ArticleLiterature Review

A Review of the Current State of the Male Circumcision Literature

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Abstract

Introduction: Male circumcision is one of the most commonly performed surgical procedures worldwide and a subject that has been the center of considerable debate. Recently, the American Association of Pediatrics released a statement affirming that the medical benefits of neonatal circumcision outweigh the risks. At present, however, the majority of the literature on circumcision is based on research that is not necessarily applicable to North American populations, as it fails to take into account factors likely to influence the interpretability and applicability of the results. Aims: The purpose of this review is to draw attention to the gaps within the circumcision literature that need to be addressed before significant changes to public policy regarding neonatal circumcision are made within North America. Methods: A literature review of peer-reviewed journal articles was performed. Main outcome measures: The main outcome measure was the state of circumcision research, especially with regard to new developments in the field, as it applies to North American populations. Results: This review highlights considerable gaps within the current literature on circumcision. The emphasis is on factors that should be addressed in order to influence research in becoming more applicable to North American populations. Such gaps include a need for rigorous, empirically based methodologies to address questions about circumcision and sexual functioning, penile sensitivity, the effect of circumcision on men's sexual partners, and reasons for circumcision. Additional factors that should be addressed in future research include the effects of age at circumcision (with an emphasis on neonatal circumcision) and the need for objective research outcomes. Conclusion: Further research is needed to inform policy makers, health-care professionals, and stakeholders (parents and individuals invested in this debate) with regard to the decision to perform routine circumcision on male neonates in North America.

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... Penile cancer is rare in developed countries [95], such that, according to the American Academy of Pediatrics (AAP), it would take between 909 and 322,000 circumcisions to prevent a single case [93]. Most of the reliable evidence suggesting a reduced risk of STIs comes from studies of adult, voluntary circumcision in African countries whose applicability to circumcision of infants in other contexts is unclear [96,97]. Moreover, STIs are not a relevant health risk to children. ...
... Adults of all genders who choose to have their genitals altered under conditions of informed consent tend to report overall satisfaction with their decision. For example, surveys of men whose genitals were cut in adulthood tend to support the notion that sexual enjoyment is not greatly impaired, on average, by voluntary circumcision, at least as far as one can infer from the generally reductive scientific approaches to studying such questions that are currently common [96,115,116]. But even taking the results of such surveys for granted, adults who feel that their sexual experience has improved as a result of genital cutting are not randomly sampled from the population. ...
... Accordingly, "the attitudes and experiences of adults who elected genital cutting cannot and should not be extrapolated to individuals whose genitals were cut in infancy or early childhood" [117]. Unfortunately, such extrapolation is a common mistake in the literature, even among medical authorities [96]. For example, two physicians who recently argued that "procedures resembling elective labiaplasty" should be allowed on young girls if requested by their parents, asserted that such procedures "create morphological changes, but are not expected to have an adverse effect on reproduction or on the sexual satisfaction of the woman or her partner" [118•]. ...
Article
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Purpose of Review The purpose of this study is to survey recent arguments in favor of preserving the genital autonomy of children—female, male, and intersex—by protecting them from medically unnecessary genital cutting practices. Recent Findings Nontherapeutic female, male, and intersex genital cutting practices each fall on a wide spectrum, with far more in common than is generally understood. When looking across cultures and comparing like cases, one finds physical, psychosexual, and symbolic overlaps among the three types of cutting, suggesting that a shared ethical framework is needed. Summary All children have an interest in genital autonomy, regardless of their sex or gender.
... In settings where circumcision is relatively common, such as the United States, prophylactic health benefits are often cited in support of the practice [29]. However the evidence is contested and is primarily associated with adult, voluntary circumcision in Sub-Saharan Africa, not newborn circumcision in economically developed regions with advanced healthcare systems [30]. In any case, the claimed health benefits can also be achieved non-surgically through, e.g., safe sex practices and basic hygiene. ...
... All three of FGCS, FGC, and MGC involve the non-therapeutic modification or removal of healthy, erotogenic tissue. Whilst there is a lively debate about the average (net) effects of these practices on health [29,30,31,69] and sexual pleasure [22,30,70,86], what is often lost in such discussions is that no one is an embodied statistical average: genital cutting affects different individuals differently, depending upon the type and extent of cutting, whether and what kind of pain control is used, the age at which it is performed, the skill of the practitioner, one's mind-set going into the cutting-or later reflecting upon it or its effects-and so on [71]. ...
... All three of FGCS, FGC, and MGC involve the non-therapeutic modification or removal of healthy, erotogenic tissue. Whilst there is a lively debate about the average (net) effects of these practices on health [29,30,31,69] and sexual pleasure [22,30,70,86], what is often lost in such discussions is that no one is an embodied statistical average: genital cutting affects different individuals differently, depending upon the type and extent of cutting, whether and what kind of pain control is used, the age at which it is performed, the skill of the practitioner, one's mind-set going into the cutting-or later reflecting upon it or its effects-and so on [71]. ...
Article
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Cambridge Core - Obstetrics and Gynecology, Reproductive Medicine - Female Genital Cosmetic Surgery - edited by Sarah M. Creighton Link: https://www.cambridge.org/se/academic/subjects/medicine/obstetrics-and-gynecology-reproductive-medicine/female-genital-cosmetic-surgery-solution-what-problem?format=PB
... Assuming that this self-reporting is reasonably accurate-that is, setting aside the concerns about SDR raised above-one is left wondering what the mechanism for this apparent effect could be. One potential lead for an explanation comes from the prior literature on this issue, where the possibility has been raised, with supporting evidence, that circumcision may increase the risk of diminished tactile sensation in the concomitantly exposed penile glans (see, e.g., Sorrells et al., 2007; but see the criticism by Waskett & Morris, 2007, as well as the reply by Young, 2007; see also Bossio et al., 2014, for a more general discussion; and see Frisch, 2012;Svoboda and Van Howe, 2013;and Earp & Darby, 2015, for further discussion of critical lettersto-the-editor by Morris and colleagues). ...
... On page 5, the authors state that "Male circumcision has not been shown to result in adverse changes in sexual function or satisfaction," and cite a review article by Morris and Krieger (2013). However, this article has been criticized on methodological grounds (e.g., Bossio et al., 2014;Boyle, 2015; but see Morris and Krieger, 2015), as have the key RCT studies upon which its primary conclusions most heavily rest (see Frisch, 2012;Earp, 2015a). ...
... As Bossio et al. (2014) state, the review by Morris and Krieger is "not a meta-analysis, thus, no statistical analyses of the data have been performed; instead, the article presents the authors' interpretation of trends." Problematically, "Morris and Krieger do not report the results of [their] review collapsed across study quality. ...
Article
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Feldblum et al. (2015) argue that voluntary medical male circumcision (VMMC) using the ShangRing device leads to increased sexual pleasure, universally satisfying cosmetic outcome, and virtually no delayed complications in a 2-3 year follow-up study. In this commentary, I suggest that socially desirable responding (SDR) is a likely candidate explanation for at least some of these reported findings, and I argue that this should have been controlled for using available measures. I also highlight evidence from the authors' own study for risk compensation as a result of circumcision (including decreased condom use and an increase in number of sexual partners) and ask why this adverse outcome was not emphasized as a cause for concern. I conclude by providing 6 concrete suggestions for improving future studies on circumcision.
... Circumcision is one of the ancient surgical procedures concerning the removal of some or all of the penile prepuce (foreskin) performed till date and has remained a highly critical subject (Bossio et al., 2014;Hutcheson, 2004). Today, male circumcision has become a common medical procedure with improved anaesthetic, surgical, and antiseptic techniques (Hutcheson, 2004). ...
... Contemporary literature about circumcision is partially skewed (Bossio et al., 2014). According to Bossio et al. (2014), quite significant amount of research has been directed towards the medical benefits of circumcision. ...
... Contemporary literature about circumcision is partially skewed (Bossio et al., 2014). According to Bossio et al. (2014), quite significant amount of research has been directed towards the medical benefits of circumcision. Emerging findings suggest that circumcision status has a significant influence on men's sexual partners. ...
Article
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Introduction This current study sought to investigate the association between male circumcision status and engaging in multiple sexual partnership among men in Ghana. Methods Data from this study come from the men’s file of the 2014 Ghana demographic and health survey. Both descriptive and inferential statistics were conducted among 1,948 men and the level of statistical significance was pegged at p<0.05. Results Results revealed that men who have been circumcised were more likely to engage in multiple sexual partnership (AOR=3.36;CI:1.14-9.89), compared to those who have not been circumcised. With the covariates, men with primary level of education were more likely to have multiple sexual partners (AOR=2.01; CI:1.10-3.69), compared to those with no education. With wealth status, men with richest (AOR=2.27;CI:1.04-4.97), richer (AOR=2.05; CI: 1.03-4.08), and middle wealth status (AOR=1.83; CI:1.01-3.34) had the highest likelihood of having multiple sexual partners, compared to those with poorest wealth status. Conversely, men who professed the Islamic faith were less likely to engage in multiple sexual partnership (AOR=0.58; CI: 0.36-0.94), compared to Christians. Similarly, men who resided in the Brong Ahafo (AOR=0.51; CI: 0.26-0.99), Upper East (AOR=0.41; CI:0.19-0.89), and Ashanti regions (AOR=0.39;CI: 0.20-0.78) were less likely to engage in multiple sexual partnership. Conclusion Based on the current findings, educational campaigns by stakeholder groups (e.g., Ministry of Health in collaboration with the National Commission on Civic Education, civil society, educational institutions) should sensitize the sexually active population at the community level to consistently use condoms, especially when having multiple sexual partners, even when a man is circumcised. Campaign messages must clearly emphasize that male circumcision should not substitute precautionary measures such as delay in the onset of sexual relationships, averting penetrative sex, reducing the number of sexual partners as well as correct and consistent use of male or female condoms regardless one’s social standing.
... In settings where circumcision is relatively common, such as the United States, prophylactic health benefits are often cited in support of the practice [29]. However the evidence is contested and is primarily associated with adult, voluntary circumcision in Sub-Saharan Africa, not newborn circumcision in economically developed regions with advanced healthcare systems [30]. In any case, the claimed health benefits can also be achieved non-surgically through, e.g., safe sex practices and basic hygiene. ...
... All three of FGCS, FGC, and MGC involve the non-therapeutic modification or removal of healthy, erotogenic tissue. Whilst there is a lively debate about the average (net) effects of these practices on health [29,30,31,69] and sexual pleasure [22,30,70,86], what is often lost in such discussions is that no one is an embodied statistical average: genital cutting affects different individuals differently, depending upon the type and extent of cutting, whether and what kind of pain control is used, the age at which it is performed, the skill of the practitioner, one's mind-set going into the cutting-or later reflecting upon it or its effects-and so on [71]. ...
... All three of FGCS, FGC, and MGC involve the non-therapeutic modification or removal of healthy, erotogenic tissue. Whilst there is a lively debate about the average (net) effects of these practices on health [29,30,31,69] and sexual pleasure [22,30,70,86], what is often lost in such discussions is that no one is an embodied statistical average: genital cutting affects different individuals differently, depending upon the type and extent of cutting, whether and what kind of pain control is used, the age at which it is performed, the skill of the practitioner, one's mind-set going into the cutting-or later reflecting upon it or its effects-and so on [71]. ...
Chapter
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In this chapter, we contrast legal and ethical perspectives on two forms of nontherapeutic female genital cutting: those commonly known as “female genital mutilation” and those commonly known as “female genital cosmetic surgeries.” We begin by questioning the usefulness of these categories—and the presumed distinctions upon which they rest— stressing the shared features of the two sets of practices. Taking UK legislation as a case study, we show that there are troubling inconsistencies in the way in which female genital cutting is understood in Western contexts. Specifically: (a) all nontherapeutic genital alterations to female minors are criminalised, typically with harsh penalties for transgressing the law, while even more invasive nontherapeutic genital alterations to male and intersex minors are permitted and almost entirely unregulated; and (b) genital alterations of adult women regarded as “cosmetic” in nature are treated as legal, while in some jurisdictions, anatomically identical procedures classified as “mutilation” are illegal. This chapter highlights these and other inconsistencies, speculates as to why they arise in Western contexts, and explores the scope for more consistent and constructive attitudes and legislation.
