Arleen A. Leibowitz, PhD, Katherine Desmond, MS, and Thomas Belin, PhD
Three recent randomized clinical trials in South
Africa, Kenya, and Uganda found that male
circumcision reduces a man’s risk of becoming
infected with HIV through contact with a
female partner by 55% to 76%.1–3These
results are consistent with meta-analyses based
on observational studies in Africa4,5and the
The recent randomized clinical trial findings
prompted the American Academy of Pediatrics
(AAP) to form a committee in June 2007 to
review its position on male circumcision.8In
1999 the AAP had adopted a neutral stance,
stating that the medical benefits were not com-
pelling enough to recommend routine neonatal
circumcision. In the wake of the AAP statement,
several states withdrew Medicaid coverage for
routine, nontherapeutic circumcision. Currently,
16 state Medicaid plans do not cover the proce-
introduced resolutions challenging the need for
state funding of routine male circumcision.9
In view of the striking results from the
African clinical trials, it is timely to examine the
impact of US hospital- and state-level policies
on domestic rates of male circumcision. In
particular, we hypothesized that male circum-
cision rates would be higher in states in
which the Medicaid program pays for routine
Sample and Measures
Data for this study came from the 2004
Nationwide Inpatient Sample (NIS), from the
Healthcare Cost and Utilization Project of the
Agency for Health Care Research and Quality.
The NIS is the largest all-payer inpatient-care
database in the United States and consists of a
random sample of hospitals in 37 states. It
contains information included in a typical dis-
charge abstract: hospital characteristics and
patient demographics, expected payment
source, diagnoses, procedures, length of stay,
and discharge status. The 2004 NIS contains
data from more than 8 million discharges from
1004 hospitals,10reflecting roughly 20% of
inpatient visits to US community hospitals. We
used data from NIS records on newborn males
who had a routine discharge from the hospital.
Because many facilities reported no births, our
analysis incorporated data from 683 hospitals,
which reported 417282 routine discharges of
The outcome of interest was circumcision
status, measured by the presence of an Inter-
national Classification of Diseases, Ninth
Revision (ICD-9),1 1procedure code indicating
circumcision among any of up to15 procedures
performed during the hospital stay. The unit of
analysis was the hospital, so rates of circumcision
for each hospital were calculated by dividing the
number of circumcised newborn male infants by
The main explanatory measure was a state
policy variable reflecting whether Medicaid
covered routine circumcisions for newborn
males in the hospital’s state in 2004.12Other
explanatory variables were those that had been
found in previous analyses to predict male
circumcision and that were also available in the
NIS.13Individual-level variables were aggregated
to a hospital-level summary. Table1presents
definitions and mean circumcision rates by each
of the variables.
Complete data were available for all hospital
and policy variables. However, there were
missing data for some patient characteristics.
All hospitals reported primary payer data for
at least 75% of admissions, and all but 8
hospitals had income data for at least 80%
of patients. We based the hospital-level insur-
ance and income variables on those cases
with complete data.
Race/ethnicity information was missing at
higher rates. Patients’ racial/ethnic group was
not provided at all in hospital records from 10
states, accounting for 178 of the 683 hospitals
analyzed. An additional 36 hospitals in other
states provided race/ethnicity data for fewer
than half of their patients.
Appending county-level and state-level
population data on the proportions of infant
Objective. We sought to determine whether lack of state Medicaid coverage
for infant male circumcision correlates with lower circumcision rates.
Methods. We used data from the Nationwide Inpatient Sample on 417282
male newborns to calculate hospital-level circumcision rates. We used weighted
multiple regression to correlate hospital circumcision rates with hospital-level
predictors and state Medicaid coverage of circumcision.
