Governor Murphy has suspended non-essential medical procedures. So why are NJ hospitals still performing circumcisions?
Note: This article was originally written on April 25, 2020
On March 23, Governor Phil Murphy issued an executive order suspending all elective surgeries in light of COVID-19. With New Jersey health care centers caring for a surge of sick patients and running low on personal protective equipment, procedures deemed not medically necessary have largely been cancelled or postponed.
But as of April 24, several facilities across the state — including maternity and neonatal care units contacted in Newark, Princeton, Atlantic City, and Trenton area hospitals¹ — are still performing routine circumcisions on infants. Given that neither the American Academy of Pediatrics nor the Centers for Disease Control and Prevention recommends circumcision for all male newborns, why are New Jersey providers continuing to cut baby boys in the midst of a global pandemic?
With more than half of American boys born in hospitals circumcised each year, the United States remains one of the few high-income countries in the world to commonly perform genital surgery on children. We are an unusual outlier here.
Male circumcision removes sensitive and deeply-innervated sexual tissue and has been described by pediatric researchers to be “among the most painful [procedures] performed in neonatal medicine.” In recent years, the practice has also been increasingly criticized given that its young patients have no capacity to consent to a procedure that irreversibly alters deeply personal anatomy. Along these lines, national medical organizations from countries including the United Kingdom, the Netherlands, Australia, Germany, and Canada have published statements in recent years discouraging or deeply questioning routine circumcision of male children.
In the United States, several public health departments have taken heed of this growing international consensus. Approximately 1 in 3 states have stopped covering routine infant circumcisions under Medicaid, citing federal regulations that require such funding to only cover “medically necessary” procedures. In these states, which include California, Florida, Missouri, and North Carolina, circumcision rates are on average 24% lower than at hospitals in other states.
From admission to discharge, the average newborn circumcision lasts “a few hours,” including preparation for anesthesia, surgery, and postoperative monitoring. In the midst of the COVID-19 crisis, the child and their parents are occupying precious space in a health facility, consuming a limited supply of PPE and staff labor, and increasing the risk of infection to both themselves and others in the building. According to the New Jersey Department of Children and Families, the procedure “results in complications” for 4 to 13% of newborns, which may endanger the child and prolong these risks.
With local officials looking to alleviate the current burden on the health care system, there is no better time than a global pandemic for New Jersey to also end Medicaid coverage for routine infant circumcision and formally classify it as a non-essential procedure — even if only temporarily until health care centers are operating normally. This decision will put greater pressure on providers to stop scheduling these unnecessary operations but may also provide longer-term ripple effects, including a decline in private insurance coverage of the practice.
In a period of economic uncertainty, New Jersey families and taxpayers would also benefit from cost savings: the average circumcision can cost upwards of $2,000 per operation. When Colorado ended Medicaid coverage for routine circumcision in 2011, officials estimated that the decision would save the state $186,500 annually.
Due to its prevalence, circumcision continues to be a controversial and divisive issue in our country. Already, faith communities that traditionally practice circumcision have expressed concern regarding COVID-19’s impact on religious ceremonies, including Jewish brisses, which are often held in large gatherings outside of hospital settings. Some have opposed prior attempts to set restrictions or age minimums, viewing them as an infringement upon parents’ religious liberty.
Child rights advocates push back, with many arguing that religious exemptions do not apply to laws banning female circumcisions or surgeries conducted on intersex children. Notably, New Jersey state law outlaws genital surgery or modification performed on young girls, termed broadly as “female genital mutilation,” but the same protections do not extend to young boys.
In this vein, delaying circumcisions until after the COVID-19 crisis has abated may also have secondary benefits. The vast majority of circumcisions in the United States occur soon after birth when the mother and son are both still hospitalized, providing a bundling effect that shields families from fully considering the costs — both monetary and physical — of the procedure. Instead, under these circumstances, some families may choose to wait and allow the child in question to decide for themself whether they wish to undergo the operation at a later age.
The merits and harms of circumcision may still be debated in the United States, but it is the responsibility of government officials and public health departments to make tough and timely decisions that ensure the well-being of citizens. As we look to support front-line medical staff in prioritizing patients most in need of care, it is time for New Jersey hospitals to roll back circumcision.
- Hospital/birthing center neonatal units contacted by phone by the author during April 2020 include Penn Medicine Princeton Medical Center (Plainsboro, NJ), Capital Health Medical Center — Hopewell (Pennington, NJ), University Hospital (Newark, NJ), AtlantiCare Regional Medical Center — Mainland Campus (Pomona, NJ), and Newark Beth Israel Medical Center (Newark, NJ)