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Male circumcision does not result in inferior perceived male sexual function – A systematic review

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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.
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Dan Med J 63/7  DANISH MEDICAL JOURNAL
ABSTRACT
INTRODUCTION: The debate on non-medical male circumci-
sion has gaining momentum during the past few years. The
objective of this systematic review was to determine if cir-
cumcision, medical indication or age at circumcision had an
impact on perceived sexual function in males.
METHODS: Systematic searches were performed in MED-
LINE 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 as-
sessed according to the level of evidence (Grade A-D).
RESULTS: Database and hand searches yielded 3,677 re-
cords. Inclusion criteria were fulfilled in 38 studies including
two randomised trials. Overall, the only identified differen-
ces in sexual function in circumcised males were decreased
premature ejaculation and increased penile sensitivity
(Grade A-B). Following non-medical circumcision, no infer-
ior sexual function was reported (A-B). Following medical
circumcision, most outcomes were comparable (B); how-
ever, 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 func-
tion 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.
Male circumcision is performed for cultural, religious
and medical reasons with a prevalence of about one
third of the world’s male population [1]. The focus on
non-medical male circumcision has been gaining mo-
mentum in public debate in both Europe and the United
States over the past few years. The Danish College of
General Practitioners has defined non-medical circumci-
sions as mutilation [2]. Some Danish medical profession-
als [3-6], Danish activists [7], and parliament members
[8] have promoted the narrative that male circumcision
results in decreased penile sensitivity or other types of
male sexual dysfunction.
Circumcision carries a risk of complications like any
other surgical intervention. Studies from Europe and the
United States report overall complication rates of 0.19-
3.8% [9]. Complication rates are lower if circumcision is
performed during infancy, by experienced providers and
under sterile conditions [10]. A Danish study from Rigs-
hospitalet [11] reported an overall complication rate of
5.1% following circumcision in children 0-16 years of age.
Short-term complications comprised superficial skin in-
fections (0.6%), bleeding (1.6%) and anaesthesiology
complications (0.6%). Long-term complications included
re-operations due to meatal stenosis (0.6%). No major
complications such as amputation or death were seen
[11]. An age stratification of the data from the Danish
study showed lower complication rates in younger boys.
These rates were comparable to the relatively low com-
plication rates previously reported in US studies [12]. The
Danish Health Authorities do not recommend a law-
enforced ban of non-medical circumcisions in Denmark
based on these low rates of short-term complications;
however, they do stress the lack of evidence with respect
to long-term complications and male sexual function [13].
Inferior sexual function following circumcision is
suggested to be caused by loss of sensory tissue fol-
lowed by keratinisation and desensitisation of the glans
penis [14-16]. This hypothesis is generated by two histo-
pathological findings; the description of Meissner’s cor-
puscles in human prepuce and longer epithelial exten-
sions into underlying connective tissue (rete ridges) in
the dorsal glans of the circumcised penis [14, 17].
The purpose of the present study was to test the
hypothesis of increased sexual dysfunction in circum-
cised men through a systematic review of the literature
and to perform a detailed synthesis of the available evi-
dence in order to guide patients, parents and decision-
makers on male circumcision.
The objective was to determine if circumcision had
an impact on sexual function in males defined as per-
ceived and self-reported erectile dysfunction, pain dur-
ing intercourse, premature ejaculation, problems in ob-
taining orgasm, sexual drive, penile sensitivity or sexual
satisfaction. A second objective was to determine
whether medical circumcision or age at circumcision
influenced perceived male sexual function.
METHODS
A protocol including outcomes and overall design was
written before searches were performed. Systematic
searches were performed in the MEDLINE and EMBASE
Male circumcision does not result in inferior perceived
male sexual function – a systematic review
Daniel Mønsted Shabanzadeh1, 2, 3, Signe Düring4 & Cai Frimodt-Møller5
SYSTEMATIC
REVIEW
1) Digestive Disease
Center,
Bispebjerg Hospital
2) Research Centre for
Prevention and Health,
Capital Region of
Denmark
3) Department of
Clinical Medicine,
Faculty of Health and
Medical Sciences,
University of
Copenhagen
4) Mental Health
Services of the Capital
Region Region of
Denmark
5) Department of
Urology, CFR Hospitals,
Denmark
Dan Med J
2016;63(6):A5245
DANISH MEDICAL JOURNAL Dan Med J 63/7 
databases. Exploded index terms (MeSH) were “Circum-
cision, male” or “Circumcision” in combination with
“Sexual dysfunction, physiological”, “Sexual dysfunction,
psychological”, “Sexual dysfunction”, “Sexual arousal
disorder”, “Premature ejaculation”, “Ejaculation dis-
order”, “Ejaculation”, “Erectile dysfunction”, “Penile
erection”, “Orgasm”, “Orgasm disorder”, “Libido”, “Lib-
ido disorder”, “Sensibility” or “Sexual satisfaction”. Key-
words were circumcision in combination with sensitivity,
sensibility, sensory, neuro*, erectile, ejaculation, or-
gasm, libido, lust, desire, satisfaction, or sex*. Final
searches were performed on 29 February 2016. Add-
itional hand-searches were performed through screen-
ing reviews, original studies and their reference lists.
Endnote X7 was used for management of references.
Study selection included a screening of titles and
abstracts by the primary author (DMS). Full texts of elig-
ible studies were obtained and screened for the inclu-
sion criteria by two authors independently (SD and
DMS). Discrepancies were resolved through discussion
until consensus was reached between all three authors.
The following inclusion criteria were applied:
1. Circumcision was the exposure or intervention.
2. Non-exposed controls were either a) uncircumcised
participants, b) same participants assessed before
circumcision, or c) individuals circumcised at
different ages.
3. Outcomes had to include perceived adult male
sexual function as defined in the previously
mentioned objective. A long-term follow-up period
was required.
4. All study designs including a non-exposed control
were included. Statistical testing had to be
performed in order to compare outcomes of
exposed and non-exposed groups. A significance
level of p < 0.05 was used to reject the null
hypothesis of no difference between exposed and
non-exposed participants.
