original research

Psychological and sexual effects of circumcision in adult males

Yasin Aydogmus, MD; Murat Semiz, MD; Okan Er, MD; Okan Bas, MD; Irfan Atay, MD;

Muhammet Fatih Kilinc, MD⁶

Department of Urology, Etimesgut Military Hospital, Ankara, Turkey; Department of Psychiatry, Gulhane Military Medical Academy, Ankara, Turkey; Department of Psychiatry, Etimesgut Military Hospital,

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

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

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

masculine drives in children.

Premature ejaculation (PE) is one of the most common

sexual disorders among the male population. It affects about

by McMahon et al.

0‒30% of all men. Up-to-date, lifelong PE has been deﬁned

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

. 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-

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

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.

. 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.

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.

satisﬁed” and 5 indicates “extremely dissatisﬁed.” We used

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

used the validated Turkish version of LSAS in our study.

indicates “none/occasionally,” and 4 indicates “severe.” We

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

(20-27)

2±±1.

23±213

(20-2.)

Age

Married

Single

Martial status

0149

Premature Ejaculation Diagnostic Tool (PEDT)

Primary

Seconday

University

Village

Education

PEDT was developed by Symonds for the systematical

diagnosis of PE.¹²We used the Turkish validated version

2±

01..

(School level)

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

Living place

0197

01±±

City

Is circumcision Yes

a religious

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,

4-18

Cuceloglu reported that circumci-

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

value

Control

n=30

value²

Before

circumcision

.019 ± ±21±

(5±–±02)

010±

7214 ± ±0

(47–90)

BCS

<010±

After

circumcision

731± ± ±012

(5±–99)

177

Before

circumcision

.16 ± 212

(3–±2)

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±

After

circumcision

301. ± 61±

(24–45)

1±.

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)

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.)

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±

conﬁdence compared to healthy controls. Body image is

313 ± ±1±

(2–6)

(questions

313 ± 017

(2–5)

a multidimensional concept involving perception, attitudes,

145

4-24)

Before

circumcision

7717 ± 5217

(0–±.0)

Table 3. Premature ejaculation (IELT <1min–Yes; IELT

5615

91. ±

0193

013.

>1min–No) before and after circumcision

IELT

<010±

After

circumcision

.514 ± 4717

(0–±.0)

(0–240)

Study

n=37

Control

n=30

_v_a_l_u_e1

_v_a_l_u_e2

Before

circumcision

913 ±51.

(0–20)

Before

Premature circumcision

No=25;

Yes=±2

169

142

1.7

.16 ± 414

(±–20)

No=23;

Yes=7

PEDT

<0.05

After

circumcision

719 ± 512

(0–20)

ejaculation

After

No=29;

Yes=.

circumcision

Analysis before and after circumcision (study group); Comparisons of (study group before

Analysis before and after circumcision (study group); Comparison of (study group before

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.

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.

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.

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

References

Remondino P. History of Circumcision from the earliest times to the present. Honolulu, Hawaii: University

Press of the Paciꢀc; 2001.

Dekkers W, Hoffer C, Wils JP. Bodily integrity and male and female circumcision. Med Health Care Philos

005;8:179-91. http://dx.doi.org/10.1007/s11019-004-3530-z

Dunsmuir WD, Gordon EM. The history of circumcision. BJU Int 1999;83:1-12. http://dx.doi.

org/10.1046/j.1464-410x.1999.0830s1001.x

Introcaso CE, Xu F, Kilmarx PH, et al. Prevalence of circumcision among men and boys aged 14 to

0,31

true males without circumcision.

Apart from Muslims, it

was reported that Jewish children also considered circumci-

sion as blessed and culturally important and did not regard

9 years in the U.S., National Health and Nutrition Examination Surveys 2005-2010. Sex Transm Dis

013;40:521-5. http://dx.doi.org/10.1097/01.OLQ.0000430797.56499.0d

it as a punishment.

WHO. Male circumcision: Global trends and determinants of prevalence, safety and acceptability. 2007;

http://apps.who.int/iris/bitstream/10665/43749/1/9789241596169_eng.pdf. Accessed April

4, 2016.

Homfray V, Tanton C, Mitchell KR, et al. Examining the association between male circumcision and sexual

function: Evidence from a British probability survey. AIDS 2015;29:1411-6. http://dx.doi.org/10.1097/

QAD.0000000000000745

Our results showed that circumcision improved physi-

cal and social perception not only in childhood, but also

in adulthood. After circumcision, our patients change of

answers to the question concerning public bathrooms in

the social phobia scale indicates that they had the anxiety

of lack of circumcision in adulthood and regarded it as a

physical defect.

Signiﬁcant improvements observed in the scores of items

with a sexual content in BCS and LSAS indicated that cir-

cumcision had positive effects in terms of sexual life and

conﬁdence. As we evaluate these ﬁndings with PE effects,

it seems that circumcision improves sexual satisfaction.

Conꢀicting results among the studies for the effect of cir-

cumcision on sexual life may be explained by cultural dif-

ferences.

Nunberg H. Circumcision and the problems of bisexuality. Rev Psicoanal 1952;9:55-122.