Results. The mean neonatal male circumcision rate was 55.9%. When we
controlled for other factors, hospitals in states in which Medicaid covers routine
male circumcision had circumcision rates that were 24 percentage points higher
than did hospitals in states without such coverage (P<.001). Hospitals serving
greater proportions of Hispanic patients had lower circumcision rates; this was
not true of hospitals serving more African Americans. Medicaid coverage had a
smaller effect on circumcision rates when a hospital had a greater percentage of
Conclusions. Lack of Medicaid coverage for neonatal male circumcision corre-
lated with lower rates of circumcision. Because uncircumcised males face greater
risk of HIV and other sexually transmitted infections, lack of Medicaid coverage
for circumcision may translate into future health disparities for children born
to poor families covered by Medicaid. (Am J Public Health. 2009;99:138–145. doi:
RESEARCH AND PRACTICE
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American Journal of Public Health | January 2009, Vol 99, No. 1
22. Millett G, Ding H, Lauby J, et al. Circumcision status
and HIV infection among Black and Latino men who
have sex with men in 3 US cities. J Acquir Immune Defic
23. Warner L, Ghanem KG, Newman D, et al. Male
circumcision and risk of HIV infection among hetero-
sexual men attending Baltimore STD clinics: an evalua-
tion of clinic-based data. Paper presented at: Society for
Epidemiologic Research Meeting; June 21–24, 2006;
Seattle, WA. Available at: http://cdc.confex.com/cdc/
std2006/techprogram/P11223. Accessed September
24. Singh-Grewal D, Macdessi J, Craig J. Circumcision
for the prevention of urinary tract infection in boys: a
systematic review of randomized trials and observational
studies. Arch Dis Child. 2005;90:853–858.
25. Castellsague ´ X, Bosch FX, Mun ˜oz N, et al. Male
circumcision, penile human papillomavirus infection, and
cervical cancer in female partners. N Engl J Med.
26. Moses S, Bailey RC, Ronald AR. Male circumcision:
assessment of health benefits and risks. Sex Transm Inf.
27. Fergusson DM, Boden JM, Horwood LJ. Circumci-
sion status and risk of sexually transmitted infection in
young adult males: an analysis of a longitudinal birth
cohort. Pediatrics. 2006;118:1971–1977.
28. Study presents new information on male circumci-
sion to prevent spread of HIV in Africa [press release].
Montreux, Switzerland: Rakai Health Sciences Program;
March 6, 2007.
29. Williams BG, Lloyd-Smith JO, Gouws E, et al. The
potential impact of male circumcision on HIV in Sub-
Saharan Africa. PLoS Med. 2006;3:e262.
30. Xu F, Markowitz LE, Sternberg MR, Aral SO.
Prevalence of circumcision and herpes simplex virus type
2 infection in men in the United States: the National
Health and Nutrition Examination Survey (NHANES),
1999–2004. Sex Transm Dis. 2007;34:479–484.
31. Health Services/Technology Assessment Commit-
tee, National Library of Medicine. Post-delivery care and
stabilization of mother and newborn. Health Technology
Advisory Committee Final Technology Evaluation Report.
1996. Available at: http://www.ncbi.nlm.nih.gov/books/
bv.fcgi?rid=hstat6.section.2644. Accessed August 2,
32. Health, United States, 2006 With Chartbook on
Trends in the Health of Americans. Hyattsville, MD:
National Center for Health Statistics; 2006.
33. Kaiser Family Foundation. Statehealthfacts.org Web
site. Births financed by Medicaid as percent of total births,
2002. Available at: http://www.statehealthfacts.org/
2&o=a&sort=n&print=1. Accessed August 3, 2007.
34. Weiss H, Polonsky J. Male Circumcision: Global
Trends and Determinants of Prevalence, Safety and
Acceptability. London, England: World Health Organiza-
tion, London School of Hygiene and Tropical Medicine,
and UNAIDS; 2007.
35. Weinstein JN, Bronner KK, Morgan TS, Wennberg
JE. Trends and geographic variations in major surgery for
degenerative diseases of the hip, knee, and spine. Health
Aff (Millwood). 2004;(suppl Web exclusive):VAR81–
36. Weinstein JN, Lurie JD, Olson PR, Bronner KK,
Fisher ES. United States’ trends and regional variations in
lumbar spine surgery: 1992–2003. Spine. 2006;31:
37. Trends in reportable sexually transmitted diseases
in the United States, 2005. STD Surveillance 2005.
Atlanta, GA: Centers for Disease Control and Prevention;
2006. Available at: http://www.cdc.gov/std/stats/
trends2005.htm. Accessed September 26, 2007.
38. O’Brien TR, Calle EE, Poole WK. Incidence of
neonatal circumcision in Atlanta, 1985–1986. South
Med J. 1995;88:411–415.
39. Owings MF, Kozak LJ. Ambulatory and inpatient
procedures in the United States, 1996. Vital Health Stat
13. 1998;(139):1–119. Available at: http://www.cdc.
March 26, 2008.
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