All publication types indexed in databases and all lan-
guages were accepted. Chinese studies were translated
orally by a fellow PhD student.
Data extraction from studies was performed onto
preformatted sheets including the first author’s name,
year of publication, country, overall study design, num-
ber of participants circumcised and non-circumcised,
indication for circumcision, rates for medical and non-
medical circumcisions, age at circumcision, follow-up
length, lost to follow-up and age adjustment. Based on
the results of statistical testing, outcomes in circumcised
males were defined as ”increased”, ”decreased” or
”non-significant”. Erectile dysfunction, pain, premature
ejaculation, difficult ejaculation and problems in obtain-
ing orgasm were defined as negative outcomes; and in-
creased levels of sexual drive, penile sensitivity and sat-
isfaction were defined as positive outcomes. If available,
estimates adjusted for age were reported. Data extrac-
tion was performed by the primary author and reviewed
by the co-authors.
The questionnaires used in the identified studies
varied with respect to their assessment of ejaculatory
function. Some assumptions therefore had to be made
for this systematic review. The Brief Male Sexual
Functioning Inventory and Male Sexual Health
Questionnaire described difficulties in ejaculation, which
was included as a separate outcome [18, 19]. The
International Index of Erectile Function assessed prob-
lems in obtaining an orgasm [20]. The Premature
Ejaculation Diagnostic Tool assessed premature ejacula-
tion [21]. Where possible, results from these question-
naires were extracted for each sub-domain of erectile
function, ejaculation, drive and satisfaction.
The quality of each study was assessed through
levels of evidence for therapy developed by The Oxford
Centre for Evidence-based Medicine in 2009 and 2011
[22, 23]. In brief, assessments were performed at the
outcome level with the possibility of downgrading if
studies failed to measure exposures and outcomes in
the same way in both exposed and non-exposed partici-
pants, failed to control known confounders, or failed to
carry out sufficiently follow-up [22]. A cohort study only
assessing sexual function retrospectively was down-
graded due to inconsistencies in measuring outcomes
and exposure causing recall bias. Both randomised
studies and cohort studies were downgraded if the
KEY POINTS
The debate about male circumcision has gained momentum in Denmark
during the past few years. A narrative about circumcision and sexual dys-
function has been promoted by some medical professionals, activists and
parliament members.
The objective of this study was to perform a systematic review to deter-
mine whether circumcision had an impact on perceived sexual function
in males and to determine the impact of age at circumcision.
Non-medical circumcision was not associated with perceived sexual dys-
function.
Following medical circumcisions, premature ejaculation was decreased
and sexual satisfaction increased. Results for erectile dysfunction were
reported with inconsistencies.
Higher age at circumcision was associated with sexual dysfunction in
adulthood.
Studies on medical circumcision and age at circumcision are of lower
quality than studies on non-medical circumcisions. Results may therefore
be biased by pre-existing pathology in prepuce.
More studies on medical circumcision and age at circumcision are
needed.
Dan Med J 63/7  DANISH MEDICAL JOURNAL
share of patients lost to follow-up exceeded 20% or if
loss to follow up was not reported. Age at assessment
and medical indication for circumcision were chosen as
possible confounders. Sexual difficulties have a rising
prevalence with age in men [24] and the indications for
circumcision differ with age as well. Studies were down-
graded if age was not included in the design through
randomisation, through prospective assessments in co-
hort studies at fixed or short periods of follow-up or
through matching. Age could also be included in the
analysis through adjustment or stratification. Indication
for circumcision was considered mainly medical or non-
medical if reported as such in more than half of the cir-
cumcisions performed in the study.
Randomised controlled trials were assessed for ran-
dom sequence generation, allocation concealment,
attrition and blinding of outcome assessment as recom-
mended by the Cochrane Handbook [25]. Blinding of
participants or personnel was unfeasible because of the
nature of circumcision. If the statistical significance of
the intervention and control group had a small absolute
effect size, the study was downgraded [23].
Perceived sexual function outcomes in circumcised
males was reported overall across studies. Subgroup
analyses were performed for circumcised versus uncir-
cumcised males, before versus after circumcision, and
both were stratified by medical indication for circumci-
sion. Evidence for each outcome was summarised as
Grade A-D with A indicating the highest level of evidence.
In studies that had the same level of evidence, statistical-
ly significant results were given higher priority than non-
significant results, and inconsistencies between statisti-
cally significant results were graded D [22]. Reporting
was performed according to the PRISMA statement [26].
RESULTS
The database searches yielded 3,673 records and the
hand searches identified four additional studies [27-30].
Of 171 eligible studies, 133 were excluded leaving 38
studies for inclusion in this systematic review (Figure 1).
The included studies comprised 36 observational studies
and two randomised controlled trials. The studies were
performed in Asia, The Middle East, North and South
America, Europe, Africa and Australia.
Indications for circumcision were mainly non-med-
ical in 11 studies, medical in ten studies and not report-
ed in 17 studies. Age at circumcision was categorised as
adulthood or non-infancy in 22 studies, infancy in one
study and childhood in three studies (Table 1).
Nine cohort studies had a risk of attrition bias due
to insufficient completion of follow-up [28, 31-38], and
ten observational studies did not adjust for age [28, 29,
37-44]. A risk of recall bias was present in four retro-
spective cohort studies [28, 36-38] (Table 1).
The two randomised controlled trials had adequate
random sequence generation, allocation concealment
[45, 46], and follow-up at one year. No blinding of out-
come assessment was performed [47, 48]. One trial was
graded down due to a very small absolute effect size,
where 98.0-99.4% had a positive sexual function at
baseline and an almost equally high sexual function
(98.7-99.9%) at follow-up in both arms [47].
A qualitative synthesis without meta-analysis was
chosen due to considerable clinical heterogeneity in cir-
cumcision indications and procedures, study designs,
quality and reporting of results in the identified studies.
