Some families are choosing to forgo the procedure for personal reasons. Eighteen states have stopped paying for babies of poor families to have the procedure under Medicaid. Maryland is not among those states.

Tobian, the Hopkins researcher, and others think the drop in coverage by Medicaid, which covers two-fifths of all births, may be deterring some parents from having their babies circumcised. A circumcision costs between $216 and $601, which may seem expensive to a family trying to make ends meet. The academy agreed that financial barriers like this need to be addressed.

But the group took careful consideration not to step on the cultural and personal beliefs of parents. Many Muslims and Jews perform circumcisions as a religious rite. They are fighting bans on the procedure in some countries in Europe based on freedom of religion.

The health benefits aren't enough to recommend that all parents choose the procedure, the academy said. The group said that physicians should tell parents of the procedure's risks and benefits in an unbiased manner so they can make the most informed decision.

"They will need to weigh medical information in the context of their own religious, ethical and cultural beliefs and practices," the academy wrote in its report. "The medical benefits alone may not outweigh these other considerations for individual families."

"We recognize the medical aspects are just one element," Freedman said. "We recognize as physicians that we can weigh in medically, but we are not the best to weigh in on all the other paradigms in a person's life."

To cut down on complications, circumcisions should be done by trained physicians and only on babies who are stable and healthy, the group recommends. It said there aren't enough studies to determine the true number of complications after circumcision. Significant acute complications are rare, occurring in 1 in 500 newborn circumcisions, the academy's analysis found.

The group said further study should be done on the link between circumcision and HIV in the United States. Current studies were done in Africa. They also said more research is needed to determine the effectiveness of circumcision during infancy, complications associated with the procedure and comparing the effectiveness of circumcision during infancy with procedures done later in life.

"Mostly we are trying to clarify the concept that we're not coming out saying that nobody should be circumcised or everybody should be circumcised," Freedman said. "We recognize that circumcision has a place in a child's life for some families. For other families it might not."

andrea.walker@baltsun.com

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Medicaid and circumcision



18 states that don't cover circumcisions under Medicaid and the year they stopped:

Colorado, 2011; South Carolina, 2011; Louisiana, 2005; Idaho, 2005; Minnesota, 2005; Maine, 2004; Montana, 2003; Utah, 2003; Florida, 2003; Missouri, 2002; Arizona, 2002; North Carolina, 2002; California, before 1999; North Dakota, before 1999; Oregon, before 1999; Mississippi, before 1999; Nevada, before 1999; Washington, before 1999

Source: The Johns Hopkins University

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