Update: The bill did not pass the Committee.

Peter W. Adler – February 17, 2015

Today approximately twenty members of New Hampshire’s Health, Human Services, and Elderly Affairs Committee heard arguments for and against House Bill 251-FN, available here, sponsored by Bedford, New Hampshire Republican Keith Murphy. The bill would exclude the circumcision of newborn boys from New Hampshire’s Medicaid plan except when medically necessary, which it is estimated will save New Hampshire $212,000 per year.

This article briefly summarizes “who said what” at the hearing. New Hampshire Public Radio also has posted a brief synopsis of the hearing and two minutes of testimony and commentary here on NHPR.org.

Representative Murphy led off the hearing, arguing that while experts would be making legal, medical, and other arguments in support of the bill, he believes that it is fundamentally unethical to strap newborn boys to a board and cut off parts of their genitals. He also said that neonatal circumcision causes on average 117 deaths per year. Mr. Murphy said that New Hampshire should join the other 18 states including Maine which have ended Medicaid coverage of circumcision.

A female opponent of the bill then spoke briefly on behalf of a rabbi who could not attend. She stated that parents have a religious right to circumcise their sons, and also that ending Medicaid coverage would deny the medical benefits of circumcision to sons of the poor.

Peter Adler, speaking as Legal Advisor to Attorneys for the Rights of the Child, then argued that under federal and New Hampshire law, Medicaid can only be used to pay for services that are medically necessary. Health care providers must assure that all services are supported by medical necessity, and peer review boards must review those decisions. New Hampshire law also expressly excludes using Medicaid to pay for cosmetic surgery. Mr. Adler handed out pages from a pamphlet for New Hampshire citizens about Medicaid to the above effect. He continued that it is uncontested that circumcision is unnecessary, non-therapeutic, elective surgery; indeed, most men who have every lived have been genitally intact. It is a felony crime under New Hampshire’s criminal statute, RSA167:61-1, for Medicaid providers to submit a claim with intent to defraud for services that are not medically necessary. Mr. Adler argued that insofar as the law is clear, and legislators are sworn to uphold federal and state law, they have a duty to pass the bill, without considering medical, religious, or other arguments that might be made against the bill. A representative asked why a bill is needed if Medicaid coverage of newborn circumcision is already illegal, and Mr. Adler answered that the bill is needed to prevent health care providers from continuing to charge Medicaid in violation of the law.

Attorney Georganne Chapin, Executive Director of Intact America, was unable to attend, and Mr. Adler summarized her written testimony following his own. Attorney Chapin argued that the foreskin is a normal body part, and that it is almost never medically necessary to circumcise boys. Circumcision is risky and kills an estimated 117 boys per year: without circumcision, none of those boys would die. Circumcision does not reduce or prevent disease: there have been a succession of false claims about the supposed benefits of the procedure in the past. Today, HIV is more prevalent in the United States than in Europe, where less than 5% of men are circumcised. Circumcision is a costly waste of money, especially when circumcision repairs are included. 18 states no longer use Medicaid to pay for circumcision, nor it is covered by the governments of the UK, Europe, Canada, New Zealand, or Australia. The public should not pay for surgery performed for religious, cultural, and personal reasons. The money saved should be used for necessary medical care. Parents can still choose it, but if so, they should pay for it themselves. Moreover, using Medicaid to pay for circumcision unlawfully violates the equal protection clause and the requirement of the separation of church and state.

Ronald Goldman, Ph. D., a psychologist, then argued that the health benefits of circumcision are speculative and potential. Physicians in the rest of the Western world reject the argument that circumcision has any meaningful medical benefits, and that it has no adverse effects. No national medical organization in the world recommends circumcision. It is painful, traumatic, affects the developing brain, and changes behavior including maternal bonding. It carries more than two dozen surgical risks, and removes one-third of the penile tissue in the adult male, 12 square inches of erogenous tissue which facilitates sexual intercourse. Circumcised men often express anger, a sense of loss, sadness, and sexual anxiety. They may suppress their feelings and lack empathy. Circumcision also may cause autism. Trauma tends to repeat itself. Europeans think we are crazy to circumcise. 38 physicians primarily from Europe have called the position of the American Academy of Pediatrics and now the CDC culturally biased.

Dr. Goldman then read testimony from Robert Van Howe, M.D., a professor of pediatrics and department chair at Central Michigan University College of Medicine. Summarizing, Dr. Van Howe stated that the circumcision of an infant does not diagnose, treat, or prevent any disease, while it does interfere with normal form and function and removes the most sensitive, erogenous genital tissue in the male. Thus, it is not a valid medical procedure, and under the federal Medicaid statute, Medicaid cannot be used to pay for it. “No other surgery to remove healthy tissue is performed on infants for cultural reasons at parental request, or to prevent some speculative unforeseen future risk of disease which can easily be prevented by less invasive measures.” Dr. Van Howe stated that over the course of a lifetime, circumcised infants incur approximately $1,000 more in current costs than infants who are not circumcised. Circumcision doubles the risk of infantile autism, increases erectile dysfunction, premature ejaculation, difficulty in achieving orgasm, and decreases penile sensation, while increasing painful intercourse for female sexual partners and decreasing their sexual satisfaction. It would cost between $31,635 and $55,575 to prevent a urinary tract infection that can be treated with an antibiotic that costs about $18. Non-circumcising developed countries have lower rates of UTIs, STIs, HPV, HIV, penile cancer, cervical cancer, phimosis, and all other purported issues attributed to retention of the foreskin. For infant circumcision to prevent one case of invasive penile cancer, the up-front cost would be between $1.21 million and $2.05 million. Not a single study in the medical literature has demonstrated an association between infant circumcision and risk of heterosexually-transmitted HIV infection. “Systematic reviews of studies in the medical literature and meta-analyses of the data from these studies have failed to find a significant association between circumcision status and common sexually transmitted infections. Overall the risk of getting a sexually transmitted infection appears to be higher in circumcised men.”

