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Sexual effects of circumcision

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The sexual effects of circumcision are the subject of some debate. Studies have been conducted to investigate whether circumcision has any effect on sexual drive, erectile function, premature and delayed ejaculation, sexual satisfaction, sexual sensation and penile sensitivity. Studies have also assessed whether circumcision affects masturbation or other sexual practices, and whether a heterosexual woman's experience of sex is affected by her partner's circumcision status.

The American Academy of Pediatrics (2012) stated that published literature on circumcision "does not support the belief that male circumcision adversely affects penile sexual function or sensitivity, or sexual satisfaction, regardless of how these factors are defined."[1] The American Academy of Family Physicians (2007) stated "The effect of circumcision on penile sensation or sexual satisfaction is unknown. Because the epithelium of a circumcised glans becomes cornified, and because some feel nerve over-stimulation leads to desensitization, many believe that the glans of a circumcised penis is less sensitive. [...] No valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction."[2]

Penile sensitivity and sexual sensation

Results of studies of the effect on penile sensitivity have been mixed. In a British study of 150 men circumcised as adults for penile problems, Masood et al. found that 38% reported improved penile sensation (p=0.01), 18% reported worse penile sensation, while the remainder (44%) reported no change.[3]

In a 2008 study of Kenyan men, Krieger et al. stated that "Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm."[4] In a 2009 study of 22 men in Mexico circumcised for medical or aesthetic reasons, Cortés-González et al. reported a statistically significant improvement in "perception of sexual events" (p=0.04).[5]

Glans sensitivity

A number of studies have looked at the question of whether sensitivity of the glans is affected by circumcision.

In a position statement first published in 2002 and reaffirmed in January 2007, The American Academy of Family Physicians (AAFP) stated "The effect of circumcision on penile sensation or sexual satisfaction is unknown. Because the epithelium of a circumcised glans becomes cornified, and because some feel nerve over-stimulation leads to desensitization, many believe that the glans of a circumcised penis is less sensitive. Opinions differ about how this decreased sensitivity, which may result in prolonged time to orgasm, affects sexual satisfaction. An investigation of the exteroceptive and light tactile discrimination of the glans of circumcised and uncircumcised men found no difference on comparison. No valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction." [2]

Bleustein et al. (2005) divided 125 patients (62 uncircumcised men and 63 neonatally circumcised men) into groups based on their sexual dysfunction using the IIEF(International Index of Erectile Function). Twenty-nine were placed in the functional group, and 96 in the dysfunctional group. Quantitative somatosensory testing (including vibration, pressure, spatial perception, and warm and cold thermal thresholds) was used on the dorsal midline glans of the penis. In the dysfunctional group, circumcised men (49 +/- 16 years) were significantly younger (P <0.01) than noncircumcised men (56 +/- 13 years). When controlling for age, hypertension, and diabetes, there was no difference in sensitivity. Bleustein et al. did not test the sensation of the foreskin nor did he compute the loss of sensation from the foreskin caused by circumcision.[6]

Sorrells et al. (2007) measured the fine-touch pressure thresholds of 91 circumcised and 68 noncircumcised, live adult male volunteers, They reported "[the] glans of the uncircumcised men had significantly lower mean (sem) pressure thresholds as measured at three points than that of the circumcised men, at 0.161 (0.078) g (P = 0.040) when controlled for age, location of measurement, type of underwear worn, and ethnicity."[7] In a letter to BJU International, however, on the basis of the unadjusted data, Waskett & Morris (2007) stated "we find no significant differences [...], consistent with previous findings."[8] However, in a further letter to BJU International, Young (2007) responded to Waskett & Morris, stating that Sorrells et al. found that one point, at least, on the glans of the circumcised penis was less sensitive than that of the intact penis.[9]

Payne et al. (2007), in a study of the glans and shaft sensitivity of twenty circumcised and twenty uncircumcised men, reported that "No differences in genital sensitivity were found between the uncircumcised and circumcised groups." Payne et al. did not test foreskin sensation.[10]

Foreskin sensitivity

Schoen (2007) stated that "anecdotally, some have claimed that the foreskin is important for normal sexual activity and improves sexual sensitivity. Objective published studies over the past decade have shown no substantial difference in sexual function between circumcised and noncircumcised men."[11]

