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Adding Insult to Injury: Acquisition of Erectile Dysfunction from Circumcision

March 2014

Authors:

Intact America

Preprints and early-stage research may not have been peer reviewed yet.

Our study published in the International Journal of Men's Health showed that circumcised men have a 4.5 times greater chance of suffering from erectile dysfunction (ED) than intact men, revealing what appears to be a significant acquisition factor.

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Adding Insult to Injury:

Acquisition of Erectile Dysfunction from Circumcision

Dan Bollinger

Our study published in the International Journal of Men’s Health showed that circumcised men

have a 4.5 times greater chance of suffering from erectile dysfunction (ED) than intact men,

revealing what appears to be a significant acquisition factor.

Robert S. Van Howe, M.D., M.S.,

FAAP and I found a surprisingly strong secondary finding between circumcision and ED in our

survey of 300 participants (OR = 4.53, p=.0058). It was outside the scope of our article to delve

deeper into this topic, but our finding does raise some questions: Are there other studies

showing a similar connection? What could be the underlying cause?

Eighteen percent of adult American men—three-fourths of whom are circumcised—have ED,

affecting 18 million men.

Circumcision’s role as a risk factor may be anecdotally reflected in ED

drug sales; while the United States represents 5% of the world’s population, it also accounts for

46% of Viagra sales.

Other studies have previously observed that circumcision’s damage results

in worsened erectile functioning,

inability to maintain an erection,

and reducing overall penis

sensitivity by an alarming 75%.

Premature ejaculation, ED, and circumcision are inextricably

linked; a recent study revealed that premature ejaculation is five times more likely when

adjusted for ED and circumcision.

A Danish study

found that circumcised men are three times

more likely to have sexual dysfunction.

Yet another study, this one from Portugal, found that

circumcision resulted in a 266% increase in erectile dysfunction.

Case studies of men circumcised as adults are revealing since they compare sexual function and

satisfaction before and after the surgery. They are also alarming. Circumcision was supposed to

correct a problem and ostensibly resulting in entirely favorable outcomes, but this is not the

case as these failure rates illustrate. In one study, circumcision worsened erectile function and

decreased penile sensitivity, and 38% reported sexual harm.

Another survey found that 27%

of recently circumcised adult men reported dissatisfaction with erectile functioning.

In a third

study, the number of men reporting erectile dysfunction almost doubled after circumcision, and

ED severity increased, too.6 A fourth study found that 35% of participants and 46% of partners

had a worsened sex life after circumcision.

The study implicated loss of nerve endings as a

reason—addressed below. The true dissatisfaction rate is probably higher since all of the men

elected circumcision, and would naturally be biased toward the outcome being beneficial.

An exhaustive case study of five impotent men circumcised as adults involved a complete

workup, including a thorough examination of genitalia, neurological examination, complete

blood counts, oral glucose tolerance tests, and protein bound iodine and T-4 uptake, serum

electrolytes, VDRL, sperm counts, and 24-hour urinary steroid tests. None of these tests were

significant, and in the end, circumcision was the only common factor between the subjects.

Circumcision is a risk factor for both physiological and psychosomatic aspects for ED since it is a

sexual trauma and damages the penis.

The traumatization from the procedure’s pain is

thought to be particularly damaging to an infant, whose brain is still developing.

One obvious cause for ED from circumcision—truncating the perineal nerve—must be

considered since injuries to this nerve are known to cause permanent sexual dysfunction.

The

perineal nerve is critically important to sex, lovemaking, and orgasms in both males and

females. Dubbed the “sex nerve,” it serves some of the most sensitive erogenous zones in the

human body. It is responsible for initiating and maintaining an erection in males

and females

(yes, females get erections, too).

Without the perineal nerve’s input, intercourse and sexual

satisfaction will be limited. In males, it contributes not only to obtaining an erection, but for

ejaculation and feelings of orgasm, too. In females it contributes to clitoral erection, feelings of

orgasm, and closes the vagina after orgasm.

The perineal nerve runs the length of the penis on the underside and terminates in the

frenulum.

The frenulum—or “little bridle”—attaches the underside of penis shaft to the inner

foreskin, is one of the most sensitive portions of the penis,6 and is solely innervated by the

perineal nerve.