... In settings where circumcision is relatively common, such as the United States, prophylactic health benefits are often cited in support of the practice [29]. However the evidence is contested and is primarily associated with adult, voluntary circumcision in Sub-Saharan Africa, not newborn circumcision in economically developed regions with advanced healthcare systems [30]. In any case, the claimed health benefits can also be achieved non-surgically through, e.g., safe sex practices and basic hygiene. ...
... All three of FGCS, FGC, and MGC involve the non-therapeutic modification or removal of healthy, erotogenic tissue. Whilst there is a lively debate about the average (net) effects of these practices on health [29,30,31,69] and sexual pleasure [22,30,70,86], what is often lost in such discussions is that no one is an embodied statistical average: genital cutting affects different individuals differently, depending upon the type and extent of cutting, whether and what kind of pain control is used, the age at which it is performed, the skill of the practitioner, one's mind-set going into the cutting-or later reflecting upon it or its effects-and so on [71]. ...
... All three of FGCS, FGC, and MGC involve the non-therapeutic modification or removal of healthy, erotogenic tissue. Whilst there is a lively debate about the average (net) effects of these practices on health [29,30,31,69] and sexual pleasure [22,30,70,86], what is often lost in such discussions is that no one is an embodied statistical average: genital cutting affects different individuals differently, depending upon the type and extent of cutting, whether and what kind of pain control is used, the age at which it is performed, the skill of the practitioner, one's mind-set going into the cutting-or later reflecting upon it or its effects-and so on [71]. ...
Chapter
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Female Genital Cosmetic Surgery - edited by Sarah M. Creighton February 2019
... (Norton, 2017, p. 3) Faced with the RCT evidence, many public health officials, medical practitioners, journalists and even some bioethicists joined the rush to engage in extrapolation (Fox and Thomson, 2010). For example, if circumcision can lower the risk of so serious and, in some contexts, so prevalent a disease as HIV/AIDS, then, some seemed to think, it must be both medically desirable and ethically acceptable to perform it anywhere (Bossio et al., 2014(Bossio et al., , 2015Fox and Thomson, 2010). Moreover, if it 'works' for consenting adults, it should also be performed on infants and young boys (see Bossio et al., 2015); and not only in response to individual (parental) demand, but through high-pressure public programs (Katisi and Daniel, 2015). ...
... in infancy on such grounds, since there is no controlled evidence that infant circumcision-as opposed to adult circumcision-can in fact reduce transmission of HIV, much less to a meaningful degree outside of the context of Sub-Saharan Africa, where absolute rates of HIV transmission are among the highest in the world (Bossio et al., 2014(Bossio et al., , 2015Darby and Van Howe, 2011;Frisch and Earp, in press;Sidler et al., 2008). Since one's susceptibility to sexually transmitted infections is far more strongly governed by socio-behavioral mechanisms than by strictly biological mechanisms (such as the presence or absence of a foreskin), it cannot be assumed that a partial protective effect accruing from adult consideration when trying to assess whether (male) children have any interest at all in being circumcised as prophylaxis against HIV. ...
Article
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McMath (2105) argues that while a child’s interest in future autonomy should generally be respected in relation to his own interests, the well-being of other parties may require that his autonomy be overridden in the interests of public health. At the same time, McMath seems conflicted about whether the seriousness of the threat of HIV, especially in developed countries, can in fact justify the sacrifice of individual freedom that is entailed by circumcision in infancy or early childhood (that is, the freedom to make one’s own decision about whether to undergo an elective genital surgery at an age of understanding). In this context, McMath’s discussion about the child’s interest in making decisions that reflect his mature preferences and values when he is older is compelling. But when considering arguments for paternalism in the name of public health, we suggest that McMath moves too quickly from certain empirical premises to associated policy proposals, skipping over gaps in evidence as well as important questions of value.
... Like their predecessors, the new generation of advocates rely most heavily on evidence that circumcision has a protective effect against sexually transmitted infections (STIs), especially HIV. 5 The problem is that children are not sexually active; that most of this "new evidence" is from studies of circumcision of adult males, not infants; and that it derives from African countries with very different social and epidemiological environments from those in the developed West (Green et al., 2010). Whether or not the evidence from the clinical trials is sufficient to justify the massive scale of the African circumcision programs, advocates of widespread circumcision in developed countries stretch it far beyond its logical and geographical limits, asserting that it constitutes a "compelling" argument (a) for circumcising infants and (b) applying the programs universally, regardless of the local conditions, no matter how different they may be from the by guest on September 29, 2016 Downloaded from regions where the evidence was generated (Bossio, Pukall, & Steele, 2014). The rhetorical maneuver by which they achieve these leaps should be examined because it involves a cluster of logical errors and failures of ethical awareness that inhibit clear thinking about the ethics, benefits, risks, and harms of NTC as a medically rationalized procedure in developed nations. ...
... 9 Both the reviews mentioned above and the policy statements of medical authorities acknowledge evidence from Africa that circumcision of adult males can reduce their risk of acquiring HIV through unprotected intercourse with an infected female partner in regions of high heterosexual HIV prevalence. But they point out that these conditions are not present in developed countries and that children, not being sexually active, are not at risk of sexually transmitted HIV (Bossio et al., 2014;Lyons, 2013). It is, therefore, far from clear that circumcision does confer the benefits claimed by its promoters, undermining the premise of both versions of the argument outlined above. ...
Article
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Recent restatements of the case for routine circumcision of normal male infants and boys typically base their arguments on a range of medical evidence showing circumcision to have a protective effect against certain pathological conditions. It is then assumed that this evidence leads automatically to a clinical recommendation that circumcision should either be “considered” or strongly urged. Closer analysis reveals that the recommendation of infant or child circumcision has less to do with the medical benefits than with the historic origins of the procedure, the convenience to the operator and the status of the patient. It is further suggested that it is not clear that the medical benefits of infant or child circumcision outweigh the risks and harms, and that this style of advocacy fails to pay due regard to basic principles of bioethics and human rights that are accepted in other areas of medical practice.
... Other studies [11][12][13] have documented severe distress of a subpopulation of men (representativeness unknown) in relation to their infant circumcisions, including reports of chronic glans insensitivity, delayed ejaculation, and unpleasant sensations (e.g., pain, numbness). The evidence regarding all these claims is contentious and contradictory [14][15][16][17][18], and precise neural mechanisms have not been postulated. More detailed knowledge of penile anatomy, innervation, and structure may thus contribute to our understanding of these phenomena. ...
Article
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Immunohistological patterns of density and distribution of neural tissue in the human penis, including the prepuce, are not fully characterized, and effects of circumcision (partial or total removal of the penile prepuce) on penile sexual sensation are controversial. This study analyzed extra- and intracavernosal innervation patterns on the main penile axes using formalin-fixed, paraffin-embedded human adult and fetal penile tissues, single- and double-staining immunohistochemistry and a variety of neural and non-neural markers, with a special emphasis on the prepuce and potential sexual effects of circumcision. Immunohistochemical profiles of neural structures were determined and the most detailed immunohistological characterizations to date of preputial nerve supply are provided. The penile prepuce has a highly organized, dense, afferent innervation pattern that is manifest early in fetal development. Autonomically, it receives noradrenergic sympathetic and nitrergic parasympathetic innervation. Cholinergic nerves are also present. We observed cutaneous and subcutaneous neural density distribution biases across our specimens towards the ventral prepuce, including a region corresponding in the adult anatomical position (penis erect) to the distal third of the ventral penile aspect. We also describe a concept of innervation gradients across the longitudinal and transverse penile axes. Results are discussed in relation to the specialized literature. An argument is made that neuroanatomic substrates underlying unusual permanent penile sensory disturbances post-circumcision are related to heightened neural levels in the distal third of the ventral penile aspect, which could potentially be compromised by deep incisions during circumcision.
... Circumcision for HIV-prevention does not appear to benefit men who have sex with men (MSM) (e.g., Goodreau et al., 2014;Templeton et al., 2010), which is a far more common mode of transmission in most Western countries. There is no reliable evidence that neonatal or early childhood circumcision has any protective effect against HIV transmission, especially in such countries (e.g., Bossio et al., 2014;Sidler et al., 2008). For critiques of the African circumcision campaigns, see the 2015 collection of papers in Global Public Health, volume 10, issues 5-6. ...
Chapter
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Moral and legal opposition to the non-therapeutic cutting of children's genitals has traditionally focused on female children. In recent years, however, a growing movement of scholars, activists, and individuals affected by childhood genital cutting have argued that all children, regardless of sex or gender, should be protected from such intimate violations. By drawing attention to the overlapping harms to which female, male, and intersex children may be exposed as a result of having their genitals cut, this movement posits a sex and gender neutral—that is, human—right to bodily integrity and genital autonomy. This article introduces and outlines some of the main arguments supporting this perspective.
... At this juncture, we should also recognise that some published studies have found that the reduction of penis sensitivity caused by circumcision can lead to deleterious effects on male sexuality. Adverse self-reported outcomes associated with foreskin removal in adulthood include impaired erection, orgasm difficulties, decreased masturbatory functioning, increase in penile pain, and loss of penile sensitivity [28][29][30][31]. Kim et al. [32] found that circumcised men reported decreased masturbatory pleasure and sexual enjoyment, and concluded that adult circumcision adversely affects sexual function in a substantial number of men due to the loss of nerve endings. ...
Article
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Objective: To investigate the prevalence of an excessive prepuce in patients with premature ejaculation (PE) and to evaluate the effectiveness of distal circumcision in reducing the penile hypersensitivity, which is thought to be a cause of PE. Patients and methods: Men were considered to have an excessive prepuce if the foreskin exceeded the external urethral meatus by ≥1 cm in the flaccid state. The diagnosis of PE was based on the Premature Ejaculation Diagnostic Tool (PEDT) questionnaire score and on the intravaginal ejaculatory latency time (IELT). These features were evaluated at baseline and at 6 months after circumcision. Results: Lifelong PE was diagnosed in 352 patients of whom 208 (59.1%) had an excessive prepuce. We offered those with an excessive prepuce a circumcision, as a potential definitive treatment for their PE, and 27 (13%) men accepted. At 6 months after circumcision, there was an increase in the mean (SD) IELT from 40.4 (16.5) to 254 (66.8) s (P
... Studies extolling its medical benefits tend to target certain geographic regions, such as those populated by sub-Saharan groups known not to practise traditional male circumcision [4]. Research targeting a specific religious profile has also linked the procedure to medical benefits in such settings as the Muslim Middle East and Turkey, and Muslim sub-Saharan Africa [5][6][7][8]. However, uptake of the procedure across HIV prevalent areas has proved irregular, and systematic evaluations of men's improved health have not been replicable in other low-and middle-income regions, such as in the Caribbean, where STI and HIV prevalence have been shown as increased among circumcised men when compared to uncircumcised [9,10]. ...
Article
Unskilled traditional healers are widely blamed for complications to male circumcision performed in low- and middle-income settings. However, attributions of culpability are mostly anecdotal. We identify self-circumcision in adults that was performed during adolescence, hereby termed retrospective self-circumcision, and unexpectedly discovered during interviews with Somali men in Sweden in 2010. This study explores the phenomenon with the aim to increase our understanding about the health needs of this group. Two focus group discussions (six and seven participants), one informal discussion with three participants, and 27 individual interviews were conducted in 2010 and 2011 with Somali-Swedish fathers, guided by a hermeneutic, comparative natural inquiry method. Eight participants had performed retrospective self-circumcision while living in rural Somalia. Actions were justified according to strong faith in Islam. Genital physiology was described as adequate for producing children, but physical sensation or characteristics were implied as less than optimal. Few had heard about penile reconstruction. There was hesitation to openly discuss concerns, but men nevertheless encouraged each other to seek care options. Presently no medical platform is available for retrospective self-circumcision. Further systematic exploration is recommended in sexual, reproductive and urological health to increase interest in this phenomenon. Our findings suggest approachability if health communication is enabled within an Islamic context.
... Yet the evidence being alluded to does not pertain to NPC in infancy or childhood, much less in the United Kingdom. Rather, it pertains only to the rate of female-to-male transmission of HIV to voluntarily circumcised African men, specifically in regions of Africa with high rates of such heterosexual transmission and a low baseline prevalence of penile circumcision (111)(112)(113). ...