Sorrells et al. (2007), in the study discussed above, measured fine-touch pressure thresholds of the penis, and concluded "The transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. Circumcision ablates" (removes) "the most sensitive parts of the penis." According to Sorrells et al., the five penile areas most sensitive to fine-touch are located on the foreskin.[7] This is disputed by Waskett & Morris, (2007) who argue that when they re-analyse Sorrells' data, no significant differences are found; that light touch is only one form of sensitivity, and that sexual pleasure may sometimes require less sensitivity. They also criticized Sorrells' recruitment methods.[8] In response, Young (2007) criticizes Waskett & Morris's use of the Bonferroni correction and argues that the methods of selecting subjects would not affect the results, that the two most sensitive positions on the circumcised penis represent small areas of circumcision scar, as compared to a much larger area of sensitive tissue on the foreskin, and that sales of sensation-dulling products do not necessarily indicate that such are widely used other than on scar tissue.[9]

The College of Physicians and Surgeons of British Columbia (2009) has written that the foreskin "is rich in specialized sensory nerve endings and erogenous tissue."[12] The Royal Australasian College of Physicians (2010) states that "the foreskin is a primary sensory part of the penis, containing some of the most sensitive areas of the penis. The effects of circumcision on sexual sensation however are not clear, with reports of both enhanced and diminished sexual pleasure following the procedure in adults and little awareness of advantage or disadvantage in those circumcised in infancy."[13] The Royal Dutch Medical Association states that many sexologists view the foreskin as "a complex, erotogenic structure that plays an important role ‘in the mechanical function of the penis during sexual acts, such as penetrative intercourse and masturbation’."[14]

Erectile function

Reports detailing the effect of circumcision on erectile dysfunction have been mixed. Studies have variously found a statistically significant increase,[citation needed] or decrease,[5][15] in erectile dysfunction among circumcised men, while other studies have shown little to no effect.[3][16][17][18]

Kim and Pang reported no significant difference in erection.[18]

Cortés-González et al. reported a statistically significant improvement in erectile function following circumcision (p=0.0007).[5]

Frisch et al. found no statistically significant differences in erectile function between circumcised and uncircumcised men.[19]

Ejaculatory function

Waldinger et al. recruited 500 men (98 circumcised and 261 not-circumcised) from five countries: the Netherlands, United Kingdom, Spain, Turkey, and the United States and studied their ejaculation times during sexual intercourse. They found that the circumcised men in the study took on average 6.7 minutes to ejaculate, compared with 6.0 minutes for the uncircumcised men. This difference was not statistically significant. The comparison excluded Turkey, which was significantly different from the other countries studied.[20] Commenting on the study, Sorrells et al. said "Turkish men, the vast majority of whom are circumcised, had the shortest IELT [Intravaginal ejaculation latency time]."[7]

In a study of men circumcised for benign disease, Masood et al. (2005) reported that of those who stated they had prior premature ejaculation, 13% reported improvement after circumcision, 33% reported that it became worse, and 53% reported no change.[3]

In a telephone survey (2006) of 10,173 Australian men, 22% of uncircumcised men and 26% of circumcised men reported reaching orgasm too quickly for at least one month in the previous year. The difference was not statistically significant.[15]

In a study (2006) of 255 circumcised men and 118 uncircumcised men, Kim and Pang reported no statistically significant difference in ejaculation or ejaculation latency time between circumcised and uncircumcised participants.[18]

Kigozi et al. (2007) reported that, in a randomised controlled trial of 4,456 men of whom 2,474 were selected to be circumcised, the authors did not find a statistically significant effect on premature ejaculation.[17]

Krieger et al. (2007) reported on a randomised controlled trial of 2,784 participants, of whom 1,391 were randomised to be circumcised. 54.5% of circumcised men described their ease of reaching orgasm as "much more" at 24 months after randomisation.[16]

In a study of 22 men circumcised as adults, Cortés-González et al. (2009) reported that 31.8% suffered from premature ejaculation before the procedure; this diminished to 13.6% afterwards.[5]

Frisch et al. (2011) studied participants in a Danish national health survey, and found that circumcised men were equally likely to report "occasional" orgasm difficulties (29% v 32%), but were more likely to report "frequent" orgasm difficulties (11% v 4%); the difference remained after adjustment for potential confounding factors. Premature ejaculation was not associated with circumcision status.[19]

