original research  
Psychological and sexual effects of circumcision in adult males  
1
2
3
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5
Yasin Aydogmus, MD; Murat Semiz, MD; Okan Er, MD; Okan Bas, MD; Irfan Atay, MD;  
Muhammet Fatih Kilinc, MD6  
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2
3
Department of Urology, Etimesgut Military Hospital, Ankara, Turkey; Department of Psychiatry, Gulhane Military Medical Academy, Ankara, Turkey; Department of Psychiatry, Etimesgut Military Hospital,  
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5
Ankara, Turkey; Department of Urology, Abdurrahman Yurtaslan Oncology Education and Research Hospital, Ankara, Turkey; Department of Urology, Health Centre of Airforce Military Academy, Istanbul,  
Turkey; Department of Urology, Ankara Training and Research Hospital, Ankara, Turkey  
6
Cite as: Can Urol Assoc J 2016;10(5-6):E156-60. http://dx.doi.org/10.5489/cuaj.3364  
Published online May 12, 2016.  
most Muslim and Jewish countries, and it is also frequently  
performed in Middle-Eastern countries, as well as in the  
2-4  
U.S. World Health Organization reported that 30% of men  
worldwide and most Muslim men have been circumcised.5  
Circumcision has historical, religious, and cultural impor-  
tance, as well as psychological significance. It was reported  
that circumcision might have positive effects on mental  
health, may contribute father-son empathy, and activate  
,6  
Abstract  
Introduction: Our aim was to investigate the psychological and  
sexual effects of circumcision in adult men, and analyze these  
changes following circumcision.  
Methods: We included 37 adults who applied to our clinic for  
circumcision and who did not have any psychiatric or urologic  
disorders and age-matched 30 controls in our study. Body Cathexis  
Scale (BCS), Liebowitz Social Anxiety Scale (LSAS), and Premature  
Ejaculation Diagnostic Tool (PEDT) were applied to the study group  
twice, once before and once three months after circumcision, and  
only once in the control group. Also, intravaginal ejaculation laten-  
cy time (IELT) was noted and premature ejaculation (PE) evaluation  
was done. Intra- and intergroup comparisons were performed.  
Results: The two groups were similar with regard to demograph-  
ic data. Comparison of preoperative BCS and LSAS scores with  
the scores of the control group showed significant differences  
7
masculine drives in children.  
Premature ejaculation (PE) is one of the most common  
sexual disorders among the male population. It affects about  
2
by McMahon et al.  
030% of all men. Up-to-date, lifelong PE has been defined  
8
We hypothesized that adult circumcision may change body  
image and social anxiety of the individual, and may affect  
ejaculation time and sexual satisfaction. Our hypothesis is  
based on the values of circumcision in the Turkish population.  
Methods  
(
p=0.003, p<0.001, and p<0.001, respectively). However, post-  
operative scores were similar to the scores obtained in the con-  
trol group (p=0.768, p>0.05, and p>0.05, respectively). Scores  
of all scales showed significant improvements postoperatively.  
Also, PEDT scores and IELT changes before and after circumci-  
sion were significant in the study group, but not when compared  
to the control group.  
Conclusions: Our results indicated that social anxiety and anxiety  
levels decreased after circumcision in adult Turkish men, and their  
body gratification increased. We found that not being circumcised  
might negatively affect individuals in adulthood when it comes to  
body image and sexual satisfaction, however, both improve after  
circumcision.  
A total of 37 men aged over 18 years admitted to our clin-  
ic for circumcision were included in the study, following  
an ethical committee approval. Individuals with a known  
psychotic disorder, mental retardation, systemic disorder,  
erectile dysfunction, congenital penile shape deformity, and  
previous penile surgery were excluded. The control group  
consisted of 30 age-matched healthy individuals who had  
circumcision performed in childhood.  
Procedure  
1
. Before circumcision, a psychiatrist examined the indi-  
viduals included in the study for psychotic disorders and  
mental retardation and an urologist evaluated them for  
ejaculation and circumcision.  
Introduction  
Circumcision has been performed since ancient times.  