Overall sexual function and circumcision status
When all studies were assessed without stratification,
non-significant differences were found for erectile dys-
function, pain, problems in obtaining an orgasm, satis-
faction (Grade A) and difficult ejaculation (Grade B)
(Table 2) in circumcised compared with uncircumcised
males. Premature ejaculation was decreased (Grade A)
(Table 2), drive and penile sensitivity were increased
(Grade B) in the circumcised participants (Table 3).
FIGURE 1
Study flow (PRISMA) diagram.
Records identified through
database searching
(MEDLINE, n = 1,816)
(EMBASE, n = 2,932)
Additional records identified
through hand searches
(n = 4)
Full-text articles excluded, with
reasons (n = 133)
No uncircumcised control
group (n = 13)
Outcome not of interest (n = 45)
Short follow-up (n = 3)
Review (n = 20)
Comments (n = 41)
Conference abstracts with
full-text available (n = 2)
Conference abstract with insuffi-
cient information and no
full-text (n = 1)
Double registrations of
records (n = 7)
Case report (n = 1)
Records after duplicates removed
(n = 3,677)
Records screened
(n = 3,677)
Full-text articles assessed
for eligibility
(n = 171)
Studies included in qualita-
tive synthesis
(n = 38)
Records excluded
(n = 3,506)
DANISH MEDICAL JOURNAL Dan Med J 63/7 
TABLE 1
Characteristics of included studies. Studies are sorted according to study design, indication for circumcision, and year of publication.
Reference, year, country Design
Participants, total
or circumcised/
uncircumcised, n
Indication for
circumcision
Age at
circumcision
Adjustment for
age in design
or in multiple
analyses
Follow-up
length lost to, %
Kigozi et al, 2008, Uganda [47] Randomized controlled
trial
2,210/2,246 Non-medical: HIV prevention 15-49 yrs Yes 1 yr/2 yrs 10/66
Krieger et al, 2008, Kenya [48] Randomized controlled
trial
1,313/1,371 Non-medical: HIV prevention 18-24 yrs Yes 1 yr/2 yrs 11/48
Senkul et al, 2004, Turkey [31] Prospective cohort 42 Religious/cosmetic Adult Yes 12 wks
Senol et al, 2008, Turkey [32] Prospective cohort 43 Non-medical Adults Yes Min. 12
wks
Decastro et al, 2010, USA [69] Prospective cohort 30 Non-medical 68%, medical 32% Adult Yes 8-10 wks 7
Senel et al, 2012, Turkey [33] Prospective cohort 142 Religious Adult Yes 12-52 mo. 24
Alp et al, 2014, Turkey [34] Prospective cohort 30 Voluntary Adult Yes 3 mo.
Yang et al, 2014, Taiwan [63] Prospective cohort 442 Non-medical 56%, medical 44% Adult Yes 90 days 0
Zulu, 2015, Zambia [30] Prospective cohort 257 Non-medical: HIV prevention Adult Yes 6-12 mo. 0.4
Collins et al, 2002, USA [70] Prospective cohort 15 Medical 93%,
cosmetic 7%
Adult Yes 12 wks 0
Shen et al, 2004, China [71] Prospective cohort 95 Medical: phimosis, balanitis,
condyloma
Adult Yes 1 yr 0
Masood et al, 2005, England [35] Prospective cohort 88 Medical: phimosis, balanitis Adult Yes Min. 3 mo. 41
Zhang et al, 2006, China [64] Prospective cohort 51/29 Medical: redundant prepuce Adult Ye s 18 mo. 4
Cortés-Gonzalez et al, 2009,
Mexico [72]
Prospective cohort 22 Medical 72%, aesthetic 14% Adult Yes 12 wks 0
Yu et al, 2009, China [73] Prospective cohort 40 Medical: redundant prepuce, bal-
anitis
Adults Yes 4 mo. 0
Yue et al, 2014, China [74] Prospective cohort 98 Medical: phimosis, abundant
foreskin
Adults Yes 19 (9-28)
mo.
0
Gao et al, 2015, China [65] Prospective cohort 575/623 Medical: phimosis and balanitis Adult Yes 1 yr 17
Feldblum et al, 2015, Kenya [28] Retrospective cohort 194 Voluntary Adult No Median
32 mo.
Fink et al, 2002, USA [36] Retrospective cohort 43 Medical 86%, non-specified 14% Adult Ye s – 56
Kim et al, 2007, South Korea [37] Retrospective cohort 255/118 Adults No
Dias et al, 2014, Portugal [38] Retrospective cohort 62 Medical: phimosis, balanitis,
condyloma
Adult No Min. 3 mo. 23
Mao et al, 2008, Australia [49] Cross-sectional 939/487 Routine 91% Infants 91%,
after infancy
9%
Yes – –
Laumann et al, 1997, USA [75] Cross-sectional 1,449 Yes – –
Laumann et al, 1999, USA [27] Cross-sectional 1,202 Yes – –
Richters et al, 2006, Australia [76] Cross-sectional 5,972/4,201 Yes – –
Son et al, 2010, Korea [77] Cross-sectional 600 Yes – –
Ferris et al, 2010, Australia [78] Cross-sectional 2,317/1,973 Yes – –
Frisch et al, 2011, Denmark [50] Cross-sectional 103/1,893 11% had non-Danish parents,
6% were Moslims or Jews among
the circumcised
15% before
age 6 mo.
Yes – –
Tang & Khoo, 2011, Malaysia [39] Cross-sectional 110/97 No
Shaeer & Shaeer, 2012, Egypt [43] Cross-sectional 796/8 No
Bronselaer et al, 2013,
Belgium [40]
Cross-sectional 310/1,059 Birth or child-
hood < 10 yrs
56%, adoles-
cence or
adulthood
> 10 yrs 44%
No – –
Hoschke et al, 2013,
Germany [51]
Cross-sectional 167/2,332 Yes: erectile
dysfunction
only
– –
Shaeer O, 2013, USA [44] Cross-sectional 909/224 No
Homfray et al, 2015, England [52] Cross-sectional 954/3,862 Yes – –
Payne et al, 2007, Canada [58] Case-control 20/20 Ye s – –
Dan Med J 63/7  DANISH MEDICAL JOURNAL
Circumcised versus uncircumcised
Sexual function outcomes in circumcised versus uncir-
cumcised participants were reported in 19 studies
(Table 2). In non-medically circumcised participants, non-
significant differences were found for erectile dysfunc-
tion, pain, problems in obtaining an orgasm, satisfaction
(Grade A), difficult ejaculation and drive (Grade B). Pre-
mature ejaculation was significantly decreased (Grade A).