Article
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The current legal status and medical ethics of routine or religious penile circumcision of minors is a matter of ongoing controversy in many countries. We focus on the United Kingdom as an illustrative example, giving a detailed analysis of the most recent guidance on the subject, from 2019, from the British Medical Association (BMA). We argue that the guidance paints a confused and conflicting portrait of the law and ethics of the procedure in the UK context, reflecting deeper, unresolved moral and legal tensions surrounding child genital cutting practices more generally. Of particular note is a lack of clarity around how to apply the “best interests” standard—ordinarily associated with time-sensitive proxy decision-making regarding therapeutic options for a medically unwell but incompetent patient, such as a young child dealing with disease or disability—to a parental request for a medically unnecessary surgery to be carried out on the genitalia of a well child. Challenges arise in measuring and assigning weights to intended sociocultural or religious/spiritual benefits, and even to health-related prophylactic benefits, and in balancing these against potential physical, functional, and psychosexual risks or harms. Also of concern are apparently inconsistent safeguarding standards applied to children based on their birth sex categorization or gender of rearing. We identify and discuss recent trends in British and international medical ethics and law, finding gradual movement toward a more unified standard for evaluating the permissibility of surgically modifying healthy children’s genitals before they can meaningfully participate in the decision.
... These national policy statements are based on research that primarily focuses on the health outcomes of circumcision (eg protection against sexually transmitted infections) while little is known about the sexual correlates of neonatal circumcision and, in particular, penile sensitivity. 3 We address this gap by assessing objective measures of penile sensitivity across men who were vs were not neonatally circumcised. ...
Article
PURPOSE: Little is known about the long-term implications of neonatal circumcision on the penile sensitivity of adult men, despite recent public policy endorsing the procedure in the United States. In the current study we assessed penile sensitivity in adult men by comparing peripheral nerve function of the penis across circumcision status. MATERIALS AND METHODS: A total of 62 men (age 18 to 37 years, mean 24.2, SD 5.1) completed study procedures (30 circumcised, 32 intact). Quantitative sensory testing protocols were used to assess touch and pain thresholds (modified von Frey filaments) and warmth detection and heat pain thresholds (a thermal analyzer) at a control site (forearm) and 3 to 4 penile sites (glans penis, midline shaft, proximal to midline shaft and foreskin, if present). RESULTS: Penile sensitivity did not differ across circumcision status for any stimulus type or penile site. The foreskin of intact men was more sensitive to tactile stimulation than the other penile sites, but this finding did not extend to any other stimuli (where foreskin sensitivity was comparable to the other sites tested). CONCLUSIONS: Findings suggest that minimal long-term implications for penile sensitivity exist as a result of the surgical excision of the foreskin during neonatal circumcision. Additionally, this study challenges past research suggesting that the foreskin is the most sensitive part of the adult penis. Future research should consider the direct link between penile sensitivity and the perception of pleasure/sensation. Results are relevant to policy makers, parents of male children and the general public.
... The interpretation of such measures is beyond what is known about male sexual function and these measures were therefore not included in the present systematic review. A recent review with focus on gaps in male circumcision research has specified the needs for consistent objective measures and for correlation of objective to subjective male sexual function outcomes [67]. Other systematic reviews from paediatric societies in the USA and Canada also conclude that circumcision is unlikely to change male sexual function [9,68]. ...
Article
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Introduction: The debate on non-medical male circumcision has gaining momentum during the past few years. The objective of this systematic review was to determine if circumcision, medical indication or age at circumcision had an impact on perceived sexual function in males. Methods: Systematic searches were performed in MEDLINE and Embase. The included studies compared long-term sexual function in circumcised and non-circumcised males, before and after circumcision, or compared different ages at circumcision. The quality of the studies was assessed according to the level of evidence (Grade A-D). Results: Database and hand searches yielded 3,677 records. Inclusion criteria were fulfilled in 38 studies including two randomised trials. Overall, the only identified differences in sexual function in circumcised males were decreased premature ejaculation and increased penile sensitivity (Grade A-B). Following non-medical circumcision, no inferior sexual function was reported (A-B). Following medical circumcision, most outcomes were comparable (B); however, problems in obtaining an orgasm were increased (C) and erectile dysfunction was reported with inconsistency (D). A younger age at circumcision seemed to cause less sexual dysfunction than circumcision later in life. Conclusions: The hypothesis of inferior male sexual function following circumcision could not be supported by the findings of this systematic review. However, further studies on medical circumcision and age at circumcision are required.
... 16 Possible effects on sexual health when the circumcised male reaches maturity have been inconclusive, but differences are more likely to be found in studies with poor design. [17][18][19] Nontherapeutic circumcision has been controversial in recent years. Although issues of autonomy have surfaced with regard to the appropriateness of parental consent for elective neonatal circumcision, beneficent and nonmaleficent considerations interact with proposed autonomy considerations on both sides of the issue. ...
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INTRODUCTION: Analyze early complications rate in neonatal circumcision performed by attending physicians and residents in obstetrics and pediatrics. METHODS: Retrospective chart review of all full term neonates who had circumcision performed using Gomco or Mogen instruments during their birth hospitalization in two community-based hospitals were reviewed retrospectively. Complications were the primary outcome and were divided into major (i.e., bleeding requiring transfusion or sutures) and minor (bleeding requiring pressure or local hemostatic agents). RESULTS: From January 2012 to December 2014 a total of 1071 medical records were reviewed. Gomco was the more common technique used [55.84% (598/1071)]. The overall complication rate was 3.83% (41/1071), all involving bleeding. Only 3 [7.32% (3/41)] major complications were encounter, requiring suture placement. No transfusions required. The rest were minor bleeding complications, controlled either by pressure [58.54% (24/41)], silver nitrate [26.83% (11/41) or thrombin [7.32% (3/41)]. Use of the Gomco clamp was more likely to result in bleeding than was the Mogen clamp, 5.69% (34/598) vs 2.96% (14/473), P=.03. Statistical significant difference was noted between pediatricians complication rate (11.49%), compared to OB/GYN physicians (3.08%) (P=.0002). CONCLUSION: Neonatal circumcision is a fairly safe procedure when performed in a hospital setting by attendings or proper supervised physicians in training. The most common complication found in our cohort, was bleeding and the majority resolved with either suture or pressure. No significant major complications were found. In our hands, the Mogen clamp was associated with less bleeding than was the Gomco clamp.
... It is rich in specialized nerve endings and sensory structures involved in the normal functionality of the penis (Cold & Taylor, 1999), and it comprises up to 100 square centimeters in adult men, with reported mean values between 30 and 50 square centimeters (Kigozi et al., 2009;Werker, Terng, & Kon, 1998). While the scientific literature on the "average" sexual consequences of circumcision is inconclusive and contradictory (Bossio, Pukall, & Steele, 2014Johnsdotter, 2013) -and granting that circumcision is likely to affect different men differently, even when it is properly performed -at least two outcomes can be known with certainty due to the inherent nature of the procedure: first, any sensation in the foreskin itself is necessarily eliminated; and, second, any sexual (e.g., masturbatory) functions that require its manipulation are also of necessity precluded (Earp, 2015a(Earp, , 2016. ...
Article
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In December of 2014, an anonymous working group under the United States’ Centers for Disease Control and Prevention (CDC) issued a draft of the first-ever federal recommendations regarding male circumcision. In accordance with the American Academy of Pediatrics’ circumcision policy from 2012 - but in contrast to the more recent 2015 policy from the Canadian Paediatric Society as well as prior policies (still in force) from medical associations in Europe and Australasia - the CDC suggested that the benefits of the surgery outweigh the risks. In this article, we provide a brief scientific and conceptual analysis of the CDC’s assessment of benefit vs. risk, and argue that it deserves a closer look. Although we set aside the burgeoning bioethical debate surrounding the moral permissibility of performing non-therapeutic circumcisions on healthy minors, we argue that, from a scientific and medical perspective, current evidence suggests that such circumcision is not an appropriate public health measure for developed countries such as the United States.
... Michael Bretthauer & Erlend Hem taler for omskjaering av guttebarn og viser til studier som viser medisinske fordeler med omskjaering (1). Dette er en interessant vinkling, og såfremt nytteverdien kan veie opp for komplikasjoner, så er det en diskusjon verdt å ha. ...
... These national policy statements are based on research that primarily focuses on the health outcomes of circumcision (eg protection against sexually transmitted infections) while little is known about the sexual correlates of neonatal circumcision and, in particular, penile sensitivity. 3 We address this gap by assessing objective measures of penile sensitivity across men who were vs were not neonatally circumcised. ...
Article
Purpose: Little is known about the long-term implications of neonatal circumcision on the penile sensitivity of adult men, despite recent public policy endorsing the procedure in the United States. The current study assessed penile sensitivity in adult men by comparing peripheral nerve function of the penis across circumcision status. Materials and methods: Sixty-two men (18-37y, M = 24.1, SD = 5.1) completed study procedures (30 circumcised, 32 intact). Quantitative Sensory Testing (QST) protocols assessed touch and pain thresholds (modified von Frey filaments) and warmth detection and heat pain thresholds (a thermal analyzer) at a control site (forearm) and 3-4 penile sites (glans penis, midline shaft, proximal to midline shaft, and foreskin, if present). Results: Penile sensitivity did not differ across circumcision status for any stimulus type or penile site. The foreskin of intact men was more sensitive to tactile stimulation than the other penile sites, but this finding did not extend to any other stimuli (where foreskin sensitivity was comparable to the other sites tested). Conclusions: Findings suggest that minimal long-term implications to penile sensitivity exist as a result of the surgical excision of the foreskin during neonatal circumcision. Additionally, this study challenges past research suggesting that the foreskin is the most sensitive part of the adult penis. Future research should consider the direct link between penile sensitivity and the perception of pleasure/sensation. Results are relevant to policy makers, parents of male children, as well as the general public.
... Weaknesses include: (1) failure to engage seriously with the literature on negative sexual effects of circumcision.[1][2][3] This includes a recent analytic review by Bossio et al.[4] as well as several published critiques of the studies by Kigozi et al. and Krieger et al.,[5][6] the latter of which did not use validated instruments. The CPS authors also conflate adult circumcision and infant circumcision in this section.[5] ...
Article
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In 2015, the Canadian Paediatric Society (CPS) updated its position statement on newborn male circumcision. Reaching a different conclusion from that of the American Academy of Pediatrics (AAP) in 2012, the CPS did not find that the benefits of the procedure outweigh the risks and harms. In this brief commentary, I discuss some of the main strengths and weaknesses of the latest CPS policy.
... In this way, parents who may be facing 'the circumcision decision' can be adequately informed about the potential consequences of the surgery for their child, at least along this dimension. Due in part to the polarised nature of scientific research on circumcision, 3 the medical literature to date has offered conflicting answers to the question of sensitivity, 4 prompting a recent turn to quantitative analyses relying on putatively objective measures. ...
Article
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A recent study (Bossio, Pukall, & Steele, 2016) reported that neonatal circumcision is not associated with changes in adult penile sensitivity, leading to viral coverage in both traditional and online media. In this commentary the author questions the conclusions drawn from the study and explores the relationship between objective assessments of penile sensitivity and subjective sexual experience and satisfaction. The author concludes with suggestions for improving future research.
... Theimpactofcircumcision(thesurgicalremovaloftheprepuce) on the sexual lives of men is not well understood (Bossio, Pukall, & Steele, 2014). One fundamental difference between circumcisedandintact(i.e.,notcircumcised)menisthephysicalappearance of their genitals (i.e., the presence or absence of a foreskin). ...
Article
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Research exploring the impact of circumcision on the sexual lives of men has failed to consider men’s attitudes toward their circumcision status, which may, in part, help to explain inconsistent findings in the literature. The current study explored the potential relationship between attitudinal factors toward one’s circumcision status, timing of one’s circumcision, and sexual correlates. A total of 811 men (367 circumcised as neonates, 107 circumcised in childhood, 47 circumcised in adulthood, and 290 intact) aged 19–84 years (M = 33.02, SD = 12.54) completed an online survey. We assessed attitudes toward one’s circumcision status, three domains of body image (Male Genital Image Scale, Body Exposure during Sexual Activities Questionnaire, Body Image Satisfaction Scale), and self-reported sexual functioning (International Index of Erectile Function). Men who were circumcised as adults or intact men reported higher satisfaction with their circumcision status than those who were circumcised neonatally or in childhood. Lower satisfaction with one’s circumcision status—but not men’s actual circumcision status—was associated with worse body image and sexual functioning. These findings identify the need to control for attitudes toward circumcision status in the study of sexual outcomes related to circumcision. Future research is required to estimate the number of men who are dissatisfied with their circumcision status, to explore the antecedents of distress in this subpopulation, and to understand the extent of negative sexual outcomes associated with these attitudes.
