ORIGINAL ARTICLE Effects of childhood circumcision age on adult male sexual functions

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1 (2007) 19, & 2007 Nature Publishing Group All rights reserved /07 $ ORIGINAL ARTICLE Effects of childhood circumcision age on adult male sexual functions E Aydur 1, S Gungor 2, ST Ceyhan 2, L Taiimaz 1 and I Baser 2 1 Department of Urology, Gülhane Military Medical Academy, School of Medicine, Ankara, Turkey and 2 Department of Obstetrics and Gynecology, Gülhane Military Medical Academy, School of Medicine, Ankara, Turkey The effects of childhood circumcision on male sexual function have been debated. However, there are no studies, to our knowledge, that assess the possible effects of childhood circumcision age on male sexual function. In an attempt to answer this question, we performed a prospective study to determine the possible relationship between circumcision age and male sexual function, using a validated questionnaire, the Golombok Rust Inventory of Sexual Satisfaction. We found no relationship between childhood circumcision age and overall sexual function; however some specific domains of sexual function (i.e. avoidance and communication) seemed to be affected by the age at circumcision procedure in this cohort of sexually active males. In addition, prevalence of sexual dysfunction was higher, with premature ejaculation being the most common dysfunction in the survey. We concluded that childhood circumcision age might affect some domains of male sexual function in adulthood, but not the overall function. (2007) 19, ; doi: /sj.ijir ; published online 22 February 2007 Keywords: circumcision; male sexual function; adult; premature ejaculation; questionnaire Introduction Male circumcision has been described since antiquity and, today, it is the most commonly performed surgical procedure worldwide. 1,2 However, there is almost no or few surgical procedures that have generated controversies and war of words as much as circumcision in the era of modern medicine. 2 One of the well-known debates is on whether circumcision affects male sexual functions or not. Current literature is replete with conflicting reports over the relationship between circumcision and sexual function. 2,3 Several authors report superior sensitivity and sexual satisfaction in uncircumcised men and their partners, 3,4 sexual dysfunction associated with circumcision 5,6 and important role of foreskin in sexual performance and satisfaction. 7 However, others did not show any significant effect 8 11 or found the procedure to be favorable on adult sexual function. 12 It has been postulated that childhood circumcision results in some genital and extra-genital Correspondence: Dr E Aydur, GATA Üroloji Kliniği, Etlik, Ankara 06018, Türkiye. eaydur@yahoo.com Received 17 August 2006; revised 30 December 2006; accepted 5 January 2007; published online 22 February 2007 changes in children. Keratinization of the more exposed glans penis would lower the sensibility, hence sexual excitability, of the circumcised male s genitalia. Early lesions of the prepuce/foreskin tissue would generate a reorganization/atrophy of the brain circuitry. This reorganization/atrophy, in turn, is suggested to lower sexual excitability. 5,7,13 17 Furthermore, the phallic period of childhood development, between the ages of 3 and 6 years, plays a major role in development of sexual identity and adult sexual attitudes. Circumcision is considered to be an important psychological trauma in neonates and primary school children. Therefore, circumcision may affect the psychological status of the child and eventually cause physical, psychological, behavioral and sexual disturbances. 3,5,18,19 However, there have been no studies, to our knowledge, that assess the possible effect(s) of childhood circumcision age on male sexual function. On the other hand, this subject is an important public concern, especially in Western countries. 20 Thus, a study to shed light on this subject would provide useful information for parents on decision-making process to have their sons circumcised. Given the alleged relationship of circumcision with sexual dysfunctions, and the postulated features and the effects of circumcision on sexual functions, we designed a prospective study to