No assessment for penile sensitivity was identified. In
medically circumcised participants, a non-significant dif-
ference was found for erectile dysfunction (Grade B).
Premature ejaculation was found to be decreased and
satisfaction increased (Grade B). No assessments for
pain, difficult ejaculation, problems in ob taining an or-
gasm, drive or sensitivity were identified (Table 2).
Before versus after circumcision
Sexual function in participants undergoing circumcision
was reported in 21 studies (Table 3). Following non-
medical circumcision, difficult ejaculation was non-sig-
nificantly changed (Grade B). Erectile dysfunction, pain,
premature ejaculation and problems in obtaining an or-
gasm were decreased (Grade B). Drive, penile sensitivity
and satisfaction were increased (Grade B). Following
medical circumcisions, pain, difficult ejaculation, drive
and sensitivity were non-significantly changed (Grade B).
Premature ejaculation was decreased and satisfaction
increased (Grade B). Problems in obtaining an orgasm
were increased (Grade C) and results for erectile dys-
function were reported with inconsistency (Grade D)
(Table 3).
Age at circumcision
Five studies reported adult sexual function outcomes for
participants who were circumcised as children or infants
compared with participants who were circumcised later
in life [29, 40-42, 49]. Four of these did not report indi-
cation or adjust for age at assessment [29, 40-42] (Table
1). Circumcision after infancy was associated with non-
significant differences in satisfaction, increased erection
difficulties and decreased premature ejaculation (Grade
B). Indication for circumcision after infancy was reported
in 49% and the most frequent indication was phimosis
[49]. Adult circumcision caused increased pain at inter-
course and decreased satisfaction (Grade C) [40]. Cir-
cumcision above the age of seven caused increased pre-
mature ejaculation (Grade C) [29]. When comparing age
groups of 0-12 years or the specific period of 3-6 years
at circumcision, non-significant differences were found
for erectile dysfunction, premature ejaculation, prob-
lems in obtaining orgasm, desire and satisfaction (Grade
C) [41, 42].
DISCUSSION
The results of the present systematic review indicate
that non-medical circumcision does not generally seem
to cause an inferior male sexual function at a statistically
significant level (Grade A-B). Following medical circum-
cisions, erectile dysfunction, pain, difficult ejaculation,
drive and sensitivity were all found to be non-signifi-
cantly changed, whereas premature ejaculation de-
creased and satisfaction improved (Grade B). However,
inconsistencies in reporting of erectile dysfunction
(Grade D) were identified in studies with the same level
of evidence, and problems in obtaining an orgasm were
increased (Grade C). A higher age at circumcision was as-
sociated with negative sexual function (Grades B-C).
Studies not reporting indication for circumcision did not
reach a high enough level of evidence for assessment of
overall sexual function, and some reported inconsistent
results when compared with studies of a higher level of
evidence.
TABLE 1 CONTINUED
Reference, year, country Design
Participants, total
or circumcised/
uncircumcised, n
Indication for
circumcision
Age at
circumcision
Adjustment for
age in design
or in multiple
analyses
Follow-up
length lost to, %
Studies exploring age at circumcision and sexual function only
Aydur et al, 2007, Turkey [41] Cross-sectional 107 0-2 yrs 11%,
3-5 yrs 27%,
6-12 yrs 62%
No – –
 Cross-sectional 80 0-3 yrs 27.5%,
3-7 yrs 27.5%,
7-11 yrs
27.5%, > 11
yrs 17.5%
No
Armagan et al, 2014, Turkey [42] Cross-sectional 302 Phallic period
3-6 yrs 45%,
non-phallic
period 55%
No – –
DANISH MEDICAL JOURNAL Dan Med J 63/7 
Best level of evidence including randomised con-
trolled trials was identified only for non-medical circum-
cisions. Although many of the outcomes of non-medical
circumcisions were from one well-designed randomised
study, outcomes from lower-quality studies were also
consistent with a conclusion of no negative impact on
sexual function in circumcised males [48]. Satisfaction
was decreased in one randomised study; however, abso-
lute effects were negligible and probably a chance find-
ing due to a type 1 error [47]. Among studies not report-
ing the indication for circumcision, four were performed
in countries where non-medical circumcisions are un-
common and indications were therefore most likely
medical [40, 50-52]. Sexual function following medical
circumcisions was explored in non-randomised studies
only and reported with some inconsistencies. Age at cir-
cumcision was only explored in studies including circum-
cised participants. Optimally, such studies should com-
pare different ages of circumcision to age-matched
non- circumcised controls at outcome assessment.
Therefore, studies on medical circumcision and on age at
circumcision were more biased than studies about non-
medical circumcisions; and conclusions should according-
ly be interpreted with caution. The discrepancy between
sexual outcomes following medical and non-medical cir-
cumcisions identified in this systematic review has been
reported before and it has been suggested that it is con-
founded by penile path ology causing sexual dysfunction
prior to circumcision [49]. Adult medical circumcision is
most often performed due to pathological conditions in
prepuce, which presumably causes inferior sexual func-
tion and mental health disturbances [53-55]. Hence, pre-
circumcision penile pathology may explain the identified
discrepancies in obtaining an orgasm when comparing
medical and non-medical circumcisions (Table 3) as well
as the discrepancies in the results of the many studies
not reporting indication when compared with results
from studies reporting indication (Table 2 and Table 3).