... Male circumcision is one of the most commonly performed surgical procedures worldwide and an issue that has been the centre of considerable debate. Recently, the American Association of Pediatrics released a statement affirming that the medical benefits of neonatal circumcision outweigh the risks (American Academy of Pediatrics,2012;Bossio et al., 2014 andMorris,2007). ...
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And he that is eight days old shall be circumcised among you, every man child in your generation, he that is born in the house, or bought with money of any stranger, which is not of your seed" Genesis 17:12 (King James Version) Male circumcision is the surgical removal of the foreskin covering the penis It is one of the oldest operations known. Circumcision is the rule rather than the exception within all Nigerian ethnic groups and religions. This review is a critical evaluation of the relationship between some haemostatic parameters, associated with circumcision of male infants. The main risk associated with this procedure include haematologic (bleeding). Several benefits of male circumcision include; medical reasons as a treatment for tight skin (phimosis), paraphimosis (inability of the foreskin to return to its original position after being pulled back, causing the head of the penis to become swollen and painful) and recurrent infection of the foreskin or Balanitis), reduction of the risk of HIV transmitting cervical HPV, improved sexual pleasure, increased penile-vaginal contact, stimulation, and marginally better staying power during penetrative sex. It is of significant medical importance that male circumcision be carried out on the eighth day after birth since the level of vitamin K is highest on this day and vitamin K plays a pivotal role in regulation and control of the important clotting factors in the coagulation pathway that helps in stopping bleeding.
... 16 Possible effects on sexual health when the circumcised male reaches maturity have been inconclusive, but differences are more likely to be found in studies with poor design. [17][18][19] Nontherapeutic circumcision has been controversial in recent years. Although issues of autonomy have surfaced with regard to the appropriateness of parental consent for elective neonatal circumcision, beneficent and nonmaleficent considerations interact with proposed autonomy considerations on both sides of the issue. ...
Article
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Objectives: To determine the incidence of immediate complications of elective newborn circumcision in 2 community teaching hospitals. Methods: We performed a retrospective chart review of all term neonates who had circumcision performed between August 2011 and December 2014 at 2 community hospitals in New York. Neonatal hospital records and subsequent inpatient and outpatient records were reviewed. We classified complications as minor, intermediate, and major. Results: Out of a total of 1115 circumcisions, 1064 met inclusion criteria. There were 41 complications (3.9%), all involving hemorrhage. Sutures were used to control hemorrhage in 3 patients (0.3%). Local pressure or application of hemostatic chemical agents controlled bleeding in the remainder of patients. Bleeding was more common with the use of the Gomco clamp than with the Mogen clamp. Circumcisions performed with Gomco clamp represented 73.2% of the total complications compared with 26.8% with the Mogen clamp. There were no injuries to structures outside the prepuce or problems requiring medical treatment after discharge from the neonatal hospitalization. Conclusions: The most common immediate complication encountered during an elective neonatal circumcision was bleeding that required only pressure or topical thrombin to achieve hemostasis. Bleeding was more common with the use of the Gomco versus the Mogen clamp. To conclude, our data support the theory that elective infant circumcision can be performed safely in a hospital setting.
... Male circumcision is one of the most commonly performed surgical procedures worldwide and a subject that has been the center of considerable debate [1] . About one third of males in the world are circumcised and it is the most common surgical procedure in the United States today [2] . ...
... Although the causal implications of this research has been questioned (Morris et al., 2012;Morris and Wiswell, 2015), these studies suggest that early-circumcision might have an impact on adult psychosocial functioning. It has been extensively debated whether circumcision affects sexual outcome variables, including sensation and satisfaction (e.g., Bossio et al., 2014;Boyle, 2015;Earp, 2016;Morris and Krieger, 2015), with research in this area often conflating studies of newborn versus adult circumcision. It is also contentious whether early-circumcised males experience long-term alterations within the limbic-hypothalamic-pituitary-adrenocortical (LHPA) system; and whether potential stress in this regard is connected to developmental factors. ...
Article
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Background Neonatal male circumcision is a painful skin-breaking procedure that may affect infant physiological and behavioral stress responses as well as mother-infant interaction. Due to the plasticity of the developing nociceptive system, neonatal pain might carry long-term consequences on adult behavior. In this study, we examined whether infant male circumcision is associated with long-term psychological effects on adult socio-affective processing. Methods We recruited 408 men circumcised within the first month of life and 211 non-circumcised men and measured socio-affective behaviors and stress via a battery of validated psychometric scales. Results Early-circumcised men reported lower attachment security and lower emotional stability while no differences in empathy or trust were found. Early circumcision was also associated with stronger sexual drive and less restricted socio-sexuality along with higher perceived stress and sensation seeking. Limitations This is a cross-sectional study relying on self-reported measures from a US population. Conclusions Our findings resonate with the existing literature suggesting links between altered emotional processing in circumcised men and neonatal stress. Consistent with longitudinal studies on infant attachment, early circumcision might have an impact on adult socio-affective traits or behavior.
... Preferring measures such as the correct use of condoms and sexual education. 8 Nevertheless, circumcision has been and always will be part of human history, either as a symbol of belonging, purification or prevention. ...
Article
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Brief history of circumcision, from the evolution of a purification practice among Egyptian priests to the prevention of sexually transmitted diseases.
... But the main data on which they relied for this support concerned adult, voluntary circumcision and heterosexual HIV transmission in sub-Saharan Africa (64)(65)(66)(67)(68)(69)(70)(71). These data cannot be straightforwardly applied to circumcision of babies in Western countries, where HIV infection is much rarer and where, moreover, it is not primarily transmitted among heterosexuals but among injecting drug users and men who have sex with men (72)(73)(74). ...
Article
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There are now legally prohibited forms of medically unnecessary female genital cutting—including the so-called ritual nick—that are less severe than permitted forms of medically unnecessary male and intersex genital cutting. Attempts to discursively quarantine the male and female forms of cutting (MGC, FGC) from one another based on appeals to health outcomes, symbolic meanings, and religious versus cultural status have been undermined by a large body of recent scholarship. Recognizing that a zero-tolerance policy toward ritual FGC may lead to restrictions on ritual MGC, prominent defenders of the latter practice have begun to argue that what they regard as “minor” forms of ritual FGC should in fact be seen as morally permissible—even when non-consensual—and should be legally allowed in Western societies. In a striking development in late 2018, a federal judge ruled that the longstanding U.S. law prohibiting “female genital mutilation” (FGM) was unconstitutional on federalist grounds, while separately acknowledging the logical relevance of arguments concerning non-discrimination on the basis of sex or gender. In light of such developments, feminist scholars and advocates of children’s rights now increasingly argue that efforts to protect girls from non-consensual FGC must be rooted in a sex and gender-neutral (that is, human) right to bodily integrity, if these efforts are to be successful in the long-run.
... Nevertheless, studies performed in impoverished third-world settings cannot justify NTC in a first-world setting with populations having dramatically different HIV profiles [40]. In Western countries, HIV primarily infects men who have sex with men, a cohort that has not been reliably proven to be protected by NTC [41,42]. ...
Article
Nontherapeutic circumcision (NTC) of male infants and boys is a common but misunderstood form of iatrogenic injury that causes harm by removing functional tissue that has known erogenous, protective, and immunological properties, regardless of whether the surgery generates complications. I argue that the loss of the foreskin itself should be counted, clinically and morally, as a harm in evaluating NTC; that a comparison of benefits and risks is not ethically sufficient in an analysis of a nontherapeutic procedure performed on patients unable to provide informed consent; and that circumcision violates clinicians' imperatives to respect patients' autonomy, to do good, to do no harm, and to be just. When due consideration is given to these values, the balance of factors suggests that NTC should be deferred until the affected person can perform his own cost-benefit analysis, applying his mature, informed preferences and values.
... Buna karşın, Amerikan Pediatri Akademisi (American Academy of Pediatrics/AAP) tarafından yayımlanan teknik raporda; sünnetin potansiyel yararının, risklerinden ve maliyetinden daha ağır bastığı görüşü yer almaktadır [9]. Ancak bu konuda pek çok düşünürün yanı sıra Jennifer Bossio tarafından, Kuzey Amerika'da bu görüşü doğrulayacak yeterli çalışma bulunmadığının ileri sürülmesi de önemlidir [45]. ...
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Türkçesi: https://dosyamerkez.saglik.gov.tr/Eklenti/30031,std-raporupdf.pdf?0 İngilizcesi: https://dosyamerkez.saglik.gov.tr/Eklenti/30037,std-raporu-yayimlanmeka96134dc-c4bb-41da-9964-7b41a43ca33dpdf.pdf?0
... It is also important to note the opinion stated in the technical report published by the American Academy of Pediatrics/AAP that the potential benefit of circumcision is more prevalent than its risks and cost [9]. However, the assertion by Jennifer Bossio as well as other scholars that there are not enough studies in North America to confirm this view is of importance [45]. ...
Chapter
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In Turkish: https://dosyamerkez.saglik.gov.tr/Eklenti/30031,std-raporupdf.pdf?0 In English: https://dosyamerkez.saglik.gov.tr/Eklenti/30037,std-raporu-yayimlanmeka96134dc-c4bb-41da-9964-7b41a43ca33dpdf.pdf?0
... In addition, the Center for Disease Control (CDC) has released a report that mirrors the AAP's endorsement of neonatal circumcision (CDC, 2014). Despite the body of research outlining health correlates of circumcision, the impact of circumcision on sexual correlates of men and their sexual partners is extremely limited (see Bossio, Pukall & Steele, 2014). Despite the existence of a handful of studies (e.g., Sorrells, et al., 2007;Payne, Thaler, Kukkonen, Carrier, & Binik, 2007), it remains unknown whether the removal of foreskin impacts men's penile sensitivity, sexual functioning, or sexual enjoyment. ...
Article
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This study was an exploration of the impact of men's circumcision status on their sexual partners, focusing on sexual functioning, sexual satisfaction, general preferences for circumcision status, and beliefs about circumcision status. A total of 196 individuals (168 women, 28 men) currently in a sexual relationship with a man were recruited for an online survey. Sexual functioning for female or male participants (assessed by the FSFI or IIEF-MSM, respectively) was not impacted by circumcision status, but women with intact partners reported higher levels of sexual satisfaction, while no differences were observed in the male sample. Women's responses indicated that circumcision status minimally impacted satisfaction with partner's genitals, while men with intact partners indicated significantly higher levels of satisfaction than those with circumcised partners. Overall, women and men rated high levels of satisfaction with their partner's circum-cision status and did not wish for it to change. Women indicated a slight preference for circumcised penises for vaginal intercourse and fellatio, and held more positive beliefs about circumcised penises, while men indicated a strong preference toward intact penises for all sexual activities assessed and held more positive beliefs about intact penises. The current study demonstrates distinct gender differences in attitudes toward circumcision status but minimal impact of circumcision status on sexual functioning. Future research should further explore sexual correlates of circumcision status, with a focus on direc-tionality of said correlates and the impact on couples, as well as replicating the findings with a larger sample, specifically with respect to the male sample.
... This body of research is plagued by weak study design, such as the inclusion of nonrandom samples, equating outcomes of adult and neonatal circumcision without evidence to suggest that the 2 are comparable, failure to control for participant expectations of study outcomes and reliance on self-report to the exclusion of objective measures. 12 These shortcomings represent a serious problem in this contentious field because they allow room for participant and author bias. One does not have to search far for these biases in the circumcision literature, such as frequent references to nonpeer-reviewed articles and author involvement in anti or pro-circumcision advocacy groups. ...