Sexual practice and masturbation

In a study by Korean researchers of 255 men circumcised after the age of 20 and 18 who were not circumcised, Kim and Pang reported that masturbatory pleasure decreased in 48% of the respondents and increased in 8%. Masturbatory difficulty increased in 63% but was easier in 37%. They concluded that there was a decrease in masturbatory pleasure after circumcision.[18]

Sexual drive

Several studies have investigated the effect of circumcision on sexual drive. Studies that did not find a statistically significant difference include Kim and Pang,[18] Cortés-González et al.,[5] and Frisch et al.[19]

Satisfaction

Kim and Pang found that 20% reported that their sex life was worse after circumcision and 6% reported that it had improved. They concluded that "there was a decrease ... sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings."[18]

Masood et al., in their study mentioned earlier of men circumcised for benign disease, found that 61% reported satisfaction with the results, while 17% felt it made things worse, and 22% expressed neutral sentiments. 44% of the patients (p = 0.04) and 38% of the partners (p = 0.02) thought the penis appearance improved after circumcision. The authors of the study concluded that the satisfaction rate was a 'poor outcome,' given the pre-procedure penile disease state and recommended discussing with prospective patients the results of this study during the informed consent process.[3]

Krieger et al. reported that in a controlled trial of circumcision to reduce HIV incidence in Kisumu, Kenya, in which 1,391 men elected to be circumcised, more than 99% were "satisfied" with their circumcisions.[16]

Kigozi et al. reported finding "no trend in satisfaction among circumcised men". The authors concluded that "[a]dult male circumcision does not adversely affect sexual satisfaction or clinically significant function in men".[17]

Cortés-González et al. found no statistically significant differences in terms of overall sexual satisfaction (p=0.15), pain during intercourse (p=0.23), or enjoyment of intercourse (p=0.32).[5]

Frisch et al. reported that "Circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment.[19]

Peterson reported that, after adult circumcision, 46.4% of men were "very satisfied", 50% were "satisfied" and 3.5% were "very dissatisfied".[21]

Female preferences and response

Cortés-González et al. (2008) studied 19 female partners of men scheduled for circumcision. They reported a significant reduction in vaginal lubrication following circumcision, from 78% to 63%, but found no statistically significant differences in "general sexual satisfaction, pain during vaginal penetration, desire, [or] vaginal orgasm".[22]

Kigozi et al. (2009) reported on a prospective study of 455 female partners of men circumcised as part of a randomised trial. 39.8% reported improved sexual satisfaction following circumcision, 57.3% reported no change, and 2.9% reported reduced sexual satisfaction after their partners were circumcised.[23]

Frisch et al. (2011) studied participants in a Danish national health survey, and found that male circumcision was associated "with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment."[19]

Summary of research findings

Study Design Peer reviewed Sample size Finding Significant¹
Sexual drive
Kim and Pang (2006)[18] Prospective; adult circumcision patients Yes 373 No difference found Not stated
Senol (2008)[24] Prospective; adult circumcision patients Yes 43 No difference found No; p = 0.11
Erectile function
Masood (2005)[3] Not stated; adult circumcision patients Yes 88 No difference found No; p = 0.40
Richters (2006)[15] Telephone survey Yes 10,173 Better in circumcised males Yes; p=0.022
Kim and Pang (2006)[18] Prospective; adult circumcision patients Yes 373 No difference found Not stated
Senol (2008)[24] Prospective; adult circumcision patients Yes 43 No difference found No; p = 0.23
Ejaculation
Waldinger (2005)[20] Multinational, stopwatch assessment Yes 500 No difference found No
Richters (2006)[15] Telephone survey Yes 10,173 Circumcised men more likely to ejaculate prematurely No; p = 0.11
Senol (2008)[24] Prospective; adult circumcision patients Yes 43 No difference found in BMSFI
Greater time to ejaculate after circumcision		 No; p = 0.48
Yes; p = 0.001
Frisch (2011)[19] National health survey Yes 2345
(2220 uc, 125 c)		 Circumcised men more likely to report frequent orgasm difficulties Yes; p < 0.05
Penile sensation
Masood (2005)[3] Not stated; adult circumcision patients Yes 88 Better after circumcision in 38%, worse in 18% Yes; p = 0.01
Bleustein (2005)[6] Quantitative somatosensory testing Yes 125
(63 c, 62 uc)²		 No difference found when controlled for other variables No
Yang (2008)[25] Used biological vibration measurement instrument to determine sensitivity Yes 169 (73 uc, 96 c) Worse after circumcision Yes; p < 0.05
Payne (2007)[10] Sensory testing to determine sensitivity to touch and pain Yes 40 (20 uc, 20 c) No difference found No
Overall satisfaction
Masood (2005)[3] Not stated; adult circumcision patients Yes 88 "Sixty-one percent were satisfied with the circumcision (p = 0.04) ... Fourteen patients (17%) were not satisfied with the circumcision, but only one patient in this group had any obvious post-operative complications (bleeding)." Not stated
Kim and Pang (2006)[18] Prospective; adult circumcision patients Yes 373 Better after circumcision in 6%, worse in 20% Yes; p < 0.05
Kigozi (2007)[17] Randomised trial; adult circumcision patients Yes 4456 "no trend in satisfaction among circumcised men" No; p = 0.8
Senol (2008)[24] Prospective; adult circumcision patients Yes 43 No difference found No; p = 0.07