Therefore, circumcision serves as a proxy for underlying
penile pathology, and studies including participants with
mainly med ical circumcision therefore measure the im-
pact of pathology on sexual function rather than the im-
pact of circumcision. Such selection bias and confound-
ing are best avoided through a randomised design, and
future observational studies should at least perform
stratification or adjustment for penile pathology.
TABLE 2
Subjective sexual outcomes in circumcised versus uncircumcised in randomised, cross-sectional, and case-control studies. Studies are sorted according to indication for circumcision
and level of evidence.
Reference, year
Level of
evidence
Erectile
dysfunction Pain
Premature
ejaculation
Difficult
ejacula-tion
Problems in
obtaining orgasm Drive
Penile
sensitivity Satisfaction
Non-medical indication
Krieger et al, 2008 [48] 1a NSaNSaDecreasea– NSa– – NSa
Kigozi et al, 2008 [47] 2b NS NS NSaNS – Decrease
Mao et al, 2008 [49] 2c NS NS NS NS
Medical indication
Zhang et al, 2006 [64] 2c Increase
Gao et al, 2015 [65] 2c NS Decrease Increase
Indication not reported
Laumann et al, 1997 [75] 2c Decrease in
45-59 yrs
NS NS NS NS Increase in
45-59 yrs
Laumann et al, 1999 [27] 2c NS NS NS
Richters et al, 2006 [76] 2c Decrease Decrease NS NS NS NS
Son et al, 2010 [77] 2c NS
Ferris et al, 2010 [78] 2c NS NS NS NS NS NS
Frisch et al, 2011 [50] 2c NS NS NS Increase NS NS
Hoschke et al, 2013 [51] 2c NS
Homfray et al, 2015 [52] 2c NS NS NS NS NS NS
Payne et al, 2007 [58] 3b NS NS NS NS
Tang & Khoo, 2011 [39] 4 Increase
Shaeer & Shaeer, 2012 [43] 4 NS
Bronselaer et al, 2013 [40] 4 Increase shaft,
NS in glans
Increase lateral
glans, NS other sites
Decrease Decrease glans,
NS shaft
Shaeer O, 2013 [44] 4 NS
Kim et al, 2007 [37] 4 NS NS NS
NS = non-significant.
a) The overall highest level of evidence.
Dan Med J 63/7  DANISH MEDICAL JOURNAL
Risks of observer and selective reporting bias were
present in the included studies since none had blinded
outcome assessment, only half of the studies included
validated questionnaires and some studies reported only
parts of questionnaires. Health-promoting beliefs re-
lated to non-medical circumcisions are present in some
cultures [56] and may have caused overestimation of
perceived sexual function towards the positive. Other
limitations included short follow-up periods of 1-2 years
in the prospective studies. Many results were non-signi-
ficant, possibly due to small sample sizes causing a risk
of type II error. Most studies focused on the heterosex-
ual practice of intravaginal intercourse and did not take
into account other important heterosexual or homosex-
ual practices that comprise male sexual function.
The strength of this systematic review was the
broad search strategy and the inclusion of non-English
literature, thereby including participants from all popu-
lated continents. The qualitative assessment of the
existing literature focused on minimising bias. The strat-
ification by medical indication was performed in order
to explore confounding. Other possible confounding
factors such as cardiovascular, neurological, and psych-
iatric co-morbidities, illegal substances, complications to
surgery, lifestyle and drugs such as use of psychophar-
maceuticals may contribute to an inferior sexual func-
tion. Some of the studies adjusted for these factors;
however, many of the factors are age-dependent why
adjustment for age at assessment was most important.
The limitation was the inability to perform a meta-ana-
lysis. A pooled analysis could, possibly, have identified
more significant associations.
This systematic review focused on the participant-
centred sexual function. A number of experimental
tudies have investigated male sexual function through
objective measures. In circumcised compared with un-
circumcised males, differences in sensory tactile thresh-
olds have been found to be non-significant [57-59] and
increased [60, 61], and differences in ejaculatory latency
period have been found to be non-significant [37, 62,
63] as well as increased [31, 32, 34, 64, 65]. Differences
in penile temperature, penilo-cavernous reflexes and
TABLE 3
Subjective sexual outcomes before versus after circumcision in cohort studies. Studies are sorted according to indication for circumcision and level of evidence.
Reference, year
Level of
evidence
Erectile
dysfunction Pain
Premature
ejaculation
Difficult
ejaculation
Problems in
obtaining orgasm Drive
Penile
sensitivity
Satisfaction
Non-medical indication
Krieger et al, 2008 [48] 2b Decrease Decrease Decrease Decrease IncreaseaIncrease
Kigozi et al, 2008 [47] 2b Decrease Decrease NSa NS – NS
Decastro et al, 2010 [69] 2b NS NSa – – NS
Yang et al, 2014 [63] 2b NS NSa– Increasea– NS
Zulu, 2015 [30] 2b NS Decrease Increasea– Increase
Senkul et al, 2004 [31] 4 NS NS NS NS
Senol et al, 2008 [32] 4 NS NS NS NS
Senel et al, 2012 [33] 4 Decrease NS NS Increase
Alp et al, 2014 [34] 4 Decrease
Feldblum et al, 2015 [28] 4 NS Increase
Medical indication
Collins et al, 2002 [70] 2b NS NS - NS NS
Zhang et al, 2006 [64] 2b Increase
Cortés-Gonzalez et al, 2009
[72]
2b Decrease NS NS NS NS NS
Yu et al, 2009 [73] 2b NS NS NS NS
Yue et al, 2014 [74] 2b NS NS NS NS
Gao et al, 2015 [65] 2b NS Decrease Increase
Shen et al, 2004 [71] 2b Increase Increase
Masood et al, 2005 [35] 4 NS Decrease NS NS Increase NS
Fink et al, 2002 [36] 4 Increase NS Increase
Dias et al, 2014 [38] 4 Increase Decrease NS Increase
Indication not reported
Kim et al, 2007 [37] 4 Increase in
masturbatory
difficulty
Decrease in
masturbatory
pleasure and
sex life
NS = non-significant.
a) The overall highest level of evidence.
