For the North Carolina General Assembly, it's a question of whether to cut or maintain Medicaid funding for this routine procedure as they try to fill the state's budget shortfall.
The funding has so far been excluded from this year's proposed budget. Still, Gov. Mike Easley, in his recently announced budget plan, vowed to maintain all optional Medicaid services. And as last year's legislative session proved, the governor is willing to apply political pressure in order to protect funding for Medicaid circumcisions.
Effective Nov. 1, 2001, the legislature discontinued funding for the controversial procedure, which many in the medical community consider both unnecessary and harmful, as part of a large-scale effort to reduce the state's growing budget deficit.
Then, five weeks later, the lawmakers suddenly reversed the decision in the final hours of the legislative session, after complaints from some members of the medical community and pressure from Gov. Easley.
The North Carolina budget cites $646,000 as the expected cost of circumcision funding for the budget's two-year period, but according to the state's Department of Health and Human Services, North Carolina Medicaid actually paid around $3.5 million for 34,112 newborn circumcisions in 2000 and 2001. The state foots about a third of that cost--$1.16 million--while county and federal sources pick up the rest. Still, the total cost to taxpayers for circumcisions during the last two-year budget period was $3.5 million.
The legislature's initial cut in spending for circumcision came on the heels of recent statements by both the American Academy of Pediatrics (AAP) and the American Medical Association (AMA) that routine neonatal circumcision is not recommended for medical reasons. Circumcision, once thought to have important medical benefits, is now widely recognized as a cosmetic procedure.
Some circumcision advocates still contend that the surgery results in slightly fewer infant urinary tract infections, a possible decrease in incidence of sexually transmitted diseases, and the prevention of penile cancer. But the AMA has stated that circumcision cannot responsibly be viewed as "protecting" against these afflictions. It maintains that in light of serious risks, the use of circumcision as a preventive practice is not justified. Currently, no national medical society in the world recommends routine infant circumcision.
The legislature's decision to take circumcision funding out of its Medicaid payments did not affect religious circumcisions, which are not normally performed by doctors in hospitals but are performed ceremonially in a religious setting. And when the cut was proposed, letters and phone calls from the public came pouring in to support it.
"I have received an amazing amount of correspondence on this issue," comments Rep. Fern Shubert (R-Marshville). "The majority of those writing support eliminating the reimbursement."
Sen. Virginia Foxx (R-Banner Elk) agrees: "I have received a lot of communications about this, many from doctors. All of them were saying we shouldn't be [funding circumcision]."
And Sen. Ellie Kinnaird (D-Carrboro) says, "I've heard from health professionals and lay people about it, all against funding. Nobody contacted me in favor of funding."
The constituents contacting their legislators wondered why the state would fund a medically unnecessary procedure when many North Carolinians don't have access to basic medical care. Some also expressed their philosophical opposition to subjecting infants to a painful and potentially damaging procedure without a medical reason.
Dr. Robert Oliver, from Sylva, N.C.--a practicing obstetrician of 43 years with a Ph.D. in human sexuality--says, "The operation is painful, expensive, and portends many future problems for the baby growing into adulthood."
Indeed, complications often occur in hospital circumcisions, including hemorrhage, infections ranging from trivial to life-threatening, and even surgical errors. The American Academy of Pediatrics has stated: "There is an inordinately large number of badly performed circumcisions with resultant deformed penises."
In 1985, two Atlanta boys were damaged the same day during routine circumcisions--one whose penis was severely and permanently burned, and one whose penis was so thoroughly damaged that he subsequently underwent a "sex reassignment" (sex change) surgery while still a newborn.
In 1986, a Louisiana family was awarded $2.75 million in a lawsuit after their son's penis was severely burned and subsequently amputated during a routine circumcision.
In 1993 a baby bled to death in Miami, Fla., after being circumcised. And in 1998, a 3-week-old boy died of anesthesia complications while doctors attempted to fix a problem with his routine circumcision.
Similar events, not always reported in the news, have occurred throughout the country, some of them right here in North Carolina.
"I can't even count how many people [in North Carolina] I've talked with whose sons have experienced a botched circumcision requiring reconstructive surgery," says Amber Craig, N.C. State Director of the National Association of Circumcision Information Resource Centers. "I have also been contacted by lawyers in North Carolina who were representing clients who had botched circumcisions."
Will the 2002 NC General Assembly vote to continue funding these circumcisions without medical indication? It is difficult to say. As the legislature's last minute reversal last year demonstrates, the doctors performing Medicaid circumcisions are able to pull political strings and protect state funding that benefits their practices. But this year, the budget deficit has created a true crisis. Lawmakers are looking for money anywhere they can find it and opponents of circumcision want to show them where to cut.
On Dec. 6, 2001, in the final hours of the longest N.C. legislative session in history, seven legislators met behind closed doors with no aide taking minutes and no media present to discuss last-minute budget "corrections." The cut in circumcision funding had been in effect for five weeks, and the Appropriations Subcommittee on Health and Human Services, after research and review, had officially recommended that the funding continue to be left out of the budget.