Ancient depictions show that Australian Aborigines, Incas,  
Aztecs, Mayas, and ancient Egyptians performed circum-  
2. The psychiatrist applied Body Cathexis Scale (BCS) and  
Liebowitz Social Anxiety Scale (LSAS); the urologist  
applied Premature Ejaculation Diagnostic Tool (PEDT)  
to the individuals and evaluated them for PE. The indi-  
1
cision. Circumcision is performed as a religious ritual in  
E156  
CUAJ • May-June 2016 • Volume 10, Issues 5-6  
2016 Canadian Urological Association  
©
Pꢀyꢁꢂꢃꢄꢃꢅꢆꢁꢇꢄ ꢇꢈd ꢀꢉxuꢇꢄ ꢉffꢉꢁtꢀ ꢃf ꢁꢆꢊꢁumꢁꢆꢀꢆꢃꢈ  
viduals self-reported Intravaginal Ejaculation Latency  
Times (IELT) of <1min were approved as PE according  
to McMahon et al.  
Statistical analysis  
8
Pre- and post-circumcision data of the study group were  
compared with the control group data. In addition, pre- and  
post-circumcision data were compared. SPSS 16.0 package  
program was used for data analysis. Normality of distribution  
was analyzed with Kolmogorov-Smirnov and Shapiro-Wilk  
tests. Independent samples t-test was used for pairwise com-  
parisons and paired samples t-test was used for comparison  
of pre- and post-circumcision data in the groups with a  
normal distribution. Pairwise comparisons of the groups that  
did not show normal distributions were done with Mann  
Whitney U test, while Wilcoxon test was used to compare  
pre- and post- circumcision data in those groups. A p value  
<0.05 was considered statistically significant.  
3
. Medical circumcision was performed under local anes-  
thesia. The patients were discharged from the hospital,  
and called for a followup three months later.  
. Three months after the circumcision, evaluation  
described in item (2) was applied to the study group.  
. Evaluation described in item (2) was applied to the con-  
trol group once.  
4
5
Age, marital status, education level, and place of living  
of the participants were noted. They were asked, “Did you  
want to be circumcised before?” and “Do you think circum-  
cision is necessary in your religion?”  
The scales below were applied to the study group twice,  
once before and once three months after circumcision,  
under the supervision of the psychiatrist and urologist.  
Results  
Scales  
The data on age, marital status, education level, and the  
religious need for circumcision of the groups are summa-  
rized in Table 1. The two groups had similar demographic  
characteristics.  
Body Cathexis Scale (BCS)  
BCS is a five-point Likert scale described in 1953, and it  
consists of 40 questions. In the scale, 1 indicates “extremely  
Only the individuals in the study group were asked  
whether they wanted to be circumcised before. Thirty-four  
of the individuals replied to this question with “Yes,” two  
replied “No,” and one replied “It does not matter.” We  
learned that the reason of the three individuals responding  
to this question as “No” or “It does not matter” was associ-  
ated with religion. These three individuals were Christian  
and only wanted to be circumcised after they had changed  
their religion to Muslim. Pre- and post-circumcision body  
image and social anxiety were not found different in those  
individuals. Statistical analysis of the latter subjects could  
not be performed due to low sample size.  
9
satisfied” and 5 indicates “extremely dissatisfied.” We used  
1
0
the validated Turkish version of the scale in our study.  
We analyzed the questions 30, 35, and 40 separately due to  
their emphasis on sexuality. Those were “my sexual potency,”  
“my sexual activities,” and “my sex organ,” respectively.  
Liebowitz Social Anxiety Scale (LSAS)  
LSAS was prepared to measure healthy people and patients’ fear  
and avoidance levels in case of social interaction and perfor-  
mance. It contains two subscales, anxiety and avoidance. Each  
section consists of 24 items. LSAS is a four- point Likert scale;  
Table 2 shows the BCS, total scores of questions 30, 35,  
and 40; scores of anxiety and avoidance subscales of LSAS;  
and the total scores of questions 4 and 24 in anxiety and  
1
used the validated Turkish version of LSAS in our study.  
indicates “none/occasionally,” and 4 indicates “severe.” We  
11  
Questions 4 and 24 in LSAS were analyzed separately  
due to the emphasis on sexual organs. Those were “trying to  
make someone’s acquaintance for the purpose of a romantic/  
sexual relationship” and “urinating in a public bathroom,”  
respectively.  
Table 1. Demographic data of two groups  
Study  
n=37  
Control  
n=30  
p value  
0130  
2
(20-27)  
2±±1.  
23±213  
(20-2.)  
Age  
Married  
Single  
4
5
25  
4
Martial status  
0149  
Premature Ejaculation Diagnostic Tool (PEDT)  
33  
3
Primary  
Seconday  
University  
Village  
Education  
PEDT was developed by Symonds for the systematical  
diagnosis of PE.12 We used the Turkish validated version  
29  
5
2±  
5
01..  
