2 percent of newborns were circumcised in 2010. Most of this drop occurred in the 1980s as the rates dropped from 63.9 percent in 1979 to 41.0 percent in 1989; but the lowest circumcision rates in the West were actually seen in 2003, when just 31.4 percent of newborn males were circumcised. In the South, rates of newborn circumcision went in the opposite direction in 1980s—increasing between 1979 and 1998 and then declining. In 2010, 58.4 percent of newborn males in the South were circumcised. Finally, rates in the Midwest were ranged from a high of 82.9 percent of males in 1998 to a low of 68.8 percent in 2009.

Some of this variation may be explained by the religious and cultural makeup of various areas. For example, seven of the eight “most Jewish” states (those in which more than 0.6 percent of the population identifies as Jewish) are in the Northeast where circumcision rates have remained consistently higher than elsewhere. Similarly, some note that an influx of immigrants to the West Coast from countries that don’t practice circumcision may explain the diminishing rates in that area. Politics and activism may also be at play on the West Coast. Led by opponents of circumcision, who refer to themselves as “intactivists,” two California cities (San Francisco and Santa Monica) went as far as to consider ballot measures to ban the procedure altogether. Such ballot measures, however, are no longer a possibility; Gov. Jerry Brown signed a “ban on bans” in 2011.

Another explanation for dropping circumcision rates has to do with insurance coverage. As Rewire reported last summer, coverage by private insurers varies widely, and there is a trend among state Medicaid programs to stop paying for the procedure. To date, at least 18 state Medicaid programs have stopped covering it, and there is strong evidence that this does affect how many newborns are circumcised in a state. For example, Arizona decided to eliminate coverage for the procedure in 2002 in order to save the state approximately $400,000 per year. The circumcision rate in that state dropped from 41 percent in 2002 to 21 percent in 2004. In fact, a report by the Healthcare Cost and Utilization Project found that circumcision rates are 24 percent higher in states where Medicaid covers the procedure.

A 2012 study, published by Archives of Pediatric and Adolescent Medicine, suggests that cutting coverage for circumcision is not cost effective in the long run. Conducted by public health experts and economists at the Johns Hopkins University School of Medicine, the study found that if circumcision rates in the United States were to fall to the same levels as in Europe (where only about 10 percent of newborn males are circumcised), we could face more than $4 billion in increased health-care costs over a decade to pay for treatment of urinary tract infections, syphilis, herpes, penile cancer, and HIV.

The data presented in the new report only goes through 2010, which is before the AAP released its most recent recommendations on the subject. As explained earlier, these new recommendations are much more supportive of the procedure. Moreover, the AAP Task Force specifically called on insurers to make the procedure available to parents. Douglas Diekema, who is a member of the task force, explained at the time of the report’s release, “The tone of the policy certainly shifts somewhat in favor of circumcision in that it recognizes that there are clear medical benefits that outweigh the risks of the procedure, and that those benefits are sufficient to justify coverage by insurance.”

It will be interesting to see if the new support from the AAP reverses the trend both in Medicaid coverage and in newborn circumcision itself.

Roundups Sexual Health

This Week in Sex: News From the HIV Epidemic

Martha Kempner

This week in sex: Scientists report the first case of HIV transmission to a patient adhering to PrEP protocols, two studies show a new vaginal ring can help women prevent HIV, and young people still aren't getting tested for the virus.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

With the death of Nancy Reagan, the 1980s AIDS crisis is back in the national spotlight. But, of course, HIV and AIDS are still ongoing problems that affect millions of people. This week in sex, we review scientists reporting the first case of HIV transmission to a patient adhering to PrEP protocols, two studies showing a new vaginal ring can help women prevent HIV, and evidence that young people still aren’t getting tested for the virus.

First Case of HIV Transmission While on Truvada

Last week, Canadian scientists reported on what they believe to be the first HIV infection in a patient who was following a PreP (Pre-Exposure Prophylaxis) regimen.

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PrEP is a method of HIV prevention. By taking a daily pill that contains two HIV medicines, sold under the name Truvada, individuals who are HIV-negative but considered to be at high risk of contracting the virus can prevent infection. Studies have found that PrEP is very effective—the Centers for Disease Control and Prevention estimates that people who take the medication every day can reduce their risk of infection by more than 90 percent from sex and by more than 70 percent from injection drug use. One study of men taking PrEP found no infections over a two-and-a-half-year period.

PrEP is less effective when not taken regularly, but the new case of reported PrEP failure involves a 43-year-old man who said that he took his medication daily. His pharmacy records back up that assertion. The man’s partner has HIV, but is on a drug regimen and has an undetectable viral load. The man did report other sexual encounters without condoms with casual partners in the weeks leading up to his diagnosis.

Dr. David Knox, the lead author of this case study, notes that it is difficult to know if a patient really did adhere to the drug regimen, but the evidence in this case suggests that he did. He concluded, “Failure of PrEP in this case was likely due to the transmission of a PrEP-resistant, multi-class resistant strain of HIV 1.”