Article
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The spectrum of practices termed “Female Genital Mutilation” (or FGM) by the World Health Organization is sometimes held up as a counterexample to moral relativism. Those who advance this line of thought suggest the practices are so harmful in terms of their physical and emotional consequences, as well as so problematic in terms of their sexist or oppressive implications, that they provide sufficient, rational grounds for the assertion of a universal moral claim—namely, that all forms of FGM are wrong, regardless of the cultural context. However, others point to cultural bias and moral double standards on the part of those who espouse this argument, and have begun to question the received interpretation of the relevant empirical data concerning FGM as well. In this article I assess the merits of these competing perspectives. I argue that each of them involves valid moral concerns that should be taken seriously in order to move the discussion forward. In doing so, I draw on the biomedical “enhancement” literature in order to develop a novel ethical framework for evaluating FGM (and related interventions—such as female genital “cosmetic” surgery and non-therapeutic male circumcision) that takes into account the genuine harms that are at stake in these procedures, but which does not suffer from being based on cultural or moral double standards.
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Despite 30 years of advocacy, the prevalence of non-therapeutic female genital alteration (FGA) in minors is stable in many countries. Educational efforts have minimally changed the prevalence of this procedure in regions where it has been widely practiced. In order to better protect female children from the serious and long-term harms of some types of non-therapeutic FGA, we must adopt a more nuanced position that acknowledges a wide spectrum of procedures that alter female genitalia. We offer a revised categorisation for non-therapeutic FGA that groups procedures by effect and not by process. Acceptance of de minimis procedures that generally do not carry long-term medical risks is culturally sensitive, does not discriminate on the basis of gender, and does not violate human rights. More morbid procedures should not be performed. However, accepting de minimis non-therapeutic f FGA procedures enhances the effort of compassionate practitioners searching for a compromise position that respects cultural differences but protects the health of their patients.
Article
Non-therapeutic circumcision refers to the surgical removal of part or all of the foreskin, in healthy males, where there is no medical condition requiring surgery. The arguments for and against this practice in children have been debated for many years, with conflicting and conflicted evidence presented on both sides. Here, we explore the evidence behind the claimed benefits and risks from a medical and health-related perspective. We examine the number of circumcisions which would be required to achieve each purported benefit, and set that against the reported rates of short- and long-term complications. We conclude that non-therapeutic circumcision performed on otherwise healthy infants or children has little or no high-quality medical evidence to support its overall benefit. Moreover, it is associated with rare but avoidable harm and even occasional deaths. From the perspective of the individual boy, there is no medical justification for performing a circumcision prior to an age that he can assess the known risks and potential benefits, and choose to give or withhold informed consent himself. We feel that the evidence presented in this review is essential information for all parents and practitioners considering non-therapeutic circumcisions on otherwise healthy infants and children.
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ABSTRACT: Preventive newborn male circumcision has been at the center of scientific debate for many years. The reason for promoting preventive newborn male circumcision, is the reduction of the incidence of UTIs (in the first six months of life), penile cancer, transmission of STDs/HIV infection/AIDS. However preventive interventions in the newborn involving violations of bodily integrity elicit several ethical questions. In this article, we reviewed the literature regarding circumcision, the prevention of UTIs, penile cancer, transmission of STDs/HIV infection/AIDS and complications of this practice in the neonatal period. The very limited reduction of incidence of UTIs and the uncertain preventive role of newborn male circumcision towards penile cancer, STDs/HIV infection and AIDS, makes it difficult to justify male circumcision in newborns. Moreover, the challenge in obtaining a unanimous opinion on newborn male circumcision derives from the fact that, as a preventive intervention, it requires evaluation criteria that are not comparable to those of therapeutic treatments. Since preventive male circumcision determines permanent alteration of the body, some authors believe that it can be used only in subjects that are capable of giving their valid consent. In the case of a newborn, the " child's best interest " should be used as a standard, but preventive newborn male circumcision does not satisfy it.
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The WHO, American Academy of Pediatrics and other Western medical bodies currently maintain that all medically unnecessary female genital cutting of minors is categorically a human rights violation, while either tolerating or actively endorsing medically unnecessary male genital cutting of minors, especially in the form of penile circumcision. Given that some forms of female genital cutting, such as ritual pricking or nicking of the clitoral hood, are less severe than penile circumcision, yet are often performed within the same families for similar (eg, religious) reasons, it may seem that there is an unjust double standard. Against this view, it is sometimes claimed that while female genital cutting has ’no health benefits’, male genital cutting has at least some. Is that really the case? And if it is the case, can it justify the disparate treatment of children with different sex characteristics when it comes to protecting their genital integrity? I argue that, even if one accepts the health claims that are sometimes raised in this context, they cannot justify such disparate treatment. Rather, children of all sexes and genders have an equal right to (future) bodily autonomy. This includes the right to decide whether their own ’private’ anatomy should be exposed to surgical risk, much less permanently altered, for reasons they themselves endorse when they are sufficiently mature.
Chapter
This chapter attempts to address most of the controversial and less controversial biopsychosocial and ethical aspects of infant circumcision. Indications for circumcision and surgical circumcision techniques, including its complications, are discussed. Ethical aspects of infant male circumcision are addressed, in order to enable the pediatric surgeon to get informed consent/assent, should the child be cognitively capable to comprehend the procedure. The importance of performing infant circumcision in a professional and safe manner, including the provision of appropriate anaesthesia and or analgesia, is emphasised. Evidence is provided to support the argument that to consider infant circumcision as a harmless procedure, without short- and long-term complications and consequences, is a misconception.
Chapter
Male circumcision is derived from Latin circumcidere, meaning “to cut around”.
Article
Congenital lymphedema of the external genitalia is a rare, disfiguring disorder. We describe here a case of a 3-year-old male with primary foreskin lymphedema persisting since birth. A compact, heterogenous swelling of the foreskin's distal third was observed, inhibiting preputial retraction (phimosis). Right lower extremity lymphedema was also observed in this case, while no further abnormalities were found. Surgery was performed, maintaining the foreskin, producing an excellent result with no recurrence at 10 months follow up.
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Legal outcomes often depend on the adjudication of what may appear to be straightforward distinctions. In this article, we consider two such distinctions that appear in medical and family law deliberations: the distinction between religion and culture, and between therapeutic and non-therapeutic. These distinctions can impact what constitutes 'reasonable parenting' or a child's 'best interests' and thus the limitations that may be placed on parental actions. Such distinctions are often imagined to be asocial facts, there for the judge to discover. We challenge this view, however, by examining the controversial case of B and G [2015]. In this case, Sir James Munby stated that the cutting of both male and female children's genitals for non-therapeutic reasons constituted 'significant harm' for the purposes of the Children Act 1989. He went on to conclude, however, that while it can never be reasonable parenting to inflict any form of non-therapeutic genital cutting on a female child, such cutting on male children was currently tolerated. We argue that the distinctions between religion/culture and therapeutic/non-therapeutic upon which Munby LJ relied in making this judgment cannot in fact ground categorically differential legal treatment of female and male children. We analyse these distinctions from a systems theoretical perspective-specifically with reference to local paradoxes-to call into question the current legal position. Our analysis suggests that conventional distinctions drawn between religion/culture and the therapeutic/non-therapeutic in other legal contexts require much greater scrutiny than they are usually afforded.
Article
The Centers for Disease Control and Prevention (“ cdc ”) is poised to recommend that physicians counsel the parents of every newborn boy and heterosexually active adolescent and man in the United States – approximately 36 million boys and men – that the benefits of circumcision outweigh the risks, that parents should take non-medical factors into account in making the “circumcision decision”, and that Medicaid should pay for it. The draft cdc recommendations are not medically correct, ethically sound, legally permissible or procedurally valid. Accordingly, they should not be implemented and would be legally invalid if they are. They provide erroneous and misleading advice to physicians that exposes them to the threat of lawsuits by men and parents. The cdc must revise its draft guidelines to comport with the correct and prevailing view in the Western world that circumcision is on balance deleterious to health; that men have the right to make the “circumcision decision” for themselves; that physicians are not permitted to circumcise healthy boys; and that it is unlawful to use Medicaid to pay for unnecessary surgery.
Article
Objectives In the last years, many surgical techniques of preputioplasty have aimed to preserve the foreskin in case of phimosis. These techniques are not reliable for patients affected by phimosis linked to balanitis xerotica obliterans (BXO) and scarred foreskin. We tried an original technique of resection of the pathological foreskin, removing the mucosal internal layer followed by reconstruction of the foreskin. The aim was to evaluate the outcome of paediatric patients who underwent modified partial circumcision for pathological phimosis. Patients and methods In all, 360 patients with phimosis underwent modified partial circumcision at our institution. The mean age of the boys was 8.9 years, range 5-15 years. In 145 (40.3%) cases, indication for surgery was clinical suspicion of BXO, in 215 (59.7%) cases it was chronic inflammation of the foreskin. Results In all cases, the postoperative period was uneventful. Cosmesis was considered by parents as excellent in 95.2% of patients. In these patients, the glans was almost completely covered by soft foreskin. Histopathological examination of the removed foreskin documented BXO in 162 (45%). Twelve (3.3%) patients complained of recurrences and five (1.4%) patients of smegmatic cysts. Conclusion The described surgical technique of modified partial circumcision for the correction of pathological phimosis appears cosmetically well accepted, safe, and simple with low rate of late postoperative complications.
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The relevance of circumcision in preventing HIV male-to-male sex transmission is poorly understood, in particular because any potential effect could be obscured by sexual practice as a mediating or confounding factor. Using data from the Health in Men (HIM) cohort of 1426 HIV-negative homosexually active men in Sydney, we compared the sexual practices and sexual experiences of circumcised and uncircumcised men. Overall 66% of men (n�=�939) in the cohort were circumcised. After adjusting for age and ethnicity, we found no difference between circumcised and uncircumcised men in anal sexual practices, difficulty using condoms, or sexual difficulties (e.g. loss of libido). Among the circumcised men, we compared those circumcised at infancy (n�=�854) with those circumcised after infancy (n�=�81). The majority cited phimosis (i.e., an inability to fully retract the foreskin) and parents' decision as the main reasons for circumcision after infancy. After adjusting for age and ethnicity, men circumcised after infancy were more likely to practise receptive anal sex (88% vs 75%, p�<�0.05) and to experience erection difficulties (52% vs 47%, p�<�0.05); but less likely to practise insertive anal sex (79% vs 87%, p�<�0.05) and to experience premature ejaculation (15% vs 23%, p�<�0.05) than those circumcised at infancy. Our data suggest that overall circumcision status does not affect HIV-negative gay men's anal sexual practices, experience of condom use or likelihood of sexual difficulties. However, there is some suggestion of differences between circumcised men depending on the age at circumcision.
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In the Journal of the American Medical Association , Tobian and Gray [ 1 ] seek to re-evaluate the risks and alleged benefi ts of male circumcision (MC), but seem blithely unaware that two authoritative medical associations, the Dutch Medical Association and Royal Australasian College of Physicians, have just completed comprehensive reviews [ 2,3 ].
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Infant male circumcision continues despite growing questions about its medical justification. As usually performed without analgesia or anaesthetic, circumcision is observably painful. It is likely that genital cutting has physical, sexual and psychological consequences too. Some studies link involuntary male circumcision with a range of negative emotions and even post-traumatic stress disorder (PTSD). Some circumcised men have described their current feelings in the language of violation, torture, mutilation and sexual assault. In view of the acute as well as long-term risks from circumcision and the legal liabilities that might arise, it is timely for health professionals and scientists to re-examine the evidence on this issue and participate in the debate about the advisability of this surgical procedure on unconsenting minors.
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Pain in infancy influences pain reactivity in later life, but how and why this occurs is poorly understood. Here we review the evidence for developmental plasticity of nociceptive pathways in animal models and discuss the peripheral and central mechanisms that underlie this plasticity. Adults who have experienced neonatal injury display increased pain and injury-induced hyperalgesia in the affected region but mild injury can also induce widespread baseline hyposensitivity across the rest of the body surface, suggesting the involvement of several underlying mechanisms, depending upon the type of early life experience. Peripheral nerve sprouting and dorsal horn central sensitization, disinhibition and neuroimmune priming are discussed in relation to the increased pain and hyperalgesia, while altered descending pain control systems driven, in part, by changes in the stress/HPA axis are discussed in relation to the widespread hypoalgesia. Finally, it is proposed that the endocannabinoid system deserves further attention in the search for mechanisms underlying injury-induced changes in pain processing in infants and children.