McMahon CG, Althof S, Waldinger MD, et al. An evidence-based deꢀnition of lifelong premature ejaculation:

Report of the International Society for Sexual Medicine Ad Hoc Committee for the Deꢀnition of Premature

Ejaculation. BJU Int 2008;102:338-50. http://dx.doi.org/10.1111/j.1464-410X.2008.07755.x

Secord PF, Jourard SM. The appraisal of body-cathexis: Body-cathexis and the self. J Consult Psychol

953;17:343-7. http://dx.doi.org/10.1037/h0060689

0. Selim H. The study of reliability and validity of body cathexis scale: Bachelor’s degree thesis (unpublished)

Ankara: Gazi University 1990.

11. Soykan C, Ozguven HD, Gencoz T. Liebowitz Social Anxiety Scale: The Turkish version. Psychol Rep

003;93:1059-69. http://dx.doi.org/10.2466/PR0.93.8.1059-1069

2. Symonds T, Perelman MA, Althof S, et al. Development and validation of a premature ejaculation diagnostic

tool. Eur Urol 2007;52:565-73. http://dx.doi.org/10.1016/j.eururo.2007.01.028

3. Serefoglu EC, Cimen HI, Ozdemir AT, et al. Turkish validation of the premature ejaculation diagnostic tool

and its association with intravaginal ejaculatory latency time. Int J Impot Res 2009;21:139-44. http://

dx.doi.org/10.1038/ijir.2008.58

As a limitation, we had relatively small sample size due

to the fact that in Turkey, circumcision is most often per-

formed in childhood.

4. Collins S, Upshaw J, Rutchik S, et al. Effects of circumcision on male sexual function: Debunking a myth?

J Urol 2002;167:2111-2. http://dx.doi.org/10.1016/S0022-5347(05)65097-5

5. Shen Z, Chen S, Zhu C, et al. Erectile function evaluation after adult circumcision. Zhonghua Nan Ke

Xue 2004;10:18-9.

6. Yang MH, Tsao CW, Wu ST, et al. The effect of circumcision on young adult sexual function. Kaohsiung

J Med Sci 2014;30:305-9. http://dx.doi.org/10.1016/j.kjms.2013.10.004

7. Zhang SJ, Zhao YM, Zheng SG, et al. Correlation between premature ejaculation and redundant prepuce.

Zhonghua Nan Ke Xue 2006;12:225-7.

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-

cision can improve sexual satisfaction. Being circumcised

8. Houle AM. Circumcision for all: The pro side. Can Urol Assoc J 2007;1:398-400.

9. Cuceloglu EA, Hosrik ME, Ak M, et al. The effects of age at circumcision on premature ejaculation. Turk

Psikiyatri Derg 2012;23:99-107. http://dx.doi.org/10.5080/u6601

20. Tian Y, Liu W, Wang JZ, et al. Effects of circumcision on male sexual functions: A systematic review and

meta-analysis. Asian J Androl 2013;15:662-6. http://dx.doi.org/10.1038/aja.2013.47

CUAJ • May-June 2016 • Volume 10, Issues 5-6

E159

aydꢃꢅmuꢀ ꢉt ꢇꢄ.

1. Watson CG, Juba MP, Manifold V, et al. The PTSD interview: Rationale, description, reliability, and

concurrent validity of a DSM-III-based technique. J Clin Psychol 1991;47:179-88. http://dx.doi.

org/10.1002/1097-4679(199103)47:2<179::AID-JCLP2270470202>3.0.CO;2-P

2. Yavuz M, Demir T, Dogangun B. The effect of circumcision on the mental health of children: A review.

Turk Psikiyatri Derg 2012;23:63-70.

3. Kerns CE, Comer JS, Pincus DB, et al. Evaluation of the proposed social anxiety disorder speciꢀer change

for DSM-5 in a treatment-seeking sample of anxious youth. Depress Anxiety 2013;30:709-15. http://

dx.doi.org/10.1002/da.22067

4. Izgic F, Akyuz G, Dogan O, et al. Social phobia among university students and its relation to self-esteem

and body image. Can J Psychiatry 2004;49:630-4.

5. Cash TF. Body image: Past, present, and future. Body Image 2004;1:1-5. http://dx.doi.org/10.1016/

S1740-1445(03)00011-1

27. Doğan T, Sapmaz F, Totan T. Adaptation of the body image coping strategies inventory to Turkish:

A validity and reliability study. Anadolu Psikiyatri Derg 2011;12:121-9.

28. Levinson CA, Rodebaugh TL, White EK, et al. Social appearance anxiety, perfectionism, and fear of negative

evaluation: Distinct or shared risk factors for social anxiety and eating disorders? Appetite 2013;67:125-

33. http://dx.doi.org/10.1016/j.appet.2013.04.002

29. Gollaher DL. Circumcision: A history of the world’s most controversial surgery: Basic Books; 2001.

30. Ozturk OM. Ritual circumcision and castration anxiety. Psychiatry 1973;36:49-60.

31. Sahin F, Beyazova U, Akturk A. Attitudes and practices regarding circumcision in Turkey. Child Care Health

Dev 2003;29:275-80. http://dx.doi.org/10.1046/j.1365-2214.2003.00342.x

Correspondence: Dr. Yasin Aydogmus, Etimesgut Military Hospital, Ankara, Turkey;

yasinaydogmus@gmail.com

6. Cohen A. Body image in the person with a stoma. J Enterostomal Ther 1991;18:68-71.

E160

CUAJ • May-June 2016 • Volume 10, Issues 5-6