Experts say, however, that they never expected PrEP to be infallible. As Richard Harrigan of the British Columbia Center for Excellence in HIV/AIDS told Pink News, “I certainly don’t think that this is a situation which calls for panic …. It is an example that demonstrates that PrEP can sometimes be ineffective in the face of drug resistant virus, in the same way that treatment itself can sometimes be ineffective in the face of drug resistant virus.”

Still, some fear that the new study will add to the ongoing debate and apathy that seem to surround PrEP. While some experts see it as a must-have prevention tool, others worry that it will encourage men who have sex with men to forgo using condoms and perhaps increase their risk for other sexually transmitted infections. Still, only 30,000 people in the United States are taking the drug—an estimated one-twentieth of those who could benefit from it.

A New Vaginal Ring Could Help Women Prevent HIV Infection

Researchers have announced promising results from two studies looking at new technology that could help women prevent HIV. The dapivirine ring, named after the drug it contains, was developed by the International Partnership for Microbicides. It looks like the contraceptive ring, Nuvaring, and is similarly inserted high up into the vagina for a month at a time. Instead of releasing hormones to prevent ovulation, however, this ring releases an antiretroviral drug to prevent HIV from reproducing in healthy cells. (A ring that could prevent both pregnancy and HIV is being developed.)

The two studies of the ring are being conducted in Africa. One study recruited about 2,600 women in Malawi, South Africa, Uganda, and Zimbabwe. It found that the ring reduced HIV infection by 27 percent overall and 61 percent for women over age 25. The other study, which is still underway, involves just under 2,000 women in seven sites in South Africa and Uganda. Early results suggest that the ring reduced infection by 31 percent overall when compared to the placebo.

Both studies found that the ring provided little protection to women ages 18-to-21. Researchers are now working to determine how adherence and other biological factors may have impacted such an outcome.

Young People Not Getting Tested for HIV

A study in the February issue of Pediatrics found that HIV testing rates among young people have not increased in the last decade. The researchers looked at data from the Youth Risk Behavior Survey (YRBS), which asks current high school students about sexual behaviors in addition to questions about drugs and alcohol, violence, nutrition, and personal safety (such as using bike helmets and seat belts). Specifically, the YRBS asks students if they’ve ever been tested for HIV.

Using YRBS data collected between 2005 and 2013, the researchers estimated that 22 percent of teens who had ever had sex had been tested for HIV. The percent who had received HIV tests was higher (34 percent) among those who reported four or more lifetime partners. Overall, male teens (17 percent) were less likely than their female peers (27 percent) to have been tested.

Researchers also looked at data from the Behavioral Risk Factor Surveillance System, which asks similar questions to young adults ages 18 to 24. Among people in this age group, between the years of 2011 to 2013, an average of 33 percent had ever been tested. This review of data also found that the percentage of young women who get tested for HIV has been decreasing in recent years—from 42.4 percent in 2011 to 39.5 percent in 2013.

The authors simply conclude, “HIV testing programs do not appear to be successfully reaching high school students and young adults.” They go on to suggest, “Multipronged testing strategies, including provider education, system-level interventions in clinical settings, adolescent-friendly testing services, and sexual health education will likely be needed to increase testing and reduce the percentage of adolescents and young adults living with HIV infection.”

Commentary Science

HPV Vaccines Are Working, So It’s Time to Stop Arguing About Them

Martha Kempner

A new study finds that HPV rates have plummeted in the last six years. Yet HPV vaccination rates continue to lag behind those of other vaccines, in part because of the stigma surrounding sexually transmitted infections.

According to a new study, human papilloma virus (HPV) rates have plummeted in the first six years vaccines against the virus have been available. Unfortunately, HPV vaccination rates lag behind those of other recommended inoculations, in part because of the stigma that stifles conversations around sexually transmitted infections.

Perhaps these new success rates—coupled with additional new research that reminds us of the possibility of non-sexual HPV transmission—will convince more parents to take advantage of this potentially life-saving vaccine.

HPV is actually a group of more than 150 related viruses, 40 of which are known to be sexually transmitted. Most types of the virus are thought of as low-risk, because they are unlikely to cause health problems. Nine types, however, have been identified as high-risk and are thought to be responsible for 99 percent of cervical cancers and a large portion of vulvar, vaginal, penile, anal, and oropharyngeal (a part of the throat) cancers.

Since 2006, there have been three vaccines against HPV developed and released on the market. The most recent, made available last year, was the most wide-ranging; it protects against the nine high-risk types of the virus.

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The vaccine is given as a series of three shots over eight months. The Centers for Disease Control and Prevention (CDC) recommends that boys and girls begin the series at age 11 or 12 in order to be sure that they are fully vaccinated before they become sexually active, but those who do not get the shots at that time can get them at any point before age 26. Experts estimate that widespread vaccination could prevent up to 90 percent of cases of cervical, anal, and genital cancer.