Nevertheless, the seven legislators--the appropriations co-chairs of both houses, namely Representatives David Redwine (D-Shallotte), Greg Thompson (R-Spruce Pine), Warren Oldham (D-Winston-Salem), and Ruth Easterling (D-Charlotte), and Senators Howard Lee (D-Chapel Hill), Aaron W. Plyler (D-Monroe), and Fountain Odom (D-Charlotte)-- took matters into their own hands and "negotiated a deal" (says Redwine) in which they quietly placed the reinstatement of circumcision funding into SB 841, the "Budget Technical Corrections" bill, a document other senators say is intended to correct "very dry details and errors" of the budget.
The bill was, in the words of Rep. Shubert, a "smorgasbord" of unrelated issues that was sure to pass.
By the time this change was made, the session was all but over. Many legislators headed home. Then, at 1:24 p.m. on Dec. 6, SB 841, including the Medicaid reimbursement for circumcision, was passed by only 23 senators--not even half of the Senate. The vote took place when 15 senators, including Sen. Odom--who had introduced the initial funding cut--were not present.
Hearing news of the cut, stunned legislators and citizens alike were left with the puzzling question: How did this happen, and why?
Sen. Marc Basnight (D-Manteo), President Pro Tempore of the North Carolina General Assembly, who advised the appropriations chairs to put the funding back in the budget, says: "I believe it's important, when possible, to allow Medicaid patients the same choice for care that patients with private medical insurance receive. To do otherwise creates a two-tiered medical system in which those who can afford medical insurance have the opportunity to make important medical decisions for themselves, while those with fewer resources have fewer choices."
Funding advocates contend that circumcision is an accepted procedure and the cultural norm. Therefore low-income parents should have the option to choose the procedure at taxpayer expense lest their baby boys be "marked" as poor and suffer a lifetime of locker-room ridicule as a result.
Gov. Easley says boys actually need to be circumcised so that they may excel unstigmatized.
"People should not be indelibly branded as economically disadvantaged because their parents could not afford this simple procedure when they were born," explains Easley in a Dec. 20, 2001 letter to concerned constituents who complained about the reinstatement. "We have made sacrifices ... and begun new education programs to make sure that every child in North Carolina has the chance to excel. No child can excel when stigmatized."
Strangely, though, these arguments did not come up while the funding cut for circumcision was being considered. Legislators report that where there had been none before, controversy suddenly arose when the cut took effect in November.
Even though no medical society in the world recommends routine infant circumcision, the push to reinstate funding was led entirely by a few doctors. Several sources in the legislature, including Sen. Lee, report that calls and letters from doctors complaining about the cut started to roll in as soon as it went into effect. Various legislators, both for and against the funding, confirm that the vast majority of communications favoring the funding were from doctors and medical lobbyists.
These doctors, many of whom stand to lose income if the surgery isn't paid for by Medicaid, argued that failure to provide state funding for circumcision deprived patients of a cultural procedure and would create the "two-tier" system.
Dr. Charles Willson, vice president and president-elect of the North Carolina Pediatric Society (NCPS), says the society advocated for funding, but not because of money. Members of the society are child advocates, he says, who did not want poor children to be slighted.
"We didn't want there to be a situation where people on Medicaid who wanted [circumcisions] couldn't get them," he says. "We didn't want there to be a class division here where boys were stigmatized."
Not all North Carolina doctors hold this viewpoint. Rep. Shubert says, "More members of the medical community advocated for discontinuing funding than not." In fact, some N.C. doctors do not circumcise at all, even if it's requested by the parents.
For men who are grown now, to lack foreskin may be the norm. In 20 years, the situation may look very different. If Medicaid continues to fund circumcision while the wealthy and educated increasingly choose to heed medical societies' recommendations against routine circumcision, in a few years it may be the poor boys, not the rich, who have been circumcised.
Either way, there's little agreement about whether circumcision protects males from a social stigma.
"Who do they think they are, saying that I'm 'marked'? Most of my friends who are circumcised are envious of me," says Devin Larkin, a non-circumcised 16-year-old from Statesville. "The last thing I'm doing in the locker-room is looking at another guy's equipment. And if I did accidentally notice their circumcised or uncircumcised status, I certainly wouldn't comment on it."
And given a growing body of medical evidence, the discussion of circumcision continues to advance far beyond the locker room. Dr. George Denniston, President of Doctors Opposing Circumcision, says: "We [DOC] feel strongly that the foreskin is an integral part of the healthy human body. No one has the right to remove it except the individual himself."
Says Tim Hammond, founder of The National Organization to Halt the Abuse and Routine Mutilation of Males (NOHARMM), circumcision is not a "snip," but the removal of a full 15 square inches of sensitive and functional tissue. "We have both a right and a responsibility to oppose a practice that has harmed us and continues to harm innocent children."