(School level)  
1
3
of PEDT developed by Serefoglu. PEDT consists of five  
items: control, frequency, minimal stimulation, distress, and  
interpersonal difficulty. Sensitivity and specificity analyses  
suggested a score of 8 indicates no PE, 9 and 10 indicate  
probable PE, and 11 indicates PE.  
±0  
27  
34  
.
Living place  
0197  
01±±  
City  
22  
30  
Is circumcision Yes  
a religious  
No  
3
0
requirement?  
CUAJ • May-June 2016 • Volume 10, Issues 5-6  
E157  
aydꢃꢅmuꢀ ꢉt ꢇꢄ.  
Discussion  
avoidance subscales. Pre-circumcision BCS and LSAS of the  
study and the control groups showed significant differences.  
However, post-circumcision scores and control group scores  
were similar. There were significant reductions between pre-  
and post-circumcision scores for both BCS and LSAS, and  
also in the mean scores of the items with a sexual content  
in BCS and LSAS.  
PE was seen in 32% of the preoperative study group, 22%  
of the postoperative study group, and 23% of controls. There  
was no significant difference between pre- and postoperative  
study group and control group for PEDT scores, IELT, values  
and presence of PE. When pre-and postoperative values  
were compared, there was significant improvement of the  
PEDT scores, IELT values, and presence of PE (Tables 2, 3).  
Several studies have been conducted on the effects of cir-  
cumcision on erection, ejaculation, sexual disorders, and  
urogenital infections.  
sion affected PE. He showed that circumcision performed  
after seven years of age increased risk for future PE when  
compared to those having the procedure at an earlier age.19  
Collins and Tian reported that adult circumcision did not  
have any effects on male sexual life in terms of erection,  
1
4-18  
Cuceloglu reported that circumci-  
1
4,20  
ejaculation, or overall satisfaction.  
Most of these studies  
were performed in patients circumcised in childhood. Our  
results showed that there were no significant differences  
between pre-and postoperative study group and control  
group. However comparisons of pre-circumcision and post-  
circumcision had significant difference for PEDT scores, IELT  
values, and presence of PE. In addition, evaluation of the  
items of sexuality in BCS and LSAS showed circumcision  
improved the sexual satisfaction in the study group.  
Table 2. Scores before and after circumcision  
Although some studies in the literature investigated the  
physical effects of adult circumcision, no recent study inves-  
tigated its psychological effects. Further, studies have most-  
ly focused on circumcision performed in childhood. One  
study showed that both medical and traditional circumcision  
increased the risk for anxiety disorder. However, traditional  
Study  
n=37  
p
value  
Control  
n=30  
p
1
value2  
Before  
circumcision  
.019 ± ±21±  
(5±–±02)  
<
010±  
7214 ± ±0  
(47–90)  
BCS  
BCS  
<010±  
<010±  
After  
circumcision  
731± ± ±012  
(5±–99)  
0
177  
Before  
circumcision  
.16 ± 212  
(3–±2)  
21  
<
010±  
circumcision carried more risk for anxiety. A review by  
415 ± ±13  
(3–7)  
(questions  
Yavuz et al hypothesized that circumcision might not affect  
children negatively due to: 1) the positive view attributed to  
circumcision in the community; 2) performing circumcision  
at an age when the child could appreciate circumcision and  
its consequences; and 3) most of the people in the com -  
After  
circumcision  
414 ± 019  
(3–6)  
30-35-40)  
01.9  
010±  
Before  
circumcision  
3.15 ± .1±  
(25–59)  
<
LSAS:  
Anxiety  
321. ± 51.  
(24–44)  
<
<
<
<
010±  
010±  
010±  
010±  
After  
circumcision  
301. ± 61±  
(24–45)  
0
1±.  
2
2
munity had been circumcised. This is supported by the  
argument that advises to perform circumcision at an age  
when the child could make his own decisions, since the  
child perceives it as a threat.  
LSAS:  
Anxiety  
Before  
circumcision  
419 ± ±15  
(2–.)  
<
<
<
010±  
216 ± 016  
(2–4)  
(questions  
After  
circumcision  
216 ± 016  
(2–4)  
0
165  
4-24)  
Social anxiety disorder (SAD) is an anxiety disorder in  
which the individual continuously carries the fear that he/she  
will be embarrassed, humiliated, and considered ridiculous  
Before  
circumcision  
4±13 ± .12  
(27–63)  
010±  
LSAS:  
Avoidance  
3413 ± 515  
(25–46)  
After  
circumcision  
3213 ± 614  
(25–4.)  