DANISH MEDICAL JOURNAL Dan Med J 63/7 
penile pudendal-evoked potentials [32, 58, 66] have also
been reported. The interpretation of such measures is
beyond what is known about male sexual function and
these measures were therefore not included in the pres-
ent systematic review. A recent review with focus on
gaps in male circumcision research has specified the
needs for consistent objective measures and for correla-
tion of objective to subjective male sexual function out-
comes [67]. Other systematic reviews from paediatric
societies in the USA and Canada also conclude that cir-
cumcision is unlikely to change male sexual function
[9, 68].
CONCLUSIONS
The highest level of evidence shows no perceived infer-
ior male sexual function following non-medical circumci-
sion. Medical circumcisions have negative outcomes for
obtaining orgasm and discrepancies for erectile dysfunc-
tion. Younger age at circumcision seemed to cause less
sexual dysfunction than circumcision later in life. The
two latter findings are most likely not causal and more
likely biased by observational designs. Future ran-
domised controlled trials of medical circumcisions
should be performed. Such studies should include non-
circumcised controls and sexual function assessment at
entry and at longer-term follow-up beyond two years.
Age at circumcision should be explored in prospective
studies including non-circumcised age-matched controls.
The hypothesis of inferior male sexual function following
circumcision is not supported by the findings of this sys-
tematic review. The popular narrative that male circum-
cision results in sexual dysfunction does not seem to be
supported by evidence.
CORRESPONDENCE: Daniel Mønsted Shabanzadeh. E-mail:daniel.moensted.
shabanzadeh.01@regionh.dk
ACCEPTED: 5 April 2016
CONFLICTS OF INTEREST: Disclosure forms provided by the authors are
available with the full text of this article at www.danmedj.dk
ACKNOWLEDGEMENTS: We would like to thank PhD student Lin Chia-Hsien
from Department of Public Health at the University of Copenhagen for her as-
sistance with the Chinese articles, and Birthe Frimodt-Møller for linguistic as-
sessment.
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... Shabanzadeh et al., 2016 [23] Mostly no difference or a decrease, in pain during intercourse, in circumcised men. ...
... RCT findings [187,188] (Level 1+), a large UK survey [189] (Level 2++), 4 systematic reviews [190][191][192][193] (Level 2++) and 2 Meta-analyses [191,192] (Level 1+) showed that MC has no adverse effect on sexual function, penile sensitivity, nor sexual sensation, arousal, or pleasure. The most recent meta-analysis found 64% of circumcised vs. uncircumcised men experienced less pain during intercourse, 28% had lower ejaculation latency time, and 58% had less erectile dysfunction [192]. ...
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Male circumcision (MC) is common in many countries. Despite clear health benefits, ethical arguments have been invoked opposing MC, especially when performed neonatally (NMC). NMC is when most MCs are performed in developed countries. Here we provide the first PRISMA-compliant systematic review of the disparate evidence of ethical and legal arguments concerning NMC and MC of older boys. Searches were performed of PubMed, Embase and Scopus for publications relevant to ethical and legal aspects of MC in developed Anglophone and European countries. This led to retrieval of 48 articles meeting the inclusion criteria. A further 18 articles and 16 Internet publications were identified from searches of bibliographies of articles retrieved. Two more were supplied by a legal academic colleague. In total 84 publications were reviewed. The literature revealed arguments by some that parent-approved MC of a nonconsenting child is unethical. But parental consent also applies to vaccination and all other medical therapies in children. Strong data support a conclusion that: (1) NMC is low risk, (2) NMC provides immediate and lifetime medical and health benefits, and (3) NMC has no adverse effect on sexual function and pleasure. The United Nations Convention on the Rights of the Child articulates the right to health and focuses on the best interests of the child as its guiding principle. Discouraging or denying MC to neonates is arguably unethical, given the overwhelming health benefits. Legal scholars regard case-law as supporting the legality of NMC. Ethical and legal arguments support the rights of males of all ages to lifetime protection against infection and diseases caused by lack of MC. Arguments opposing NMC generally involve distortion of the medical evidence, poorly designed studies and opinions. Opposition to NMC goes against the principles of evidence-based medicine used in reviews conducted to develop pediatric policies in support of optimum public health, sexual health, mental health, and human rights.
Chapter
Circumcision consists of removal of the male prepuce (foreskin), leaving the penile glans (head) intact. Over a billion men alive today have undergone circumcision. The procedure has been widely performed for at least four millennia, largely as a religious or cultural rite. Performed on a healthy young boy under reasonably hygienic conditions, circumcision carries minimal risk of severe injury. There is no convincing evidence that it is a significant cause of urinary, reproductive, or sexual dysfunction. This chapter reviews the evidence on both sides of the circumcision debate. The chapter rejects or refutes deontic arguments against circumcision. Finding no strong evidence that childhood circumcision is a health risk, the chapter applies the State Intervention Test and finds that state interference with parental authorization of circumcision falls outside appropriate state scope of action.
Article
Objectives To determine the risk of complications requiring treatment following male circumcision by health-care professionals and to explore the impact of participant characteristics, type of circumcision and study design. Methods We identified studies through systematic searches in online databases (MEDLINE, EMBASE and CENTRAL) and hand searches. We performed random-effects meta-analysis to determine risk of circumcision complications and mixed-effects meta-regression analyses to explore the impact of participant characteristics, type of circumcision and study design. Methods were pre-specified in a registered protocol (Prospero CRD42020116770) and according to PRISMA guidelines. Results We included 351 studies with 4.042.988 participants. Overall complication risk was 3.84% (95% confidence interval 3.35-4.37). Our meta-analysis revealed that therapeutic circumcisions were associated with a two-fold increase in complications as compared to non-therapeutic (7.47% and 3.34%, respectively). Adhesions, meatal stenosis and infections were the most frequent complication subgroups to therapeutic circumcisions. Bleeding, device removals and infections occurred more frequently in non-therapeutic circumcisions. Additionally, adjusted meta-regression analyses revealed that children above two years, South American continent, older publication year and smaller study populations increased complication risk. Type of circumcision method, provider and setting were not associated with complication risk. Sensitivity analyses including only better-quality studies confirmed our main findings while accounting better for heterogeneity. Conclusions Circumcision complications occur in about four per hundred circumcisions. Higher risks of complications were determined by therapeutic circumcisions and by childhood age when compared to infant. Future studies should assess therapeutic and childhood circumcisions separately.