2 determine the relationship between age of childhood circumcision and male sexual function using a validated questionnaire. Methods Subjects and procedures Following approval of the Institutional Ethics Committee, an extensive survey was conducted at our institution between December 2005 and March 2006, to determine the contributing factors to sexual functions of women, men and couples. This paper focused on the findings related to childhood circumcision age and sexual function of male subjects. Accompanying partners of nulliparous or primiparous women attending the outpatient clinics of the Obstetrics and Gynecology Department were consecutively identified by filter questions and asked to complete a demographic survey and an inventory of sexual function. Accompanying partners of multiparous women, apparently pregnant women and those with a stillbirth were excluded from the study to avoid the possible confounding factors of those conditions. The study protocol was explained to all participants. Complete privacy was assured and the voluntary nature of participation in the study was emphasized. Written informed consent was obtained from all volunteers before their participation in the study. The male partners completed the questionnaires in a separate room allowing for sufficient privacy. One of the investigators was on hand in the event study participants had questions relevant to the study. All the questionnaires were coded, recorded daily and kept in computerized files by the investigators. Questionnaires The self-administered questionnaire consisted of two parts; Part I was designed to collect data about individual and lifestyle characteristics of males such as age, weight, height, educational level, employment status and medical background. Other questions included duration of marriage, type of marriage, contraceptive use and female partner s obstetric history. Part I was tested on a male group before start of the study to ensure that participants would understand what was required of each question. Part II of the questionnaire included the Golombok Rust Inventory of Sexual Satisfaction (GRISS) and provides an objective assessment of the quality of sexual relationships and sexual functioning The questionnaire has two separate forms: one for males and the other for females. Each form consists of 28 items and covers the most frequently occurring sexual dysfunctions of heterosexual persons with a steady partner. Male form of GRISS comprises 28 questions each with five possible answers, ranging from never to always. Each of these 28 items are scored and 24 of them converted to provide eight discrete scores, one for overall sexual function and seven for each specific area of sexual function; that is frequency of intercourse, communication, degree of satisfaction, avoidance, sensuality, ejaculatory function and erectile function. This allows for a breakdown of specific areas of sexual dysfunction in males. The final scores on each of the GRISS subscales range from 1 to 9; scores of 1 4 indicate normal sexual function and scores of 5 9 indicate increased degrees of sexual dysfunction. GRISS can be applied as a screening instrument and for the measurement of therapy outcome The factor structure, internal consistency and stability of the Turkish adaptation have been examined in our population. 