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Let the sons decide

Foes of circumcision want the state to end Medicaid coverage of it

Tuesday, April 25, 2000

By Christopher Snowbeck, Post-Gazette Staff Writer

Opponents of circumcision are asking the Pennsylvania Department of Public Welfare to stop paying doctors and hospitals to perform circumcisions on the newborns of Medicaid recipients.

Greg Hartley with his son, Matthew. Hartley and his wife, Karen, chose to leave Matthew, who is adopted, uncircumcised. (Andy Starnes, Post-Gazette) 

The Pittsburgh chapter of the National Organization of Circumcision Information Resource Centers -- NOCIRC for short -- has joined with four other chapters around the state in making the request.

Pointing to a statement issued last year by the American Academy of Pediatrics, foes of the surgical removal of the penis' foreskin argue that Medicaid spends millions each year on a procedure that is not medically necessary. What's more, NOCIRC members believe circumcision amounts to genital mutilation.

Greg Hartley, a Franklin Park man who is the director of NOCIRC of Pennsylvania, is so passionate about the issue that he believes circumcision should be outlawed for newborns because they cannot give informed consent.

If it's against the law to circumcise girls, Hartley asked, why doesn't the same hold true for boys?

"This is an emotional issue for me," he said. "One of the drivers in this for me is that I'm very upset that this was taken from me. When I was strapped onto a board on day one of life, I couldn't say 'Hey, I need that [foreskin].' "

A 1995 study from the National Center for Health Statistics estimated that 64.1 percent of male infants were circumcised in the United States during 1995, but that estimate is based on data from fewer than 5 percent of all hospitals in the country.

Most boys around the world are not circumcised, but the removal of the foreskin has been a religious custom for centuries, particularly for Jews and Muslims. In the United States, circumcision has often been defended as medically necessary, but last year's statement from the American Academy of Pediatrics weakened that argument.

To be sure, there are potential medical benefits to circumcision.

Several studies published in the past 15 years have shown an increased risk of urinary tract infections in uncircumcised males, with the greatest risk in infants younger than 1 year, according to the academy statement. The academy noted, however, that these studies aren't perfect and might overstate the relative risk.

The academy estimates that seven to 14 of every 1,000 uncircumcised male infants will develop a urinary tract infection during the first year of life, compared with one to two of 1,000 uncircumcised male infants. So, while the relative risk of infection is higher in uncircumcised boys, the absolute risk remains low, at about 1 percent.

Penile cancer rates also are higher in uncircumcised men, but, again, the actual number of cancer cases is quite low -- nine to 10 cases per 1 million men.

As for sexually transmitted diseases, the academy noted that several studies have suggested uncircumcised men have a greater risk for HIV infection. Even so, the academy said that an individual's behavior is a much more important risk factor than circumcision status.

On the other side, while circumcision has long been considered an important part of good hygiene, the academy found little evidence to support this.

And the academy noted there are a few complications that have occurred with the procedure, most frequently minor bleeding and infection. Dramatic complications in which a botched procedure leads to penile amputation are quite rare, the academy noted.

Looking at all the evidence, the doctors adopted the following statement: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances 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."

Dr. Walter F. O'Donnell, chief of the division of urology at Pittsburgh Mercy Hospital, said most doctors agree with the pediatricians' sentiment.

"Urologists are sort of a mixed breed on this," he said. "Some still feel that circumcision has a benefit. Others aren't sure and there's still the majority who agree with the pediatricians. ... I certainly understand the pediatricians' position and I sympathize with it a great deal."

Most parents in Pittsburgh still want their children circumcised, said Dr. Ashi Daftary, the medical director of obstetric services at Magee-Womens Hospital. Daftary met many more parents who wanted their children left intact when he practiced in California and even in St. Louis.

Rio Cruz, executive co-director of the International Coalition for Genital Integrity of Santa Cruz, Calif., has worked with NOCIRC for about nine months sending letters to state Medicaid programs asking them to drop coverage of the procedure.

Seven state Medicaid programs -- California, Mississippi, Nevada, North Dakota, Oregon, Texas and Washington -- don't cover the procedure. Another four states -- Colorado, Tennessee, Michigan and Florida -- plan to study the issue in response to the letter campaign.

Some health-care advocates have questioned whether limiting circumcision for Medicaid recipients might stigmatize poor children, but Cruz said he wasn't worried about it.

"We believe that it's unfair to mutilate your child, so you're doing your kid a favor if you allow him to grow up naturally," Cruz said. "Sometimes it's cool to be different."

In Pennsylvania, the medical director of the Medical Assistance program believes circumcision should continue to be covered because of the minor health risks, according to a department spokesman. Medical Assistance pays doctors $79 to perform each circumcision.

Aetna U.S. Healthcare and HealthAmerica cover the costs due to market demand, but Highmark Blue Cross Blue Shield doesn't.

"The data from a number of sources indicate it's not medically necessary," said Dr. Brent O'Connell, a Highmark medical director.

About 80 people have signed Hartley's petition asking the state's Medical Assistance program to end coverage.

There are four active members in the Pittsburgh group and at least a dozen others who are on the group's mailing list. But now that the five NOCIRC groups in the state have come together in NOCIRC of Pennsylvania, Hartley believes they will build momentum. This spring he will publish a newsletter called the "Intact Times."

    For more information

National Organization of Circumcision Information Resource Centers (NOCIRC) - You can reach this organization at Box 2512 San Anselmo, Calif., 94979-2512. (415) 488-9883 or check the Web:

This Web site also includes links to sites that explain ways to restore the foreskin.

NOCIRC of Pennsylvania - Call Greg Hartley at 412-445-5570. Or check the Web:


Hartley, a 38-year-old engineer, became interested in the issue a few years ago when he and his wife were considering whether they would circumcise their adopted son from Russia. At the time, Hartley happened upon a magazine article that criticized the procedure. He was shocked and the more he studied the issue, the more determined he became to not circumcise his adopted son.

Now, he often speaks to groups of parents who are adopting children. Many tell him they are concerned that their sons will look different from other boys in the locker room and get teased. But children get teased for all sorts of reasons, and Hartley plans to teach his son how to face it.

If the boy wants to get circumcised when he's older, then it would be his choice, Hartley said.

"There was a kid from India when I was in junior high, he had his foreskin," he said. "Some kid looked at him and said 'What's wrong with your penis?' He said back, 'What's wrong with yours?' And that was pretty much the end of it."

Hartley's passion is unusual, but he believes opponents of circumcision -- much like opponents of tobacco have in the past -- will win once they succeed in getting people to look at the medical facts.

"You have to acknowledge that a very treasured part of your body is a little screwed up," he said. "I always thought my penis was great, but when you know what's missing, it forces you to think about things."

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