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Introduction Active debate concerns whether male circumcision (MC) affects sexual function, penile sensation, or sexual pleasure. Aim To perform a systematic review examining the effect of MC on these parameters. Methods PRISMA-compliant searches of PubMed, EMBASE, the Cochrane Library, and Google Scholar were performed, with “circumcision” used together with appropriate search terms. Articles meeting the inclusion criteria were rated for quality by the Scottish Intercollegiate Guidelines Network system. Main Outcome Measure Evidence rated by quality. Results Searches identified 46 publications containing original data, as well as 4 systematic reviews (2 with meta-analyses), plus 29 critiques of various studies and 15 author replies, which together comprised a total of 94 publications. There was overall consistency in conclusions arising from high- and moderate-quality survey data in randomized clinical trials, systematic reviews and meta-analyses, physiological studies, large longitudinal studies, and cohort studies in diverse populations. Those studies found MC has no or minimal adverse effect on sexual function, sensation, or pleasure, with some finding improvements. A consensus from physiological and histological studies was that the glans and underside of the shaft, not the foreskin, are involved in neurological pathways mediating erogenous sensation. In contrast to the higher quality evidence, data supporting adverse effects of MC on function, sensation, or pleasure were found to be of low quality, as explained in critiques of those studies. Conclusion The consensus of the highest quality literature is that MC has minimal or no adverse effect, and in some studies, it has benefits on sexual functions, sensation, satisfaction, and pleasure for males circumcised neonatally or in adulthood. Morris BJ, Krieger JN. The Contrasting Evidence Concerning the Effect of Male Circumcision on Sexual Function, Sensation, and Pleasure: A Systematic Review. Sex Med 2020;8:577–598.
Article
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Medical male circumcision has been adopted by the WHO, and other professional public health and medical bodies, as a vital weapon in the fight against HIV. This has prompted a large body of research into the acceptability of the procedure, attitudes to it, and barriers to it. A systematic review of these studies found that satisfaction with circumcision is strongly associated with having accurate knowledge about it. A survey-based paper by Earp, Sardi and Jellison entitled “False beliefs predict increased circumcision satisfaction in a sample of US American men” is the only one to find the opposite. It therefore merits scrutiny. The present article presents the results of a critical examination of the study. Serious flaws were discovered. Half of the small number of 10 “true/false” statements used in its survey are questionable. All the large body of literature that contradicts the findings of Earp and co-workers is ignored. Importantly, the crucial question about whether dissatisfied circumcised males hold false beliefs about circumcision is not considered. Unlike most of the research on the acceptability of circumcision, the study is not motivated by a desire to evaluate the likely effectiveness of a public health measure, or how best to implement it. Rather it appears to be an attempt by a prominent anti-circumcision activist and his associates to generate a body of literature that they can then cite to further their cause. Considering this, and the serious flaws it contains, the study should be dismissed as misleading, biased and undermining public health.
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Background: Voluntary medical male circumcision (VMMC) is an important HIV prevention strategy, particularly in regions with high HIV incidence and low rates of male circumcision. However, 88% of the Zambian male population remain uncircumcised, and of these 80% of men surveyed expressed little interest in undergoing VMMC. Methods: The Spear and Shield study (consisting of 4 weekly, 90-minute sexual risk reduction/VMMC promotion sessions) recruited and enrolled men (N = 800) who self-identified as at risk of HIV by seeking HIV testing and counseling at community health centers. Eligible men tested HIV-negative, were uncircumcised, and expressed no interest in VMMC. Participants were encouraged (but not required) to invite their female partners (N = 668) to participate in the program in a gender-concordant intervention matched to their partners’. Men completed assessments at baseline, post-intervention (about 2 months after baseline), and 6 and 12 months post-intervention; women completed assessments at baseline and post-intervention. For those men who underwent VMMC and for their partners, an additional assessment was conducted 3 months following the VMMC. The ancillary analysis in this article compared the pre- and post-VMMC responses of the 257 Zambian men who underwent circumcision during or following study participation, using growth curve analyses, as well as of the 159 female partners. Results: Men were satisfied overall with the procedure (mean satisfaction score, 8.4 out of 10), and nearly all men (96%) and women (94%) stated they would recommend VMMC to others. Approximately half of the men reported an increase or no change in erections, orgasms, and time to achieve orgasms from pre-VMMC, while one-third indicated fewer erections and orgasms and decreased time to achieve orgasms post-VMMC. Nearly half (42%) of the men, and a greater proportion (63%) of the female partners, said their sexual pleasure increased while 22% of the men reported less sexual pleasure post-VMMC. Growth curve analysis of changes in sexual functioning and satisfaction over time revealed no changes in erectile functioning or intercourse satisfaction, but there were increases in orgasm functioning, overall sexual satisfaction, and sexual desire. The majority (61% to 70%) of men and women thought penile cleanliness and appearance had improved post-VMMC. Of the 69% of men who reported having sexual intercourse at least once between having the procedure and their 3-month post-VMMC assessment, the large majority (76%) waited at least 6 weeks before resuming sex. Sexual intercourse prior to the 6-week healing period was associated with adverse events and lower levels of post-VMMC sexual satisfaction. Conclusion: Both men and their partners can generally expect equal or improved sexual satisfaction and penile hygiene following VMMC. Future studies should consider innovative strategies to assist men in their efforts to abstain from sexual activities prior to complete healing.