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Circumcision of males is commonly carried out worldwide for reasons of health, medical need, esthetics, tradition, or religion. Whether circumcision impairs or improves male sexual function or pleasure is controversial. The study aims to conduct a systematic review of the scientific literature. A systematic review of published articles retrieved using keyword searches of the PubMed, EMBASE, and Cochrane databases was performed. The main outcome measure is the assessment of findings in publications reporting original data relevant to the search terms and rating of quality of each study based on established criteria. Searches identified 2,675 publications describing the effects of male circumcision on aspects of male sexual function, sensitivity, sensation, or satisfaction. Of these, 36 met our inclusion criteria of containing original data. Those studies reported a total of 40,473 men, including 19,542 uncircumcised and 20,931 circumcised. Rated by the Scottish Intercollegiate Guidelines Network grading system, 2 were 1++ (high quality randomized controlled trials) and 34 were case-control or cohort studies (11 high quality: 2++; 10 well-conducted: 2+; 13 low quality: 2-). The 1++, 2++, and 2+ studies uniformly found that circumcision had no overall adverse effect on penile sensitivity, sexual arousal, sexual sensation, erectile function, premature ejaculation, ejaculatory latency, orgasm difficulties, sexual satisfaction, pleasure, or pain during penetration. Support for these conclusions was provided by a meta-analysis. Impairment in one or more parameters was reported in 10 of the 13 studies rated as 2-. These lower-quality studies contained flaws in study design (11), selection of cases and/or controls (5), statistical analysis (4), and/or data interpretation (6); five had multiple problems. The highest-quality studies suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation, or satisfaction. Morris BJ and Krieger JN. Does male circumcision affect sexual function, sensitivity, or satisfaction?-A systematic review. J Sex Med **;**:**-**.
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Objective The aims of this study were to investigate the frequency of male circumcision among men who have sex with men (MSM) in Buenos Aires, Argentina; the association between circumcision and sexually transmitted infections (STIs); and, among those uncircumcised, the willingness to be circumcised. Methods A cross-sectional study was conducted among 500 MSM recruited through the respondent-driven sampling (RDS) technique. Participants underwent a consent process, responded to a Web-based survey that included questions on demographic information, sexual behaviour, and circumcision and provided biological samples. HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), Treponema pallidum, and human papiloma virus (HPV) diagnoses were performed using standard methodologies. For all analyses, data were weighted based on participants’ network size. Results Only 64 (13%) of the 500 MSM in our study reported being circumcised. Among uncircumcised men (n=418), 302 (70.4%) said that they would not be willing to get circumcised even if the procedure could reduce the risk of HIV infection. When considering all participants, circumcision status was not significantly associated with HIV, HBV, HCV, T. pallidum or HPV infections. However, when we restricted the sample to men who do not practice receptive anal intercourse (RAI) and compared circumcised to uncircumcised men, the former (N=33) had no cases of HIV infection, while 34 of 231 (14.8%) uncircumcised men were HIV positive (p=0.020). Regarding HPV, uncircumcised men had a significantly larger number of different HPV types compared with circumcised men (mean 1.83 vs. 1.09, p<0.001) and a higher frequency of high-risk-HPV genotypes (47.6% vs. 12.5%, p=0.012). Conclusions Consistent with international evidence, male circumcision appears to have a partial protective effect among MSM. The efficacy of circumcision in reducing risk of HIV infection among MSM appears to be correlated with sexual practices. Given the lack of motivation among MSM with regard to circumcision, proper awareness on the risks and benefits of circumcision needs to be created, if circumcision has to be introduced as a prevention strategy.
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The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. A systematic review and meta-analyses were performed on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus, and contracting a sexually transmitted infection of any type. Chlamydia, gonorrhea, genital herpes, and human papillomavirus are not significantly impacted by circumcision. Syphilis showed mixed results with studies of prevalence suggesting intact men were at great risk and studies of incidence suggesting the opposite. Intact men appear to be of greater risk for genital ulcerative disease while at lower risk for genital discharge syndrome, nonspecific urethritis, genital warts, and the overall risk of any sexually transmitted infection. In studies of general populations, there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections. Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.
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To determine which factors parents consider to be most important when pursuing elective circumcision procedures in newborn male children. Prospective survey. Saskatoon, Sask. A total of 230 participants attending prenatal classes in the Saskatoon Health Region over a 3-month period. Parents' plans to pursue circumcision, personal and family circumcision status, and factors influencing parents' decision making on the subject of elective circumcision. The reasons that parents most often gave for supporting male circumcision were hygiene (61.9%), prevention of infection or cancer (44.8%), and the father being circumcised (40.9%). The reasons most commonly reported by parents for not supporting circumcision were it not being medically necessary (32.0%), the father being uncircumcised (18.8%), and concerns about bleeding or infection (15.5%). Of all parents responding who were expecting children, 56.4% indicated they would consider pursuing elective circumcision if they had a son; 24.3% said they would not. In instances in which the father of the expected baby was circumcised, 81.9% of respondents were in favour of pursuing elective circumcision. When the father of the expected child was not circumcised, 14.9% were in favour of pursuing elective circumcision. Regression analysis showed that the relationship between the circumcision status of the father and support of elective circumcision was statistically significant (P < .001). Among couples in which the father was circumcised, 82.2% stated that circumcision by an experienced medical practitioner was a safe procedure for all boys, in contrast to 64.1% of couples in which the father of the expected child was not circumcised. When the expecting father was circumcised, no one responded that circumcision was an unsafe procedure, compared with 7.8% when the expecting father was not circumcised (P = .003). Despite new medical information and updated stances from various medical associations, newborn male circumcision rates continue to be heavily influenced by the circumcision status of the child's father.
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Purpose: Urinary tract infection is common in infant males who are uncircumcised and can lead to renal parenchymal disease of the still growing pediatric kidney. Although the rate of urinary tract infection is highest in the first year of life, the cumulative incidence during the rest of the lifetime is under-recognized, but is expected to be nontrivial. Thus, any intervention that might prevent urinary tract infection would be expected to reduce suffering and medical costs. Materials and methods: We conducted a meta-analysis of 22 studies examining the single risk factor of lack of circumcision, then determined the prevalence and relative risk of urinary tract infection in different age groups (0 to 1, 1 to 16 and older than 16 years). From these data we estimated the lifetime prevalence. Results: For age 0 to 1 year the relative risk was 9.91 (95% CI 7.49-13.1), for age 1 to 16 years RR was 6.56 (95% CI 3.26-13.2) and for older than 16 years it was 3.41-fold (95% CI 0.916-12.7) higher in uncircumcised males. We then calculated that 32.1% (95% CI 15.6-49.8) of uncircumcised males experience a urinary tract infection in their lifetime compared with 8.8% (95% CI 4.15-13.2) of circumcised males (RR 3.65, 95% CI 1.15-11.8). The number needed to treat was 4.29 (95% CI 2.20-27.2). Conclusions: The single risk factor of lack of circumcision confers a 23.3% chance of urinary tract infection during the lifetime. This greatly exceeds the prevalence of circumcision complications (1.5%), which are mostly minor. The potential seriousness of urinary tract infection supports circumcision as a desirable preventive health intervention in infant males.
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Objective: The etiology of premature ejaculation (PE) is unknown. Over the past two decades several studies have suggested that lifelong and acquired PE may be caused by somatic disorders and/or neurobiological disturbances. One controversial factor is the effect of circumcision on ejaculation. This prospective study investigated the relationship between postcircumcision penile mucosal cuff length, circumcision scar thickness and the PE syndromes. Features of PE patients were compared with those of a normal healthy control (NHC) group. Material and methods: In total, 160 circumcised men were studied: 80 men with PE and 80 men in the NHC group. The following data and measurements were evaluated: age, type of PE syndrome, intravaginal ejaculation latency time (IELT), circumcision scar thickness and postcircumcision mucosal cuff length. Results: In terms of the mean IELT, a statistically significant difference was detected between the PE syndromes (p < 0.05), and between the PE patients and the control group (p < 0.05). Among the four PE syndromes, there was no significant difference related to the mean mucosal cuff length and mean circumcision scar thickness (p > 0.05). No significant difference was observed between the two groups for mean mucosal cuff length (p > 0.05) or mean circumcision scar thickness (p > 0.05). Conclusion: In this study, no relationship was observed between PE and postcircumcision penile mucosal cuff length and circumcision scar thickness. Further studies are required to evaluate the positive and negative effects of circumcision on PE syndromes.
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Male circumcision has been shown to reduce the risk of acquiring and transmitting a number of venereal infections. However, little is known about the association between male circumcision and the risk of Chlamydia trachomatis infection in the female partner. The authors pooled data on 305 adult couples enrolled as controls in one of five case-control studies of invasive cervical cancer conducted in Thailand, the Philippines, Brazil, Colombia, and Spain between 1985 and 1997. Women provided blood samples for C. trachomatis and Chlamydia pneumoniae antibody detection; a type-specific microfluorescence assay was used. Multivariate odds ratios were computed for the association between male circumcision status and chlamydial seropositivity in women. Compared with women with uncircumcised partners, those with circumcised partners had a 5.6-fold reduced risk of testing seropositive for C. trachomatis (82% reduction; odds ratio = 0.18, 95% confidence interval: 0.05, 0.58). The inverse association was also observed after restricting the analysis to monogamous women and their only male partners (odds ratio = 0.21, 95% confidence interval: 0.06, 0.72). In contrast, seropositivity to C. pneumoniae, a non-sexually-transmitted infection, was not significantly related to circumcision status of the male partner. These findings suggest that male circumcision could reduce the risk of C. trachomatis infection in female sexual partners.
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Objective: To report on the prevalence and demographic variation in circumcision in Australia and examine sexual health outcomes in comparison with earlier research. Methods: A representative household sample of 4,290 Australian men aged 16-64 years completed a computer-assisted telephone interview including questions on circumcision status, demographic variables, reported lifetime experience of selected sexually transmissible infections (STIs), experience of sexual difficulties in the previous 12 months, masturbation, and sexual practices at last heterosexual encounter. Results: More than half the men (58%) were circumcised. Circumcision was less common (33%) among men under 30 and more common (66%) among those born in Australia. After adjustment for age and number of partners, circumcision was unrelated to STI history except for non-specific urethritis (higher among circumcised men, OR=2.11, p<0.001) and penile candidiasis (lower among circumcised men, OR=0.49, p<0.001). Circumcision was unrelated to any of the sexual difficulties we asked about (after adjusting for age) except that circumcised men were somewhat less likely to have worried during sex about whether their bodies looked unattractive (OR=0.77, p=0.04). No association between lack of circumcision and erection difficulties was detected. After correction for age, circumcised men were somewhat more likely to have masturbated alone in the previous 12 months (OR=1.20, p=0.02). Conclusions: Circumcision appears to have minimal protective effects on sexual health in Australia.
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Bacterial vaginosis (BV) is common in sexually active women, and in a large proportion the underlying aetiology is unknown. We evaluated partner circumcision status as a potential risk and hypothesised that women with uncircumcised partners were at increased risk for BV. Retrospective audit of a partner study (272 heterosexual couples) conducted in Baltimore between 1990 and 1992. BV defined by clinical criteria and circumcision status of males was determined by physical examination. BV was diagnosed in 83 (30%) female partners; 75 (27%) males were uncircumcised. In males and females respectively, gonorrhoea was diagnosed in 20% and 16%, and chlamydia in 7% and 11%. In women with circumcised partners, 58/197 (29%) had BV compared with 25/75 (33%) with uncircumcised partners (p = 0.53). Women with uncircumcised current partners are not at increased risk for BV.