25,26 On the basis of the findings, it was justified to maintain the original subscale structure. The results of the standardization study indicated that GRISS could be used in Turkish population both in clinical practice and in research, as a valid and reliable scale. In the present study, all internal calculations of GRISS were carried out electronically using appropriate formulas. Data analysis The primary outcome of this study was the difference in overall sexual function score among males who had undergone circumcision procedure during infancy (0 2 years of age), preschool period (3 5 years of age), childhood period (6 12 years of age) and thereafter. Although the primary endpoint of the study was overall sexual function, the specific areas of sexual function were also included as secondary endpoints. This enabled us to assess men s sexual function in a fuller picture. For the primary analysis, the sample was divided into three groups according to age at circumcision. In one sample, the Kolmogorov Smirnov test was used to analyze the normality of variable distribution. Levene s test was used to test the homogeneity of variance for the continuous variables. Comparisons between proportions were made using w 2 -test. Continuous variables were compared by using Student s t-test and analysis of variance, where appropriate. Data are expressed as mean7s.d. (m7s.d.), number and percentage, according to the variables. Differences were considered significant when Po0.05 for the two tails. Data analysis was carried out using SPSS for Windows, version Results Demographics Of the 107 Caucasian men, all accepted to participate in the study. The mean age was (95% CI: , range 22 44). Circumcision procedure was performed in the first 2 years of life in 12 men 425

3 426 Table 1 Socio demographics and marital characteristics of the participants by the circumcision age groups Characteristics a 0 2 ages (n ¼ 12) 3 5 ages (n ¼ 29) 6 12 ages (n ¼ 66) P Age (year) b b c Body mass index c Educational level Primary/Secondary 1 (8.3%) 3 (4.5%) High school 5 (41.7%) 15 (51.7%) 42 (63.6%) Some college/college 6 (50.0%) 14 (48.3%) 21 (31.8%) Holding a regular job Yes 12 (100.0%) 29 (100.0%) 62 (93.9%) Family income Low 1 (3.4%) 5 (7.6%) Middle 12 (100.0%) 28 (96.6%) 60 (90.9%) High 1 (1.5%) Age at first coitus (year) b b c Marriage duration (year) c Lifestyle habits (yes) Smoking 5 (41.7%) 7 (24.1%) 27 (40.9%) Coffee consumption 5 (41.7%) 3 (10.7%) 9 (13.6%) Alcohol 3 (25.0%) 2 (6.9%) 1 (1.5%) Marriage type Love marriage 12 (100.0%) 24 (82.8%) 54 (81.8%) Arranged marriage 9 (17.2%) 12 (18.2%) Number of children (8.3%) 11 (37.9%) 37 (56.1%) 1 11 (91.7%) 18 (62.1%) 29 (43.9%) Degree of pleasure for relationship with the spouse Very good 8 (66.7%) 18 (62.1%) 46 (69.7%) Good 2 (16.7%) 10 (34.5%) 17 (25.8%) Neither good nor bad 2 (16.7%) 1 (3.4%) 3 (4.5%) Bad/very bad Last method of contraception Withdrawal 6 (50.0%) 11 (37.9%) 22 (33.3%) Combined oral contraceptive 1 (8.3%) 3 (10.3%) 5 (7.6%) IUD 1 (8.3%) 3 (10.3%) 6 (9.1%) Condom 4 (33.3%) 6 (20.7%) 9 (13.6%) Other 1 (3.4%) 5 (7.6%) None 5 (17.2%) 19 (28.8%) Pleasure for the last contraceptive method Both spouses pleased 7 (58.3%) 19 (79.2%) 32 (68.1%) Either spouse not pleased 2 (16.7%) 3 (12.5%) 8 (17.0%) Both spouses not pleased 3 (25.0%) 2 (8.3%) 7 (14.9%) Gravidity/delivery mode of wife Not delivered 1 (8.3%) 12 (41.4%) 37 (56.1%) Caesarean delivery 5 (41.7%) 5 (17.2%) 11 (16.7%) Vaginal delivery 6 (50.0%) 12 (41.4%) 18 (27.3%) Medical background Chronic medical illness 1 (8.3%) 1 (1.5%) a Values are given as mean7s.d. or number (percentage). b The mean difference is significant at the 0.05 level between these two groups according to Bonferroni test. c ANOVA; All other P-values are according to w 2 -test. (11.2%), in preschool years in 29 men (27.1%), and between the 6 and 12 years of age in 66 men (61.7%). None of the males was circumcised later than 12 years of age. Socio demographic and reproductive characteristics of the three groups are demonstrated in Table 1.