23  
0
1±7  
or clumsy in social situations and avoids them. Individuals  
with SAD have significantly worse body image and self-  
LSAS:  
Before  
Avoidance circumcision  
After  
circumcision  
512 ± ±14  
(2–.)  
010±  
24  
confidence compared to healthy controls. Body image is  
313 ± ±1±  
(2–6)  
(questions  
313 ± 017  
(2–5)  
a multidimensional concept involving perception, attitudes,  
0
145  
4-24)  
Before  
circumcision  
7717 ± 5217  
(0–±.0)  
Table 3. Premature ejaculation (IELT <1min–Yes; IELT  
7
5615  
91. ±  
0193  
013.  
>1min–No) before and after circumcision  
IELT  
<010±  
<010±  
After  
circumcision  
.514 ± 4717  
(0–±.0)  
(0–240)  
Study  
n=37  
p
Control  
n=30  
p
value1  
value2  
Before  
circumcision  
913 ±51.  
(0–20)  
Before  
Premature circumcision  
No=25;  
Yes=±2  
0
169  
169  
0
142  
1.7  
.16 ± 414  
(±–20)  
No=23;  
Yes=7  
PEDT  
<0.05  
After  
circumcision  
719 ± 512  
(0–20)  
ejaculation  
After  
No=29;  
Yes=.  
0
0
circumcision  
Analysis before and after circumcision (study group); Comparisons of (study group before  
±
2
Analysis before and after circumcision (study group); Comparison of (study group before  
±
2
circumcision vs1 control group) & (study group after circumcision vs1 control group); BCS:  
Body Cathexis Scale; IELT: intravaginal ejaculation latency time; LSAS: Liebowitz Social  
Anxiety Scale; PEDT: Premature Ejaculation Diagnostic Tool1  
circumcision vs1 control group) & (study group after circumcision vs1 control group); IELT:  
intravaginal ejaculation latency time1  
E158  
CUAJ • May-June 2016 • Volume 10, Issues 5-6  
Pꢀyꢁꢂꢃꢄꢃꢅꢆꢁꢇꢄ ꢇꢈd ꢀꢉxuꢇꢄ ꢉffꢉꢁtꢀ ꢃf ꢁꢆꢊꢁumꢁꢆꢀꢆꢃꢈ  
thoughts, beliefs, feelings, and behaviour of the individual.  
It may be defined as the picture of one’s own body in one’s  
contributes to psychosocial and sexual well-being of indi-  
viduals in adulthood.  
2
5,26  
own mind.  
Individuals with a negative body image are  
known to avoid meeting with new people and being in  
social situations. This pattern of avoidance is common in  
Competing interests: The authors declare no competing ꢀnancial or personal interests.  
2
7,28  
SAD and body dysmorphic disorder.  
Acknowledgment: Ethical Approval was taken according to WMA declaration of Helsinki (Ethical  
Principles for Medical Research Involving Human Subjects) with the paper number of “07.  
Nov.2014.8000-45-14/KAL.GUV.”  
No studies in the literature have investigated the effect of  
adult circumcision on body image and social phobia. Our  
study is the first one. Our study showed significant improve-  
ments on body image and social anxiety levels after adult  
circumcision. Psychoanalytic views have hypothesized that  
preputium was considered as part of the penis and that its  
This paper has been peer-reviewed.  
2
9
removal could cause perception of physical deficiency.  
The varying opinions may be related to different cultures  
and religions of the study population, as well as that of  
investigators. It was reported that the Turkish population did  
not accept absence of circumcision; boys felt ashamed of it  
and perceived their bodies as defective. A similar study per-  
formed on the Turkish population reported that circumcision  
created a social stress and children did not feel themselves as  
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Conclusion  
As far as we know, no recent studies investigated both psy-  
chological and sexual effects of adult circumcision. Our  
results indicated psychosocial and physical negative effects  
in adult age when circumcision is not performed in child-  
hood; however these negative effects can be improved after  
circumcision, even if it occurs in adulthood. Also, circum-  
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1
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Correspondence: Dr. Yasin Aydogmus, Etimesgut Military Hospital, Ankara, Turkey;  
yasinaydogmus@gmail.com  
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CUAJ • May-June 2016 • Volume 10, Issues 5-6  

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