During intercourse the foreskin inverts and the frenulum is exposed,

presenting a great number of perineal nerve endings to repeated stimulation every time the

penis enters and withdraws from the vagina. Circumcision partially or completely excises the

frenulum, always severing the nerve at this point. This variable frenular aspect, and because

there are other risk factors, might explain why not all circumcised men suffer from ED or other

sexual dysfunctions, including satisfaction loss.

This news that circumcision, once considered as beneficial to a man’s sexual health, is now

connected to sexual dysfunction is disheartening. Every man has the right to good sexual health

and to feel sexual pleasure for full psychophysical wellbeing. Erectile dysfunction is devastating

to the lives of so many men and their partners. This new research now calls elective and infant

circumcision into question.

November 17, 2011; Revised March 15, 2016

References:

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sectional study. J Sex Med,2011;8:2071–8.

Christensen BS, Grønbæk M, Frisch M, et al. Sexual dysfunctions and difficulties in Denmark: Prevalence and associated

sociodemographic factors. Arch Sex Behav, 2011;40:121–32.

M. Frisch speaking about his study at a press conference. Available online at:

http://www.israelwhat.com/2011/10/16/norwegian-mens-rights-group-compares-male-circumcision-to-female-genital-

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activity and satisfaction. J Urol, 2002;167:2113–6.

Coursey JW, Morey AF, McAninch JW, et al. Erectile function after anterior urethroplasty. J Urol, 2001;166:2273–6.

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Yucel S, Baskin LS. Neuroanatomy of the male urethra and perineum. BJU Int, 2003;92:624–30.

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Ought Implies Can: A Kantian Analysis of the Morality of the Use of Neonatal Tissue in Biotechnology

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Nov 2021

Eric James Cunningham

This paper seeks to address the ethical and moral implications of the utilization of neonatal foreskin tissue in biotechnology. Under the framing of Heidegger’s 𝘛𝘩𝘦 𝘘𝘶𝘦𝘴𝘵𝘪𝘰𝘯 𝘊𝘰𝘯𝘤𝘦𝘳𝘯𝘪𝘯𝘨 𝘛𝘦𝘤𝘩𝘯𝘰𝘭𝘰𝘨𝘺, I extend the Heideggerian concept of Enframing and standing-reserve into the utilization of neonatal tissue as a resource for biotechnology and as a commodity in general. I proceed with a meticulous moral analysis of this practice employing a synthesis of Kantian and Schopenhauerian moral philosophies. I argue that the practice of using neonatal tissue in this routine, commodified manner constitutes partial murder of the child, theft, and wrongful use, which violates Kantian ethical principles. As such, the use of neonatal foreskin tissue in the current paradigm must be abandoned.

Child Genital Cutting as an Adverse Childhood Experience

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Aug 2019

This white paper presents compelling evidence that child genital cutting (CGC)-in its myriad forms performed on males, females, and intersex children-is a known early trauma. As such it is also an Adverse Childhood Experience (ACE). More than a million children in the United States continue to suffer from CGC annually; many go on to experience repercussions, some lasting for years or even decades. Yet CGC is not included in the ACE questionnaire, while less frequent and possibly less traumatic experiences are. Consequently, victims of CGC are being ignored by the ACEs' community. To solve this, we have created this paper and AdverseChildhoodExperiences.net, which together alert health authorities and researchers to this omission and propose a minor addition to the popular ACE questionnaire.

Alexithymia and Circumcision Trauma: A Preliminary Investigation

Article

Full-text available

May 2011

This preliminary study investigates what role early trauma might have in alexithymia acquisition for adults by controlling for male circumcision. Three hundred self-selected men were administered the Toronto Twenty-Item Alexithymia Scale checklist and a personal history questionnaire. The circumcised men had age-adjusted alexithymia scores 19.9 percent higher than the intact men; were 1.57 times more likely to have high alexithymia scores; were 2.30 times less likely to have low alexithymia scores; had higher prevalence of two of the three alexithymia factors (difficulty identifying feelings and difficulty describing feelings); and were 4.53 times more likely to use an erectile dysfunction drug. Alexithymia in this population of adult men is statistically significant for having experienced circumcision trauma and for erectile dysfunction drug use.