4 Overall sexual function and specific domains Mean scores of overall and specific areas of sexual function are demonstrated in Table 2, according to the circumcision age. In all age groups, mean scores of all subscales were in the normal range, except for ejaculatory function. The mean scores of ejaculatory function were similar in all groups; however, all of the mean scores were abnormal. The mean scores of frequency of coitus, degree of satisfaction, sensuality and erectile function were worst in the 3 5 year age group, whereas this group had the best mean score of ejaculatory function. However, the differences did not reached to statistical significance for all comparisons. The only statistically significant difference among the three groups was in the avoidance domain. Multiple comparisons between groups (i.e. 0 2 vs 3 5, 0 2 vs 6 12 and 3 5 vs 6 12) indicated that the mean score of avoidance was significantly lower in the infantile circumcision group, compared with that of the circumcision group of 3 5 ages (Po0.05). Further analysis using binary logistic regression demonstrated that age at survey, age at first coitus, alcohol consumption and number of children were not the predictors of avoidance. Prevalence of sexual dysfunction is demonstrated in Table 3, according to study groups. Overall, 28 men (26.2%) demonstrated sexual dysfunction. Premature ejaculation (PE) was the most common dysfunction with a prevalence of 49.5% (n ¼ 53). When the mean score of this subscale was taken into consideration, this was an expected finding. Interestingly, none of the men demonstrated nonsensuality. Prevalence of sexual dysfunction was 23.4% (n ¼ 25) in erectile function, 19.6% (n ¼ 21) in communication, 15.9% (n ¼ 17) in avoidance, 13.1% (n ¼ 14) in frequency of intercourse and 4.7% (n ¼ 5) in degree of satisfaction. Prevalence of sexual dysfunction in overall and specific areas of GRISS did not demonstrate any statistically significant difference among the three groups. Comparison of normal sexual functioning and sexually dysfunctional groups When the males were divided into two groups, sexually functional and dysfunctional groups, according to overall sexual function, and compared with the mean age at circumcision procedure, there was no difference between the two groups regarding 427 Table 2 Mean scores of the circumcision age groups in overall and specific areas of sexual functions GRISS Subscales Crude scores of GRISS for normal sexual functioning 0 2 ages (n ¼ 12) 3 5 ages (n ¼ 29) 6 12 ages (n ¼ 66) P a Overall sexual function p Specific areas of sexual function Frequency of intercourse p Communication p Degree of satisfaction p Avoidance p b b Sensuality p Premature ejaculation p Erectile dysfunction p Abbreviation: GRISS, Golombok Rust Inventory of Sexual Satisfaction. a ANOVA. b The mean difference is significant at the 0.05 level between these two groups according to Bonferroni test. Table 3 Prevalence of overall sexual dysfunction and its specific areas by the circumcision age groups GRISS Subscales 0 2 ages (n ¼ 12) 3 5 ages (n ¼ 29) 6 12 ages (n ¼ 66) P a Overall sexual dysfunction 3 (25.0%) 9 (31.0%) 16 (24.2%) Specific areas of sexual dysfunction Infrequent intercourse 1 (8.3%) 7 (24.1%) 6 (9.1%) Noncommunication 2 (16.7%) 7 (24.1%) 12 (18.2%) Dissatisfaction 1 (8.3%) 1 (3.4%) 3 (4.5%) Avoidance 1 (8.3%) 8 (27.6%) 8 (12.1%) Nonsensuality 0 (0.0%) 0 (0.0%) 0 (0.0%) Premature ejaculation 7 (58.3%) 14 (48.3%) 32 (48.5%) Erectile dysfunction 4 (33.3%) 8 (27.6%) 13 (19.7%) Abbreviation: GRISS, Golombok Rust Inventory of Sexual Satisfaction. a w 2 test.

5 428 Table 4 Comparisons of mean circumcision age between sexually normal functioning and dysfunctional men GRISS Subscales Circumcision age Mean7s.d. (n) P a Normal sexual function Sexual dysfunction Overall sexual function (28) (79) Specific areas of sexual dysfunction: Frequency of intercourse (14) (93) Communication (21) (86) Degree of satisfaction (5) (102) Avoidance (17) (90) Sensuality (107) NA Ejaculatory function (53) (54) Erectile function (25) (82) a Student s t-test. overall sexual function. The mean age of these two groups was similar at survey ( vs , respectively. P ¼ 0.339). Among the seven specific areas of sexual function, only the communication domain demonstrated a statistically significant difference between the two groups, showing that the mean age at circumcision of sexually dysfunctional men was significantly younger than the normal functioning men (Table 4). Discussion To our knowledge we report the first prospective study assessing the relationship between childhood circumcision age and male sexual function. We demonstrated no relationship between circumcision age and overall male sexual function. However, comparisons of subgroups yielded that, of specific domains of sexual function, avoidance and communication seemed to be affected by age at circumcision procedure in this cohort of sexually active males. In addition, prevalence of sexual dysfunction is higher and PE was the most common dysfunction in the survey. Although many have speculated about the effect of childhood circumcision on sexual function, the current state of knowledge is based on anecdote rather than scientific evidence Myths have mostly addressed changes in penile sensitivity, 5,7,13 17 but some have also regarded sexual activity and satisfaction with appearance. 