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Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
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Objectives: To ascertain clinical sequelae, client satisfaction and sexual behavior 2+ years after male circumcision using the ShangRing device. Methods: We enrolled 199 men from the Kenya sites (Homa Bay district) participating in a 2012 study of the ShangRing device used in routine male circumcision services (N = 552). We enrolled men who had had the ShangRing placed successfully, and over-sampled men who had had an adverse event and/or were HIV-positive during the field study. In the present study, each participant was examined and interviewed by a study clinician, and penile photographs were taken to document longer-term cosmetic results and any abnormal findings. Results: 194 men were included in the analysis. The mean and median times between circumcision and the longer-term follow-up visit in this study were 31.8 and 32 months, respectively. Four men (2.1%) had signs/symptoms of a sexually transmitted infection (STI). Virtually all (99.5%) of the men were very satisfied with the appearance of their circumcised penis, and all would recommend a ShangRing circumcision to friends or family members. The most prevalent reported advantage of the circumcision was the ease of bathing and enhanced cleanliness of the penis (75.8%). 94.3% of the men did not cite a single negative feature of their circumcision. 87.5% of men reported more sexual pleasure post-MC, the most common reason being more prolonged intercourse. The majority of men (52.6%) reported one sexual partner post-MC, but more than a quarter of the men (28.1%) reported an increased number of partners post-MC. Less than half of the men (44.3%) reported using condoms half of the time or more, but the great majority of condom users stated that condom use was much easier post-MC, and 76.9% of users said they used condoms more after circumcision than before. Conclusions: This study supports the safety and acceptability of ShangRing male circumcision during 2-3 years of follow-up. It should allay worries that the ShangRing procedure could lead to delayed complications later than the observation period of most clinical studies. Trial registration: ClinicalTrials.gov NCT01567436.
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Objective: Despite biological advantages of male circumcision in reducing HIV/sexually transmitted infection acquisition, concern is often expressed that it may reduce sexual enjoyment and function. We examine the association between circumcision and sexual function among sexually active men in Britain using data from Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Natsal-3 asked about circumcision and included a validated measure of sexual function, the Natsal-SF, which takes into account not only sexual difficulties but also the relationship context and overall level of satisfaction. Methods: A stratified probability survey of 6293 men and 8869 women aged 16-74 years, resident in Britain, undertaken 2010-2012, using computer-assisted face-to-face interviewing with computer-assisted self-interview for the more sensitive questions. Logistic regression was used to calculate odds ratios (ORs) to examine the association between reporting male circumcision and aspects of sexual function among sexually active men (n = 4816). Results: The prevalence of male circumcision in Britain was 20.7% [95% confidence interval (CI): 19.3-21.8]. There was no association between male circumcision and, being in the lowest quintile of scores for the Natsal-SF, an indicator of poorer sexual function (adjusted OR: 0.95, 95% CI: 0.76-1.18). Circumcised men were as likely as uncircumcised men to report the specific sexual difficulties asked about in Natsal-3, except that a larger proportion of circumcised men reported erectile difficulties. This association was of borderline statistical significance after adjusting for age and relationship status (adjusted OR: 1.27, 95% CI: 0.99-1.63). Conclusion: Data from a large, nationally representative British survey suggest that circumcision is not associated with men's overall sexual function at a population level.
Article
Objective The purpose of this study is to investigate the effects of adult male circumcision on premature ejaculation (PE). Methods Therefore, between December 2009 and March 2014, a total of 575 circumcised men and 623 uncircumcised men (control group) were evaluated. Detailed evaluations (including circumcision and control groups) on PE were conducted before circumcision and at the 3-, 6-, 9-, and 12-month follow-up visits after circumcision. Self-estimated intravaginal ejaculatory latency time (IELT), patient-reported outcome measures, and 5-item version of the International Index of Erectile Function were used to measure the ejaculatory and erectile function for all subjects. Results The results showed that, during the 1 year follow-up, men after circumcision experienced higher IELT and better scores of control over ejaculation, satisfaction with sexual intercourse, and severity of PE than men before circumcision (P<0.001 for all). Similarly, when compared with the control group, the circumcised men reported significantly improved IELT, control over ejaculation, and satisfaction with sexual intercourse (P<0.001 for all). These findings suggested that circumcision might have positive effects on IELT, ejaculatory control, sexual satisfaction, and PE severity. Conclusions In addition, circumcision was significantly associated with the development of PE.
Article
Objective: To investigate the effects of adult circumcision on male and female sexual function. Methods: Sexual performance of 40 men was evaluated using the Brief Male Sexual Function Inventory (BMSFI) and Intravaginal Ejaculatory Latency Time (IELT) before circumcision and at 4 months after circumcision. And their spouse's sexual function was also evaluated using Female Sexual Function Index (FSFI) at corresponding time. The scores of the BMSFI and the IELT for treated men and the scores of FSFI for their spouse were comparatively analyzed. Results: No significant differences in the mean scores of BMSFI on five sections were found between after circumcision and before circumcision. However, the mean IELT was significantly longer after circumcision compared with that before circumcision. There was no obvious difference in the sexual arousal and orgasm sections after circumcision, significant difference in the scores of lubrication and pain sections of FSFI. Conclusion: Adult circumcision had no effects on male sexual function except increasing the mean IELT. But their spouse might have some negative experiences such as vaginal dryness and pain during sex intercourse after male circumcision. Thereafter, the man with redundant prepuce should have a scientific attitude on adult circumcision treatment.
Article
Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and he provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.
Article
The circumcision of newborn males in Canada has become a less frequent practice over the past few decades. This change has been significantly influenced by past recommendations from the Canadian Paediatric Society and the American Academy of Pediatrics, who both affirmed that the procedure was not medically indicated. Recent evidence suggesting the potential benefit of circumcision in preventing urinary tract infection and some sexually transmitted infections, including HIV, has prompted the Canadian Paediatric Society to review the current medical literature in this regard. While there may be a benefit for some boys in high-risk populations and circumstances where the procedure could be considered for disease reduction or treatment, the Canadian Paediatric Society does not recommend the routine circumcision of every newborn male.