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To describe the attitudes of Sexually Transmitted Infection (STI) clinic attendees towards male circumcision. A convenience sample of attendees at the main STI clinic in Kingston was interviewed using a structured questionnaire in June 2008. One-hundred men and 98 women were interviewed. Over 90% of the men were not circumcised. Although 60% of men and 67% of women reported that they had heard of circumcision, the research nurse assessed that 28% of men and 40% of women actually understood what circumcision was. When asked about the benefits of circumcision, 32% of men and 41.8% of women said that circumcision makes it easier to clean the penis while 13% of men and 20.4% of women said that circumcision lessens the likelihood of STI. Twenty-two per cent of men and 13.3% of women said that the foreskin offers protection while 18% of men and 10.2% of women said that the penis looks more attractive when uncircumcised. When informed that research showed that circumcision reduced the risk of HIV 35% of men said that they were willing to be circumcised and 67.3% of women said that they would encourage their spouse to be circumcised (p < 0.001) while 54% of men and 72.4% of women said that they would circumcise their sons (p = 0.057). Knowledge of circumcision and its benefits were limited among STI clinic attendees. Significantly more women than men were in favour of circumcision when informed that it reduced the risk of HIV infection.
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To examine the relation between health and several dimensions of sexuality and to estimate years of sexually active life across sex and health groups in middle aged and older adults. Cross sectional study. Two samples representative of the US population: MIDUS (the national survey of midlife development in the United States, 1995-6) and NSHAP (the national social life, health and ageing project, 2005-6). 3032 adults aged 25 to 74 (1561 women, 1471 men) from the midlife cohort (MIDUS) and 3005 adults aged 57 to 85 (1550 women, 1455 men) from the later life cohort (NSHAP). Sexual activity, quality of sexual life, interest in sex, and average remaining years of sexually active life, referred to as sexually active life expectancy. Overall, men were more likely than women to be sexually active, report a good quality sex life, and be interested in sex. These gender differences increased with age and were greatest among the 75 to 85 year old group: 38.9% of men compared with 16.8% of women were sexually active, 70.8% versus 50.9% of those who were sexually active had a good quality sex life, and 41.2% versus 11.4% were interested in sex. Men and women reporting very good or excellent health were more likely to be sexually active compared with their peers in poor or fair health: age adjusted odds ratio 2.2 (P<0.01) for men and 1.6 (P<0.05) for women in the midlife study and 4.6 (P<0.001) for men and 2.8 (P<0.001) for women in the later life study. Among sexually active people, good health was also significantly associated with frequent sex (once or more weekly) in men (adjusted odds ratio 1.6 to 2.1), with a good quality sex life among men and women in the midlife cohort (adjusted odds ratio 1.7), and with interest in sex. People in very good or excellent health were 1.5 to 1.8 times more likely to report an interest in sex than those in poorer health. At age 30, sexually active life expectancy was 34.7 years for men and 30.7 years for women compared with 14.9 to 15.3 years for men and 10.6 years for women at age 55. This gender disparity attenuated for people with a spouse or other intimate partner. At age 55, men in very good or excellent health on average gained 5-7 years of sexually active life compared with their peers in poor or fair health. Women in very good or excellent health gained 3-6 years compared with women in poor or fair health. Sexual activity, good quality sexual life, and interest in sex were higher for men than for women and this gender gap widened with age. Sexual activity, quality of sexual life, and interest in sex were positively associated with health in middle age and later life. Sexually active life expectancy was longer for men, but men lost more years of sexually active life as a result of poor health than women.
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To evaluate the effect of circumcision on sexual satisfaction perception in males with stable sexual partners. Twenty two heterosexual male adults, sexually active with a stable partner, scheduled for circumcision for medical (MR) or esthetic reasons (ER) at our clinic between June 2005 and June 2006 were included in this study. Men with severe erectile dysfunction (ED) were excluded from the study. These men were surveyed to assess erectile function, penile sensitivity, esthetical penis' appearance, sexual activity and overall satisfaction before the procedure and 12 weeks after. Categorical scores were evaluated with Chi square. Surgical indications were: Phimosis 50%, balanitis 18.2%, condyloma 13.6% and esthetics 13.6%. After the procedure 82% of patients referred an upgrade on the quality of their sexual intercourse, 4.5% referred it diminished and 13.5% referred no change at all. 95.5% of the patients felt better with the appearance of their penis. Almost all areas of sexual satisfaction weren't statistical significant except for the improvement in erectile function (p 0.0007) and perception of sexual events (p 0.04). This improvement on erectile function was reported as shifts from mild to normal on International Index of Erectile Function 5 scores. Premature ejaculation was observed in 31.8%(7) before the procedure and diminished to 13.6%(3). Because of our statistic limitations and mix indications for circumcision in the study, we cannot conclude that circumcision might bring certain benefit on sexual satisfaction by itself but certainly does not bring deleterious effects and, when dissatisfaction is associated with local problems, some benefit could be expected.
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To assess circumcision status as a risk factor for HIV seroconversion in homosexual men. The Health in Men (HIM) study was a prospective cohort of homosexual men in Sydney, Australia. HIV-negative men (n = 1426) were recruited primarily from community-based sources between 2001 and 2004 and followed to mid-2007. Participants underwent annual HIV testing, and detailed information on sexual risk behaviour was collected every 6 months. HIV incidence in circumcised compared with uncircumcised participants, stratified by whether or not men predominantly practised the insertive role in anal intercourse. There were 53 HIV seroconversions during follow-up; an incidence of 0.78 per 100 person-years. On multivariate analysis controlling for behavioural risk factors, being circumcised was associated with a nonsignificant reduction in risk of HIV seroconversion [hazard ratio 0.78, 95% confidence interval (CI) 0.42-1.45, P = 0.424]. Among one-third of study participants who reported a preference for the insertive role in anal intercourse, being circumcised was associated with a significant reduction in HIV incidence after controlling for age and unprotected anal intercourse (UAI) (hazard ratio 0.11, 95% CI 0.03-0.80, P = 0.041). Those who reported a preference for the insertive role overwhelmingly practised insertive rather than receptive UAI. Overall, circumcision did not significantly reduce the risk of HIV infection in the HIM cohort. However, it was associated with a significant reduction in HIV incidence among those participants who reported a preference for the insertive role in anal intercourse. Circumcision may have a role as an HIV prevention intervention in this subset of homosexual men.
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Non-therapeutic infant circumcision has become a medicalised ritual mainly in English speaking countries and is unjustly and increasingly advocated as a prevention tool of HIV/AIDS without critical consideration of its practicality, cost and risks. It is of concern that the WHO/UNAIDS is hastily advising mass MC roll-out as a prevention tool of female to male HIV acquisition, without considering risks involved to woman.49 A much broader review process is necessary, involving more objective scientific opinion and representative panel of African experts, including pediatric surgeons before any MC could be written into policy.
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Circumcision is generally considered a simple, rapid operation with medical benefits which accrue throughout life. The influence of circumcision on sexual satisfaction has always been argued. In this study, the assessment of the pudendal evoked potentials (PEP) in adults before and at least 12 weeks after circumcision was done. Healthy males aged between 18-27 years, who were willing to undergo circumcision were included in the study. Before and after circumcision, sexual performance was evaluated with the Brief Male Sexual Function Inventory (BMSFI), consisting of sexual drive, erection, ejaculation, problem assessment, and overall satisfaction sections. Forty-three adult males were enrolled in the study. Mean PEP latency was 41.97 +/- 0.25 (39.90-44.50) ms and 44.73 +/- 0.33 (40.90-47.60) ms before and after circumcision, respectively. Mean difference between pre- and postoperative PEP values was 2.76 ms which was statistically significant (p < 0.001). Mean ejaculatory latency time was significantly longer after circumcision (p < 0.001). In the light of our findings, we conclude that circumcision may contribute to sexual satisfaction by prolonging PEP latency but further studies are warranted also regarding the other dimensions of circumcision.
Article
OBJECTIVE: Male circumcision reduces the risk of HIV acquisition by approximately 60%. Male circumcision services are now being introduced in selected populations in sub-Saharan Africa and further interventions are being planned. A serious concern is whether male circumcision can be provided safely to large numbers of adult males in developing countries. METHODS: This prospective study was conducted in the Bungoma district, Kenya, where male circumcision is universally practised. Young males intending to undergo traditional or clinical circumcision were identified by a two-stage cluster sampling method. During the July-August 2004 circumcision season, 1007 males were interviewed 30-89 days post- circumcision. Twenty-four men were directly observed during and 3, 8, 30 and 90 days post-circumcision, and 298 men underwent clinical exams 45-89 days post-procedure. Twenty-one traditional and 20 clinical practitioners were interviewed to assess their experience and training. Inventories of health facilities were taken to assess the condition of instruments and supplies necessary for performing safe circumcisions. FINDINGS: Of 443 males circumcised traditionally, 156 (35.2%) experienced an adverse event compared with 99 of 559 (17.7%) circumcised clinically (odds ratio: 2.53; 95% confidence interval: 1.89-3.38). Bleeding and infection were the most common adverse effects, with excessive pain, lacerations, torsion and erectile dysfunction also observed. Participants were aged 5 to 21 years and half were sexually active before circumcision. Practitioners lacked knowledge and training. Proper instruments and supplies were lacking at most health facilities. CONCLUSION: Extensive training and resources will be necessary in sub-Saharan Africa before male circumcision can be aggressively promoted for HIV prevention. Two-thirds of African men are circumcised, most by traditional or unqualified practitioners in informal settings. Safety of circumcision in communities where it is already widely practised must not be ignored.
Article
The Effects of Age at Circumcision on Premature Ejaculation Objective: The objective of this study was to analyze the effect of age at circumcision on premature ejaculation (PE). Materials and Methods: The study included 40 healthy male controls and 40 male patients diagnosed as PE according to American Psychiatric Association criteria and the Golombok-Rust Inventory of Sexual Satisfaction (CRISS) premature ejaculation subscale. The 2 groups were compared according to age at circumcision and GRISS score. Results: The PE group and control group were sociodemographically similar, but differed in marital status. The groups differed in GRISS communication, degree of satisfaction, avoidance, sensuality, erectile dysfunction, and PE subscale scores. These differences only displayed a dysfunction in the degree of satisfaction and premature ejaculation subscales. The groups also differed in age at circumcision; accordingly, those that were circumcised at >= 7 years of age had higher GRISS scores and a higher risk of having PE than those that were circumcised at >7 years of age. Conclusion: Age at circumcision had an effect on PE; circumcision at >= 7 years of age was associated with an increase in the risk of PE, as compared to circumcision at >7 years of age. We think that families should have their boys circumcised before the age of 7 years and highly recommend that the procedure be performed within in the first 3 years of life.
Article
Male circumcision significantly reduced the incidence of human immunodeficiency virus (HIV) infection among men in three clinical trials. We assessed the efficacy of male circumcision for the prevention of herpes simplex virus type 2 (HSV-2) and human papillomavirus (HPV) infections and syphilis in HIV-negative adolescent boys and men. We enrolled 5534 HIV-negative, uncircumcised male subjects between the ages of 15 and 49 years in two trials of male circumcision for the prevention of HIV and other sexually transmitted infections. Of these subjects, 3393 (61.3%) were HSV-2-seronegative at enrollment. Of the seronegative subjects, 1684 had been randomly assigned to undergo immediate circumcision (intervention group) and 1709 to undergo circumcision after 24 months (control group). At baseline and at 6, 12, and 24 months, we tested subjects for HSV-2 and HIV infection and syphilis, along with performing physical examinations and conducting interviews. In addition, we evaluated a subgroup of subjects for HPV infection at baseline and at 24 months. At 24 months, the cumulative probability of HSV-2 seroconversion was 7.8% in the intervention group and 10.3% in the control group (adjusted hazard ratio in the intervention group, 0.72; 95% confidence interval [CI], 0.56 to 0.92; P=0.008). The prevalence of high-risk HPV genotypes was 18.0% in the intervention group and 27.9% in the control group (adjusted risk ratio, 0.65; 95% CI, 0.46 to 0.90; P=0.009). However, no significant difference between the two study groups was observed in the incidence of syphilis (adjusted hazard ratio, 1.10; 95% CI, 0.75 to 1.65; P=0.44). In addition to decreasing the incidence of HIV infection, male circumcision significantly reduced the incidence of HSV-2 infection and the prevalence of HPV infection, findings that underscore the potential public health benefits of the procedure. (ClinicalTrials.gov numbers, NCT00425984 and NCT00124878.)