6 Little has been written about the effect of childhood circumcision on erectile function 5 and, few studies have investigated the relationship between childhood circumcision and adult sexual function. 5,10 Hammond, 5 has reported the results of the study conducted by the National Organization to Halt the Abuse and Routine Mutilation of Males (NO- HARMM) and concluded that circumcision would result in physical, sexual and psychological adverse consequences. NOHARMM s study was entirely based on the poll of participants who were unsatisfied with infantile circumcision and has claimed that adverse sexual consequences were secondary to decreased penile sensitivity and emotional distress. However, there is no evidence supporting the theory of decreased penile sensitivity owing to circumcision, though it is plausible. Furthermore, Masters and Johnson 8 and, more recently Bleustein et al. 10 have found no significant difference in sensation by neurological testing on the glans of circumcised and uncircumcised men. On the other hand, emotional distress as a claimed cause of adult sexual dysfunction after neonatal circumcision may be, of course, culture, individual or partner related. For example, an uncircumcised Turkish man would have emotional distress, because male circumcision is deeply woven into the fabric of Turkish society and Turks consider that one is not a man until he is circumcised. 31 Laumann et al. 12 analyzed data from the National Health and Social Life Survey and found that neonatally circumcised men were slightly less likely to experience sexual dysfunction. Also, several authors have reviewed the literature and concluded that circumcision does not interfere with sexual sensation and satisfaction Childhood circumcision is reported as a psychological trauma as in all interventions. Furthermore, infantile circumcision may also cause short-term behavioral changes. However, long-term psychological effects associated with circumcision are difficult to establish. 18 Actually, there is no circumcision study that demonstrates psychological adverse effects experienced in adulthood. We found that the mean score of avoidance was significantly lower in males who had undergone circumcision in infancy, compared with that of the group including men circumcised between 3 and 5 years of age. Also, in the communication domain,

6 there was a statistically significant difference between the two groups, where the mean age of sexually dysfunctional men was younger than that of the normal functioning men. Although NO- HARMM s study has reported that many respondents suffered physical/emotional distress impeding emotional intimacy with partner(s), resulting in sexual dysfunction, 5 we could not comment on these findings. The nonsensuality scores in the study may result from and also represent the well being of participants, who were at their the most sexually active period, as sensuality is considered as a yield of endocrine function. 32 Men who have undergone circumcision in adulthood have potentially a unique position to assess the effect of the prepuce on sexual intercourse. 6 Therefore, we do not mention findings from adult circumcision studies. However, the well-known controversies also continue to exist regarding the sexual effects of adult circumcision. 2,3,6,9 The rationale of the present study is based on the available literature summarized in the introduction. Little is known about the effects of male circumcision on male sexual function, even though it is easy to test their possible relationship, as circumcision is highly prevalent procedure throughout the world. 1,5,6 Thus, there are many myths surrounding circumcision, affecting public behavior, particularly in Western countries. 2,20 This study is a part of our large survey, which was conducted to determine the contributing factors to sexual functions of women, men and couples. The present study attempts to shed light on the circumcision debate by assessing the possible relationship between childhood circumcision age and sexual function of adult male, using a validated questionnaire, GRISS. Several means, including interviews, diaries and questionnaires, have been developed and commonly used for assessment of sexual function in both men and women. 