Even now, when to lack a foreskin may indeed be the cultural norm for grown men, many men are upset that they were circumcised as infants. The National Organization of Restoring Men (NORM), a peer-to-peer support organization of circumcised men who desire reversal of the cosmetic surgery, has been active for 12 years and consists of chapters around the globe.
In a few years, as more and more parents choose not to circumcise and groups like NORM become more active, it may be common for circumcised males to take legal action. Bill Stewart, a retired UNC-Chapel Hill law professor, believes there is "an excellent chance" that such men will have legal recourse, and that this is part of the reason medical societies are now recommending against the procedure.
"They are beginning to realize that it's unethical to cosmetically cut nonconsenting infants' genitals," he says, "and they also realize that these children, when they grow up, might turn around and sue them."
"It will take a long time to have people's rights vindicated," says Stewart, "but it will happen."
Currently, the legislature has again proposed to cut circumcision funding through Medicaid. But given the medical lobby's political clout and connections to Gov. Easley, the battle lines could again be drawn between the legislature's need to trim the budget and doctors' hopes to protect their incomes.
Dr. Kenneth Baker, past chairman of obstetrics and pediatrics at Union County Regional Medical Center, a fellow of the American College of Obstetricians and Gynecologists, and Medical Director of the National Organization of Circumcision Information Resource Centers, says, "I just spoke to a pediatrician who said he only does it because it's easy money. It's $150 to $175 for less than five minutes' work. It doesn't get any better than that."
Dr. Oliver in Sylva agrees: "The doctors I hear are screaming that they have lost income by this ban."
In fact, recent data indicate that states whose Medicaid programs pay doctors more than $60 per circumcision have almost twice as high a circumcision rate as states that pay under $50. North Carolina pays about $200. (The national average is about $85.) Here, where one out of every two pregnant women (and their babies) is on Medicaid, one quick circumcision per week would increase a physician's income by about $10,000 a year.
Dr. Willson with the N.C. Pediatric Society maintains that money is not the real issue when it comes to circumcision, it's choice. "Basically, all of us would like to have people not ask for circumcision--it's not medically necessary, but at this point, many people want that. Until parents stop asking for it, I think we oughta do it."
To those who "do it," the state continues to pay. But Rep. Redwine insists, "In no way did the medical community [financially] influence the decision to reinstate Medicaid funding for circumcision."
During the 2000 election cycle, the North Carolina Medical Society gave a total of $12,500 to the legislators who ended up protecting circumcision funding. The N.C. OB-GYN PAC also made contributions to many of them. Rep. Redwine received $18,750 in contributions from the health sector, nearly 15 percent of the financing for his campaign. Sen. Plyler received more than $21,000 from the health sector, and Sen. Lee received nearly $33,000.
Money aside, the most powerful political force behind circumcision funding was clearly Gov. Easley. Legislators report that in addition to the appeals from a few doctors, pressure to reinstate funding came from the governor's office as well. Amy Fulk, spokeswoman for Sen. Basnight, says the governor spoke with legislative leaders who then communicated his wishes to the appropriations subcommittee.
"The governor really pushed for this," says Fulk. Gov. Easley's press secretary, Fred Hartman, confirms that Easley took measures to have funding reinstated. Upon hearing of the funding cut, says Hartman, Easley "instructed the [Department of Health and Human Services] to find a way to put it back."
Which raises the question of why the governor would have wanted this specific, unrecommended procedure to be funded at a time when he vowed to leave no stone unturned in the quest to cut unnecessary spending. Hartman says it was mainly because "cutting that funding adversely affected low-income families."
He continues: "It was a much-needed service, and a very nominal amount--one that we could restore easily."
The governor himself expressed reasoning that people's intact penises would create a state "divided by social and class lines."
For Easley, it's family ties that connect him to the issue. He has two brothers who are obstetricians. One, Dr. Henry Alexander Easley, practices in North Carolina. The governor's office admits Easley received counsel from his brother, who, says Communications Director Cari Boyce, "made him aware of the medical society's concerns about this issue."
Boyce says the medical society argued that the cost of doing circumcisions is less than the cost of treating the diseases that might occur later if one doesn't circumcise. However, the society, (and any assistant researching and advising the governor on this decision), must surely have been aware that the AMA has denounced circumcision's value as a preventive practice.
A look at the governor's campaign finance report offers some other, significant insight into his motivations for pushing this isolated funding. During the 2000 election cycle, the health sector donated more $661,000 in contributions to Easley's campaign.
If only the state were as generous to those seeking affordable health care. The governor's 2002 budget plan cuts $228.9 million in funding for Health and Human Services (the department that oversees Medicaid), by slashing funding for (among other things) mental health services, the Smart Start program (day care, immunizations, etc.), services for the disabled, women and children's public health, rural primary care clinics, and health care access for low-income individuals.
Will the state once again go along with Easley's wish to maintain funding for an unnecessary surgery while denying many individuals access to basic care? How many other primary medical services will be cut while N.C. taxes continue to fund circumcisions?
In 2002, we will find out.