Sexual Dysfunctions and Difficulties in Denmark: Prevalence and Associated Sociodemographic Factors

Article

Full-text available

Feb 2010
ARCH SEX BEHAV

Sexual dysfunctions and difficulties are common experiences that may impact importantly on the perceived quality of life, but prevalence estimates are highly sensitive to the definitions used. We used questionnaire data for 4415 sexually active Danes aged 16-95 years who participated in a national health and morbidity survey in 2005 to estimate the prevalence of sexual dysfunctions and difficulties and to identify associated sociodemographic factors. Overall, 11% (95% CI, 10-13%) of men and 11% (10-13%) of women reported at least one sexual dysfunction (i.e., a frequent sexual difficulty that was perceived as a problem) in the last year, while another 68% (66-70%) of men and 69% (67-71%) of women reported infrequent or less severe sexual difficulties. Estimated overall frequencies of sexual dysfunctions among men were: premature ejaculation (7%), erectile dysfunction (5%), anorgasmia (2%), and dyspareunia (0.1%); among women: lubrication insufficiency (7%), anorgasmia (6%), dyspareunia (3%), and vaginismus (0.4%). Highest frequencies of sexual dysfunction were seen in men above age 60 years and women below age 30 years or above age 50 years. In logistic regression analysis, indicators of economic hardship in the family were positively associated with sexual dysfunctions, notably among women. In conclusion, while a majority of sexually active adults in Denmark experience sexual difficulties with their partner once in a while, approximately one in nine suffer from frequent sexual difficulties that constitute a threat to their well-being. Sexual dysfunctions seem to be more common among persons who experience economic hardship in the family.

Male circumcision for HIV prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya

Article

Sep 2008
B WORLD HEALTH ORGAN

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.

Cortical evoked responses from the perineal nerve

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Sep 1999

Adult circumcision and male sexual health: A retrospective analysis

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Apr 2013
ANDROLOGIA

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.

Prevalence and Correlates of Premature Ejaculation in a Primary Care Setting: A Preliminary Cross-Sectional Study

Article

Apr 2011
J SEX MED

Premature ejaculation (PE) is common. However, it has been underreported and undertreated. To determine the prevalence of PE and to investigate possible associated factors of PE. This cross-sectional study was conducted at a primary care clinic over a 3-month period in 2008. Men aged 18-70 years attending the clinic were recruited, and they completed self-administered questionnaires that included the Premature Ejaculation Diagnostic Tool (PEDT), International Index of Erectile Function, sociodemography, lifestyle, and medical illness. The operational definition of PE included PE and probable PE based on the PEDT. Prevalence of PE. A total of 207 men were recruited with a response rate of 93.2%. There were 97 (46.9%) Malay, 57 (27.5%) Chinese, and 53 (25.6%) Indian, and their mean age was 46.0 ± 12.7 years. The prevalence of PE was 40.6% (N = 82) (PE: 20.3%, probable PE: 20.3% using PEDT). A significant association was found between ethnicity and PE (Indian 49.1%, Malay 45.4%, and Chinese 24.6%; χ(2) = 8.564, d.f. = 2, P = 0.014). No significant association was found between age and PE. Multivariate analysis showed that erectile dysfunction (adjusted odds ratio [OR] 4.907, 95% confidence interval [CI] 2.271, 10.604), circumcision (adjusted OR 4.881, 95% CI 2.346, 10.153), sexual intercourse ≤5 times in 4 weeks (adjusted OR 3.733, 95% CI 1.847, 7.544), and Indian ethnicity (adjusted OR 3.323, 95% CI 1.489, 7.417) were predictors of PE. PE might be frequent in men attending primary care clinics. We found that erectile dysfunction, circumcision, Indian ethnicity, and frequency of sexual intercourse of ≤5 times per month were associated with PE. These associations need further confirmation.