6,33 However, few questionnaires have been cross-validated in multiple samples of sexually functional and dysfunctional women. Published data indicate that the GRISS questionnaire is valid, reliable and responsive to change following standard psychometric testing. Evidence has been published on all aspects and the questionnaire is relevant for use with persons with sexual dysfunction The advantage of the present study is that we were able to examine the sexual function by the use of a self-report questionnaire cross-validated in multiple samples of sexually functional and dysfunctional men, rather than relying on general questions about sexual problems or focusing on only certain types of sexual dysfunction. This provided a fuller picture of overall sexual function in the study groups. Considering that sexuality is a complex entity with physical, emotional, psychological, cultural and religious dimensions, differing from person to person, future investigators wishing to compare sexuality should consider using self- reported and validated questionnaires. It will be easy to compare studies and increase the ability to draw clinical inferences from the findings. However, different questionnaires have been used partly or entirely in the published studies to assess the effects of circumcision on male sexual functions, including nonvalidated and validated questionnaires, such as the International Index of Erectile Function (IIEF), Brief Sexual Function Questionnaire, Changes in Sexual Functioning Questionnaire, Center for Marital and Sexual Health Functioning Questionnaire, and National Health and Social Life Survey. To our knowledge, GRISS questionnaire is firstly used in the study for such a purpose. 2,3,6,34 38 Male participants were at their most sexually active period in terms of age, allowing to determine easily the possible relationship between childhood circumcision age and sexual functions. The accompanying partners of multiparous women, pregnant women and those with a stillbirth were excluded from the study to avoid possible confounding factors. Our study may have methodological limitation owing to lack of control (uncircumcised men) group to compare, but almost all of the men are circumcised in our country, 31 and we, therefore preferred the present design to test the study s objective. Of all the dysfunctions, PE was the only specific dysfunction found in our study, with a mean score above the normal range. Moreover, it was the most common problem in accordance with the previous studies. 11 PE has been reported as affecting from 5 to 40% of sexually active men, depending on age. 39,40 Prevalence estimates of PE vary widely, probably because there is no universally accepted definition of PE and ejaculatory function can be affected by psychological, physical, financial or partner-related factors, even in the same man. 41 There are few, if any, large-scale studies providing community-based, normative data and there is no standardized screening tool to identify PE. Considering the age range of our study population, the rate of PE was higher than that reported previously. 39,40 There is no evidence supporting notion that circumcision causes PE. 11 In our sample of male participants from a gynecological outpatient clinic of a University hospital, a rather high prevalence of sexual dysfunction (26.2%) was found. 42 None of the men had self-presented their sexual dysfunctions before the present study. This finding corroborates earlier contentions that the clinician should actively ask for the existence of sexual dysfunctions, because patients tend not to disclose their sexual problems by themselves, usually owing to embarrassment, despite their apparent need for professional assistance Although physicians are able to elicit information regarding sexual function on specific questioning, patients appear comfortable and willing to discuss their condition with physicians Some methodological shortcomings may limit the value of the findings. First, our study consists of 429

7 430 small sample size, especially in subscales. Second, it has no control (uncircumcised men) group to compare owing to scarce of uncircumcised men in our country. Third, the study was conducted in a unique cultural environment, which is a confounding factor in studies regarding circumcision. 45 Finally, the female factor in the study was not considered. However, we cannot know the way in which all the limitations will affect the study s results. To our knowledge, we present the first study to evaluate specifically the relationship between childhood circumcision age and male sexual function. Although our study has some methodological shortcomings, it contributes to our knowledge about the effects of childhood circumcision age. We demonstrated that circumcision age does not affect overall male sexual function, however, some specific domains of sexual function (i.e., avoidance and communication) seemed to be affected by the age at circumcision. In addition, prevalence of sexual dysfunction was higher and PE was the most common dysfunction in the survey. Our findings may help health professionals interested in circumcision better counsel parents on decision-making process of male circumcision. Prospective studies, including large cohort studies and those based on scientifically objective measurements, are needed to understand better the effects of childhood circumcision on adult life. Conflict of interest None. Acknowledgments We thank Zuhal Baltaci, PhD, for the assistance in recruiting women to participate in this study and Serap Gungor, PhD, for her invaluable advice and assistance in preparing the questionnaire. We would also thank Dr Bedreddin Seçkin and Dr Kaan Aydos for their precious reviews and helpful corrections in the text. We are especially grateful to the participants of the study who so generously gave their time and support to complete this study. 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