Friday, August 18, 2006

Circumcision craziness

Anyone who knows me well knows that I'm strongly opposed to circumcision, but I've found it difficult to change the opinions of proponents and convince relatives I was doing the right thing by leaving my son intact.

The reason I'm opposed is becaused although the risks are low, I suffered from a side effect until I was about 20 and could find the cause and remedy. So it's very emotional to me, but one of my good friends has told me that my old way of arguing about it was just wrong, even though people who think circumcision is good just look stupid to me, nobody likes being told they are stupid, so I was just making them angry and closing them off, rather than drawing them over to my point of view.

I only started convincing my mom after reading up on all the statistics and numbers and studies, so I could show her counterpoints and examples of why common reasons to circumcise aren't that good. Lately I've been getting into economics, reading up stuff on finance and mostly microeconomics just so I can understand the ebb and flow of money to and from me, trying to control it more. So let's put my new economic knowledge to use on the circumcision debate. I could do a raw statistical argument, but there are a million websites out there already that try to do that from both points of view.

I'm going to do a quick rough cost-benefit analysis of neonatal circumcision with the common reasons why people advocate it, and hopefully try to explain why the American Academy of Pediatrics' official stance on circumcision is: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision."

1. UTI's in the first year of life - a neighbor that had a son after us was frustrated that he got sent home without circumcision due to being too jaundiced to have it done yet. She was afraid that he would get a Urinary Tract Infection, no doubt referring to a study that said uncut baby boys are a whopping 10 times more likely to get one in the 1st year of life than cut boys. If you look at the numbers from that study, it was something on the order of 1 in 100 uncut boys versus 1 in 1000 cut boys. In other words, that giant 10 times more likely was 1% instead of 0.1%. The cure for a UTI is a round of antibiotics. If you don't have insurance, the circumcision would cost about $150 and the antibiotics about $40..... so getting your baby boy circumcised to avoid a UTI in the first year of life is the same as paying $150 now to reduce your chance of possibily paying $40 in the next year from 1 in 100 to 1 in 1000. Granted most people have insurance that would distort the money they see out of pocket, but some insurance plans, most notably Medicaid in 16 states have dropped coverage of neonatal circumcision, like the UK national health service did in the 1940's.

2. Phimosis/Balanitis - Phimosis is a condition where the foreskin cannot be retracted fully. Technically all babies are born with it, since the foreskin starts off fused to the head of the penis, and should fully separate by sexual maturity, but some grown men still can't, and their condition is called Phimosis. Balanitis is inflammation of the head of the penis, and when really bad with the foreskin retracted, the foreskin can't go back to its natural state, covering the head. Both have simple nonsurgical cures, but when a man has these problems repeatedly or severely, he might want to be circumcised. So in America, alot of parents circumcise to avoid these problems. Let's say there are 1 million boys born every year and they all get circumcised. At $150 each, that's $150 million, alot of money. Even if Phimosis/Balanitis affected 6% of them, and all of those affected chose circumcision, that will only be 60000 men times $150, resulting in $9 million. Again, you might say "but insurance paid for the circumcision" and I'll say "but you paid for the insurance". Ignoring the medical costs of the boys who suffered circumcision complications (I'll get to that next) that's $141 million extra the insurance companies would have to pay out, and recover somewhere: higher insurance premiums... and people wonder why our health care costs are going up faster than inflation. Again, this boils down to paying for surgery on an infant because he may need it as an adult... paying $150 now to avoid a 6% chance of paying for it later at a possibly higher price.

3. Penis Cancer - Hopefully, the sheer probability numbers will show how weak the penis cancer argument is, but I'll try to break it down with a cost benefit analysis. A study has shown that penis cancer occurs in about 1 in 100000 uncircumcised men over 80 years old. Is the life expectancy for men even 80 yet in USA? A quick check with google shows it to be 75, meaning most men are expected to die before they are old enough to even get penis cancer. Ignoring the actuaries, my mom wanted us to circumcise our son to avoid penis cancer. Let's say there's 1 million boys born this year and all get circumcised at $150 each to avoid penis cancer. And let's say 10% live to be old enough to get penis cancer, so 100000. With the above probability, only one of them would have gotten penis cancer had he been left uncut. So $150 million worth of circumcisions have to be performed to prevent one case of penis cancer, but I won't stop there, I'm going to add in some of the circumcision complications. The rate varies depending on who you ask, but the complications vary from mild - excess bleeding, infection - to severe - loss of penis, loss of life. Let's take the low end, 0.2%, or 1 in 500, and while the medical costs to fix the complications vary, let's say they average out to $100 per person. Then 2000 boys suffered complications at a cost of $200000 to save this 1 old man from penis cancer, all while when caught early, penis cancer can be cured by freezing the tumor like you would a wart, or just cutting off the penis, probably at most $500. So when someone is asking USA to circumcise all our newborn boys to prevent penis cancer, they're asking society to pay $150 million now, $200 thousand real soon, just to avoid paying $500 on one old man about 85 years from now.

So there you have it: neonatal circumcision is not cost effective. Some people may point out the recent HIV studies. I deliberately left them out, because that issue is much more complicated, since it all boils down to sexual behaviors of a bunch of horny boys. So I won't pretend to know how much money dumped into sex ed it would take to convince teen boys to have safe sex or no sex, which is worlds better at preventing HIV than circumcision.

However, I do want to wrap it up with what convinced my sister we were doing the right thing by not circumcising. She was saying one of her boyfriend's frat brothers was embarassed because he had to miss class to recover from circumcision. She was concerned our son would have to go through the same thing in college. I told her that first of all, a low percent of uncircumcised men actually need it as adults, the ones that weren't circumcised and didn't need it also didn't feel the need to tell her about it. I then asked her if she would cut out the tonsils, appendix, or gallbladder of a newborn because it might cause problems later. She said no. It's the same thing. Doctors used to cut out kids' tonsils at the drop of a hat, but now they wait till they really really need to be taken out. I hope foreskins go the same way, doctors waiting to cut them off till they really need to go, insurance making non medically necessary circumcisions an out of pocket cost. In fact, the first intact boys I saw as a kid were sons of a doctor. The American Academy of Pediatrics knew what they were saying when they didn't recomend routine neonatal circumcision. Another way to phrase their stance is: the benefits do not outweigh the costs.