Jennifer Frezell, Vice President of Planned Parenthood New Hampshire and a member of Planned Parenthood New England, then spoke in opposition to the bill. She said that circumcision has medical value in reducing the risk of various diseases. The American Academy of Pediatrics revised its position to a more favorable one in 2012 based on a finding that circumcision reduces HIV and STDs. She stated that the AAP found that circumcision poses only a .5% surgical risk for infants, but a much higher risk for men. She said in answer to a question that she knew of no federal Medicaid policy or regulation about circumcision, but that when the federal government wants to set a policy about Medicaid, it can do so. She said that 38% of births in New Hampshire, male and female, were covered by Medicaid, but she did not have at hand the number of births.

Richard Angell, a New Hampshire intactivist, then noted that so far only two women had argued against passage of the bill, and that since 1997, girls have been protected from genital cutting, but not boys. Moreover, he said, Planned Parenthood are the people who claim that for girls and women when it comes to abortion, it is “her body, her choice”. The same rules should apply to boys and men. He argued, whose body is it anyway? Boys are entitled to the same autonomy and genital integrity as girls. It is “my body, my choice”. The legislature should absolutely pass this bill. Taxpayers’ money should not be used to pay for the unnecessary mutilation of children.

Jay Smith, a retired New Hampshire family physician, then spoke against the bill on behalf of the New Hampshire Public Health Association. He said that it is bad policy to remove Medicaid coverage when it is covered by other insurance. Yes, there are some deaths from circumcision. Yes, the medical benefits are tiny. But for Jews, it is a sacred ritual to circumcise boys on the 8th day after birth, which is often done by a mohel. Circumcision is not so easy later. New Hampshire should have a full debate about whether circumcision should be legal or illegal, rather than consider a bill only about Medicaid and circumcision. When asked whether circumcision rates were declining, he said that he did not know. He also was asked whether the American Congress of Obstetricians and Gynecologists has a policy on circumcision, and he responded that he thought ACOG followed the position of the American Academy of Pediatrics.

Barry Borella, a New Hampshire citizen, then spoke. He said that he was a pilot and did not have specific expertise about circumcision, but wanted to speak in favor of the bill. Mr. Borella argued that if New Hampshire is paying for this cosmetic surgery, it should pay for all cosmetic surgeries. In fact, the government should not be paying for any cosmetic medical procedures, and should not be spending money on non-therapeutic circumcision.

Another New Hampshire citizen, David Branch, then spoke passionately in support of the bill. He said that New Hampshire admires and the legislators embody individualism, values, and integrity. According to European physicians, members of the American Academy of Pediatrics with a pro-circumcision viewpoint are culturally biased. Four of the doctors on the AAP Task Force on Circumcision were Jewish. In America and in New Hampshire, every citizen has a right to life, liberty, and the pursuit of happiness. Men do not want their bodies altered. As legislators you need to say no, that circumcision is not covered by Medicaid. Circumcision violates a boy’s and man’s right to freedom of religion: being branded as belonging to one religion takes that freedom away. Mr. Branch said, “I know how much a man would lose to have the most erogenous part of his genitals cut off”. Doing that is barred by laws and by the rules of medical ethics. In New Hampshire we value the Constitution and the rights of the individual.

Chairman then declared the hearing, which had started at 10:00 a.m., over at approximately 11:40 a.m.

The Chairman thanked every presenter during the hearing, and the legislators certainly appeared to be interested and engaged in the testimony throughout the hearing. (This contrasted with the hearing several years ago on the bill in Massachusetts to make male genital cutting illegal. In Massachusetts, legislators were mostly represented by their aides, seemed disinterested, and the committee chair reportedly had assured her constituents that the bill would never leave her committee.) The New Hampshire Chairman said several times that the Committee was interested in whether Medicaid should pay for circumcision in New Hampshire, and not in debating the merits of circumcision generally.

After the hearing, Representative Keith Murphy thanked those of us who had spoken in favor of the bill for our testimony. Based on a question asked by a committee member, Mr. Murphy may contact the director of Medicaid for the state of New Hampshire to see what that agency’s position is on the question at hand. Mr. Murphy said that the Committee would likely make a decision within two weeks. Options for any bill include recommending passage, sending it to a sub-committee for further analysis, or killing the bill.

So we will have to stand by to see what discussions ensue with New Hampshire’s Medicaid Director, and for the Committee’s vote. It would certainly be a “big win” to end Medicaid coverage of circumcision even for newborns in New Hampshire.