Though the research released last month uses data collected before the latest vaccine was available, the success of the original vaccine supports an optimistic outlook for the future prevention of HPV.

For the new study, which was published in the journal Pediatrics, researchers used data from the CDC’s National Health and Nutrition Examinations Survey (NHANES). They compared cervical and vaginal specimens from individuals ages 14-to-34 collected between 2003 and 2006—before the vaccine was available—with samples collected between 2009 and 2012, after the first vaccine was in use. They also used vaccination records from the latter group.

They found that 11.5 percent of young women ages 14-to-19 in the pre-vaccine group had one of the four types of HPV covered by the original vaccine. This dropped to about 4 percent in the group examined after the vaccine was available. Among those ages 20-to-24, the prevalence rate dropped from 18.5 percent to roughly 12 percent. There was no change among the oldest age group.

Overall, the study concludes, within six years of the vaccine’s introduction, HPV rates were down 64 percent among teen girls and 34 percent among women in their 20s.

Dr. Laurie E. Markowitz, lead author of the study, told the Guardian that results were better than expected.“The fact that we are seeing a larger decrease overall than what we expect given our coverage rates does suggest there may be some herd protection,” which occurs when a large enough portion of the population is vaccinated to slow the spread of the virus, she said. “There also may be effectiveness from less than a complete three dose series,” Markowitz continued.

Researchers anticipate that more people will continue to benefit from the vaccines. Markowitz told the Guardian, “As women who got the vaccine when they were younger age move into these older age groups, we should continue to see a continued decrease,” because they will not transmit the strains to anyone else as they become sexually active.

In addition, vaccination rates have improved since this data was collected. In 2009, only about 44 percent of girls had received one dose of the vaccine and only about 27 percent had received all three. By 2014, two-thirds of teenage girls ages 17 and under had received at least one of the three recommended doses of the HPV vaccine, and about 40 percent had received all three doses.

The CDC recommends that boys get the HPV vaccine as well, but vaccinations rates among boys have always been lower than those among young women—perhaps because when the vaccine was originally introduced, it was only suggested for girls, or perhaps because it is best known for preventing cervical cancer. But vaccination rates for boys have been on the rise as well. In 2014, roughly 42 percent of teenage boys ages 17 and under had received at least one dose of the vaccine: about 8 percentage points higher than the year prior.

Unfortunately, HPV vaccination rates still lag behind those of other recommended vaccines. For comparison, in 2014, about eight in ten teens ages 17 and under had received the quadrivalent meningococcal conjugate vaccines and roughly 87 percent had received the Tdap vaccine, which covers tetanus, diphtheria, and pertussis.

There are a number of reasons that HPV vaccination rates might be lower than others, including the fact that only two states and Washington, D.C. require the vaccine for school-aged children. By contrast, the Tdap vaccine is required in most states; meningitis vaccines are required in about half. Additionally, some parents may not have the resources or time to take their children to get a series of three vaccinations.

Not surprisingly, there still exists a discomfort with the sexually transmitted nature of HPV. Since, the HPV vaccine was introduced, there have been those who argue that vaccination will be seen by teenage recipients as permission to have sex, thereby increasing their risky behavior. This faction also argues that it is not necessary to inoculate young people against HPV because they can easily avoid it by just not having sex.

Numerous studies have found that HPV vaccines do not, in fact, turn young people into sex machines. A study last year from the United Kingdom, for example, found girls who have been vaccinated are less likely to engage in risky sexual behavior than those who have not. An earlier study in the United States found that teen girls who had been vaccinated were more likely to use condoms than their non-vaccinated peers. Other studies have found that young people’s perception of sexual risk and risk behaviors do not change after vaccination.

Perhaps a new article will take the wind out of the sails of the argument that teens should “just say no” to prevent HPV. The paper, cleverly titled “Penises Not Required,” reviewed 51 studies that found evidence of transmission through means other than penile-vaginal or penile-anal intercourse. Some of the studies reviewed found HPV DNA in the genital tract of female “virgins”—though the definitions of “virgin” varied widely among studies, and were based on respondents’ self-reported sexual activity. Other studies found HPV DNA in children who had not been sexually abused. Some studies focused on evidence of HPV DNA on medical equipment, toilet seats, and sex toys, and questioned whether this would be sufficient to transmit the virus. And others suggested the possibility of finger-to-genital transmission either from a partner or even from one’s own hands.

The researchers told Rewire in an email that their results have to be interpreted cautiously, as they do not provide proof of non-penetrative or non-sexual transmission. Nonetheless, the possibility that this virus can be transmitted without sex should help us rid the HPV vaccine debate of moralizing. As the researcher concludes in the article, “The distribution of HPV vaccines has been hindered, in part, by societal discomfort with the role of HPV in human sexuality. A fuller appreciation of the potential for non-sexual HPV transmission could help increase vaccine acceptance.”

The facts are simple. We have a vaccine that prevents cancer, it’s working, and that’s a major public health victory. It’s time to stop arguing about whether vaccinating kids against an STD is a good idea and start protecting everyone.