Article
Five men underwent circumcision in adulthood for reasons of infection, inflammation, or phimosis. Several years later, they reported on the erotosexual sequelae. All reported a prolongation of the period prior to ejaculation, though none had been genuine premature ejaculators. Other variable sequelae were diminished penile sensitivity, less penile gratification, more penile pain, and cosmetic deformity. Orgasm frequency was the same or less, and there was no postsurgical impotence. Loss of stretch receptors and reflexes might explain the major erotosexual changes. In most instances, a dorsal cut and/or antibiotic treatment achieves the same effect as circumcision, and is less risky in terms of possible pathological sequelae.
Article
We aimed to evaluate possible associations of circumcision with several sexual dysfunctions and to identify predictors for the development of these outcomes post-operatively. Telephone surveys about sexual habits and dysfunctions before and after intervention were conducted post-operatively to patients that underwent circumcision in Centro Hospitalar Vila Nova de Gaia/Espinho during 2011. McNemar test was used for a matched-pairs analysis of pre- and post-operative data. Odds ratios, adjusted in a multivariate analysis, explored predictors of de novo sexual dysfunctions after circumcision. With intervention, there was an increase in frequency of erectile dysfunction (9.7% versus 25.8%, P = 0.002) and delayed orgasm (11.3% versus 48.4%, P < 0.001), and a significant symptomatic improvement in patients with pain with intercourse (50.0% versus 6.5%, P < 0.001). Significant predictors for de novo erectile dysfunction were diabetes mellitus (OR 9.81, P = 0.048) and lack of sexual desire (OR 8.76, P = 0.028). Less than three sex partners (OR 7.04, P = 0.007) and low sexual desire (OR 7.49, P = 0.029) were significant predictors for de novo delayed orgasm.
Article
Premature ejaculation (PE) is one of the most prevalent male sexual dysfunctions. Selective resection of the dorsal nerve (SRDN) of penis has recently been used for the treatment of PE and has shown some efficacy. To further clarify the efficacy and safety of SRDN on PE, we performed a preliminary, randomized, placebo-controlled clinical observational study. Persons with the complaints of rapid ejaculation, asking for circumcision because of redundant foreskin, intravaginal ejaculation latency time (IELT) within 2 min, not responding to antidepressant medication or disliking oral medication were randomly enrolled in two groups. From April 2007 to August 2010, a total of 101 eligible persons were enrolled, 40 of them received SRDN which dorsal nerves of the penis were selectively resected, and those (n = 61) enrolled in the control group were circumcised only. IELT and the Brief Male Sexual Function Inventory (BMSFI) questionnaire were implemented pre- and post-operatively for the evaluation of the effect and safety of the surgery. There are no statistically significant differences in the baseline data including mean ages, mean IELTs, perceived control abilities and the BMSFI mean scores between the two groups. With regard to the post-operative data of the surgery, both IELTs and perceived control abilities were significantly increased after SRDN (1.1 ± 0.9 min vs. 3.8 ± 3.1 min for pre- and post-operative IELT, respectively, p < 0.01),whereas the post-operative results were not significantly improved for the control group (1.2 ± 0.7 min vs. 1.5 ± 1.1 min, p > 0.05). Also, there were no statistically significant differences both in BMSFI composite and subscale scores between the two groups after surgery. Hence, we conclude that SRDN is effective in delaying ejaculation and improving ejaculatory control, whereas erectile function is not affected. The results imply that SRDN may be an alternative method for the treatment of PE for some patients.
Article
Introduction: Intravaginal ejaculation latency time (IELT), defined as the time between the start of vaginal intromission and the start of intravaginal ejaculation, is increasingly used in clinical trials to assess the amount of selective serotonin reuptake inhibitor-induced ejaculation delay in men with premature ejaculation. Prospectively, stopwatch assessment of IELTs has superior accuracy compared with retrospective questionnaire and spontaneous reported latency. However, the IELT distribution in the general male population has not been previously assessed. Aim: To determine the stopwatch assessed-IELT distribution in large random male cohorts of different countries. Methods: A total of 500 couples were recruited from five countries: the Netherlands, United Kingdom, Spain, Turkey, and the United States. Enrolled men were aged 18 years or older, had a stable heterosexual relationship for at least 6 months, with regular sexual intercourse. The surveyed population were not included or excluded by their ejaculatory status and comorbidities. This survey was performed on a "normal" general population. Sexual events and stopwatch-timed IELTs during a 4-week period were recorded, as well as circumcision status and condom use. Main outcome measures: The IELT, circumcision status, and condom use. Results: The distribution of the IELT in all the five countries was positively skewed, with a median IELT of 5.4 minutes (range, 0.55-44.1 minutes). The median IELT decreased significantly with age, from 6.5 minutes in the 18-30 years group, to 4.3 minutes in the group older than 51 years (P<0.0001). The median IELT varied between countries, with the median value for Turkey being the lowest, i.e., 3.7 minutes (0.9-30.4 minutes), which was significantly different from each of the other countries. Comparison of circumcised (N=98) and not-circumcised (N=261) men in countries excluding Turkey resulted in median IELT values of 6.7 minutes (0.7-44.1 minutes) in circumcised compared with 6.0 minutes (0.5-37.4 minutes) in not-circumcised men (not significant). The median IELT value was not affected by condom use. Conclusion: The IELT distribution is positively skewed. The overall median value was 5.4 minutes but with differences between countries. For all five countries, median IELT values were independent of condom usage. In countries excluding Turkey, the median IELT values were independent of circumcision status.
Article
Introduction. The main functional factors related to lifelong premature ejaculation (PE) etiology have been suggested to be penile hypersensitivity, greater cortical penile representation, and disturbance of central serotoninergic neurotransmission. Aims. To quantitatively assess penile sensory thresholds in European Caucasian patients with lifelong PE using the Genito-Sensory Analyzer (GSA, Medoc, Ramat Yishai, Israel) as compared with those of an age-comparable sample of volunteers without any ejaculatory compliant. Methods. Forty-two consecutive right-handed, fully potent patients with lifelong PE and 41 right-handed, fully potent, age-comparable volunteers with normal ejaculatory function were enrolled. Each man was assessed via comprehensive medical and sexual history; detailed physical examination; subjective scoring of sexual symptoms with the International Index of Erectile Function; and four consecutive measurements of intravaginal ejaculatory latency time with the stopwatch method. All men completed a detailed genital sensory evaluation using the GSA; thermal and vibratory sensation thresholds were computed at the pulp of the right index finger, and lateral aspect of penile shaft and glans, bilaterally. Main Outcome Measures. Comparing quantitatively assessed penile thermal and vibratory sensory thresholds between men with lifelong PE and controls without any ejaculatory compliant. Results. Patients showed significantly higher (P < 0.001) thresholds at the right index finger but similar penile and glans thresholds for warm sensation as compared with controls. Cold sensation thresholds were not significantly different between groups at the right index finger or penile shaft, but glans thresholds for cold sensation were bilaterally significantly lower (P = 0.01) in patients. Patients showed significantly higher (all P ≤ 0.04) vibratory sensation thresholds for right index finger, penile shaft, and glans, bilaterally, as compared with controls. Conclusions. Quantitative sensory testing analysis suggests that patients with lifelong PE might have a hypo- rather than hypersensitivity profile in terms of peripheral sensory thresholds. The peripheral neuropathophysiology of lifelong PE remains to be clarified. Salonia A, Saccà A, Briganti A, Carro UD, Dehò F, Zanni G, Rocchini L, Raber M, Guazzoni G, Rigatti P, and Montorsi F. Quantitative sensory testing of peripheral thresholds in patients with lifelong premature ejaculation: A case-controlled study. J Sex Med 2009;6:1755–1762.
Article
Introduction. Male circumcision is being promoted for HIV prevention in high-risk heterosexual populations. However, there is a concern that circumcision may impair sexual function. Aim. To assess adult male circumcision's effect on men's sexual function and pleasure. Methods. Participants in a controlled trial of circumcision to reduce HIV incidence in Kisumu, Kenya were uncircumcised, HIV negative, sexually active men, aged 18–24 years, with a hemoglobin ≥9.0 mmol/L. Exclusion criteria included foreskin covering less than half the glans, a condition that might unduly increase surgical risks, or a medical indication for circumcision. Participants were randomized 1:1 to either immediate circumcision or delayed circumcision after 2 years (control group). Detailed evaluations occurred at 1, 3, 6, 12, 18, and 24 months. Main Outcome Measures. (i) Sexual function between circumcised and uncircumcised men; and (ii) sexual satisfaction and pleasure over time following circumcision. Results. Between February 2002 and September 2005, 2,784 participants were randomized, including the 100 excluded from this analysis because they crossed over, were not circumcised within 30 days of randomization, did not complete baseline interviews, or were outside the age range. For the circumcision and control groups, respectively, rates of any reported sexual dysfunction decreased from 23.6% and 25.9% at baseline to 6.2% and 5.8% at month 24. Changes over time were not associated with circumcision status. Compared to before they were circumcised, 64.0% of circumcised men reported their penis was “much more sensitive,” and 54.5% rated their ease of reaching orgasm as “much more” at month 24. Conclusions. Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm. These data indicate that integration of male circumcision into programs to reduce HIV risk is unlikely to adversely effect male sexual function. Krieger JN, Mehta SD, Bailey RC, Agot K, Ndinya-Achola JO, Parker C, and Moses S. Adult male circumcision: Effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med 2008;5:2610–2622.
Article
Introduction: Research, theory, and popular belief all suggest that penile sensation is greater in the uncircumcised as compared with the circumcised man. However, research involving direct measurement of penile sensation has been undertaken only in sexually functional and dysfunctional groups, and as a correlate of sexual behavior. There are no reports of penile sensation in sexually aroused subjects, and it is not known how arousal affects sensation. In principle, this should be more closely related to actual sexual function. Aim: This study therefore compared genital and nongenital sensation as a function of sexual arousal in circumcised and uncircumcised men. Methods: Twenty uncircumcised men and an equal number of age-matched circumcised participants underwent genital and nongenital sensory testing at baseline and in response to erotic and control stimulus films. Touch and pain thresholds were assessed on the penile shaft, the glans penis, and the volar surface of the forearm. Sexual arousal was assessed via thermal imaging of the penis. Results: In response to the erotic stimulus, both groups evidenced a significant increase in penile temperature, which correlated highly with subjective reports of sexual arousal. Uncircumcised men had significantly lower penile temperature than circumcised men, and evidenced a larger increase in penile temperature with sexual arousal. No differences in genital sensitivity were found between the uncircumcised and circumcised groups. Uncircumcised men were less sensitive to touch on the forearm than circumcised men. A decrease in overall touch sensitivity was observed in both groups with exposure to the erotic film as compared with either baseline or control stimulus film conditions. No significant effect was found for pain sensitivity. Conclusion: These results do not support the hypothesized penile sensory differences associated with circumcision. However, group differences in penile temperature and sexual response were found.
Article
• To test clinical observations that the penilo-cavernosus reflex is much more difficult to elicit in circumcised men. • Men consecutively referred for uro-neurological or uro-neurophysiological examination were prospectively included. • Those with possible sacral neuropathic lesions were excluded. • A history was obtained, and a clinical neurological examination was performed. • The penilo-cavernosus reflex was tested clinically and neurophysiologically using electrical and mechanical stimulation. • Reflex elicitability scores in groups of circumcised men, men with foreskin retraction and a control group of uncircumcised men were compared using the Mann-Whitney U test. • The reflex was clinically non-elicitable in 73%, 64% and 8% of 30 circumcised men, 15 men with foreskin retraction, and 29 control men, respectively. • The scored reflex elicitability was significantly (P < 0.001) higher in control men than in the other two groups clinically, but not neurophysiologically. • The study confirmed the lower clinical and similar neurophysiological elicitability of the penilo-cavernosus reflex in circumcised men and in men with foreskin retraction. This finding needs to be taken into account by urologists and other clinicians in daily clinical practice.
Article
To determine whether measures of successful aging are associated with sexual activity, satisfaction, and function in older postmenopausal women. Cross-sectional study using self-report surveys; analyses included chi-square and t-tests and multiple linear regression analyses. Community-dwelling older postmenopausal women in the greater San Diego region. One thousand two hundred thirty-five community-dwelling women aged 60 to 89 participating at the San Diego site of the Women's Health Initiative. Demographic information and self-reported measures of sexual activity, function, and satisfaction and successful aging. Sexual activity and functioning (desire, arousal, vaginal tightness