Impotence and adult circumcision

Article

Apr 1973
J NATL MED ASSOC

J M Stinson

Effect of neonatal circumcision on pain response during subsequent routine vaccination

Article

Apr 1997

Preliminary studies suggested that pain experienced by infants in the neonatal period may have long-lasting effects on future infant behaviour. The objectives of this study were to find out whether neonatal circumcision altered pain response at 4-month or 6-month vaccination compared with the response in uncircumcised infants, and whether pretreatment of circumcision pain with lidocaine-prilocaine cream (Emla) affects the subsequent vaccination response. We used a prospective cohort design to study 87 infants. The infants formed three groups--uncircumcised infants, and infants who had been randomly assigned Emla or placebo in a previous clinical trial to assess the efficacy of Emla cream as pretreatment for pain in neonatal circumcision. Infants were videotaped during vaccination done at the primary care physician's clinic. Videotapes were scored without knowledge of circumcision or treatment status by a research assistant who had been trained to measure infant facial action, cry duration, and visual analogue scale pain scores. Birth characteristics and infant characteristics at the time of vaccination, including age and temperament scores, did not differ significantly among groups. Multivariate ANOVA revealed a significant group effect (p < 0.001) in difference (vaccination minus baseline) values for percentage facial action, percentage cry time, and visual analogue scale pain scores. Univariate ANOVAs were significant for all outcome measures (p < 0.05): infants circumcised with placebo had higher difference scores than uncircumcised infants for percentage facial action (136.9 vs 77.5%), percentage cry duration (53.8 vs 24.7%), and visual analogue scale pain scores (5.1 vs 3.1 cm). There was a significant linear trend on all outcome measures, showing increasing pain scores from uncircumcised infants, to those circumcised with Emla, to those circumcised with placebo. Circumcised infants showed a stronger pain response to subsequent routine vaccination than uncircumcised infants. Among the circumcised group, preoperative treatment with Emla attenuated the pain response to vaccination. We recommend treatment to prevent neonatal circumcision pain.

Perineal nerve stimulation: Role in penile erection

Article

Mar 1997
INT J IMPOT RES

Ali A. Shafik

The effect of perineal nerve stimulation on penile erection was studied in ten dogs. Through a paraanal incision, the nerve was exposed in the ischiorectal fossa and a bipolar electrode was applied to it. A radiofrequency receiver was implanted subcutaneously in the abdomen. Upon perineal nerve stimulation, the corporeal pressure and EMG activity of the bulbo- and ischiocavernosus muscles increased; penile erection occurred. With increased stimulus frequency up to 80 Hz, the pressure and muscles' response augmented while the latency and duration of response diminished. No further changes occurred above a frequency of 80 Hz (P > 0.05). Response was reproducible indefinitely after an off-time of double the time of the stimulation phase. Penile erection upon perineal nerve stimulation is suggested to be an effect of corporeal pressure elevation resulting from cavernosus muscles' contraction. In terms of force and speed of contraction, a stimulus frequency of 80 Hz evokes the most adequate cavernosus muscles' contraction.

Innervation of the human glans penis

Article

Feb 1999

We demonstrate the innervation of the glans penis through nerve blockade and electrophysiological tests. The study was conducted in 14 healthy, sexually potent volunteers. The dorsal nerves of the penis were anesthetized bilaterally with lidocaine. Electrophysiological testing was performed by stimulating the dorsal nerve of the penis at the penile base distal to the block and recording action potentials at the glans. Dorsal nerve of the penis block resulted in anesthesia of the dorsal, lateral and glanular aspects of the penis. The ventral surface, including the frenulum, was intact to pinprick sensation. Dorsal nerve of the penis stimulation resulted in responses from the corona, dorsal and ventral mid glans, and penile shaft. Frenular responses were less consistently obtained. The most common recorded pattern was a monophasic waveform representing the arrival of a standing potential at a nerve terminal. Latencies were progressively longer with increasing distance from the point of stimulation with the longest latencies measured at the frenulum. Amplitudes of the responses decreased with increasing distance from the point of stimulation. The dorsal nerve of the penis innervates the glans, including the frenulum which is also innervated by a branch of the perineal nerve. Branches of the dorsal nerve of the penis extend through the glans ventrolaterally. Electrical representation of glanular innervation reveals the glans to be filled with nerve endings supporting its function as a sensory structure.