Notes:

  1. If stated, author's analysis is used. Otherwise, significance is considered to be p <= 0.05.
  2. c = circumcised; uc = uncircumcised.

See also

References

  1. ^ American Academy of Pediatrics (2012). "Technical Report: Male Circumcision". Pediatrics. 130 (3): e756-85. doi:10.1542/peds.2012-1990. PMID 22926175. {{cite journal}}: Unknown parameter |month= ignored (help)
  2. ^ a b "Circumcision: Position Paper on Neonatal Circumcision". American Academy of Family Physicians. 2007. Retrieved 2007-01-30.
  3. ^ a b c d e f g Masood, S (2005). "Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly?". Urol Internationalalis. 75 (1): 62–6. doi:10.1159/000085930. PMID 16037710. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  4. ^ Krieger, JN (2008). "Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya". The journal of sexual medicine. 5 (11): 2610–22. doi:10.1111/j.1743-6109.2008.00979.x. PMC 3042320. PMID 18761593. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  5. ^ a b c d e f Cortés-González JR, Arratia-Maqueo JA, Martínez-Montelongo R, Gómez-Guerra LS (2009). "DOES CIRCUMCISION AFFECT MALE'S PERCEPTION OF SEXUAL SATISFACTION?". Arch. Esp. Urol. 62 (9): 733–736. PMID 19955598. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  6. ^ a b Bleustein, Clifford B. (2005). "Effect of neonatal circumcision on penile neurologic sensation". Urology. 65 (4): 773–7. doi:10.1016/j.urology.2004.11.007. PMID 15833526. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  7. ^ a b c Sorrells M, Snyder JL, Reiss MD, et al.. Fine-touch pressure thresholds in the adult penis. BJU Int. 2007;99:864-9. doi:10.1111/j.1464-410X.2006.06685.x. PMID 17378847. Cite error: The named reference "sorrells" was defined multiple times with different content (see the help page).
  8. ^ a b Waskett, Jake H. (2007). "Fine touch pressure thresholds in the adult penis". BJU Int. 99 (6): 1551–1552. doi:10.1111/j.1464-410X.2007.06970_6.x. PMID 17537227. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  9. ^ a b Young, Hugh (2007). "Fine touch pressure thresholds in the adult penis". BJU Int. 100 (3): 699. doi:10.1111/j.1464-410X.2007.07072_1.x. PMID 17669150. {{cite journal}}: Unknown parameter |month= ignored (help)
  10. ^ a b Payne, Kimberley (2007). "Sensation and sexual arousal in circumcised and uncircumcised men". J Sex Med. 4 (3): 667–674. doi:10.1111/j.1743-6109.2007.00471.x. PMID 17419812. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  11. ^ Schoen EJ (2007). "Should newborns be circumcised?: YES". Can Fam Physician. 53 (12): 2096–8, 2100–2. PMC 2231533. PMID 18077736. {{cite journal}}: Unknown parameter |month= ignored (help)
  12. ^ College of Physicians and Surgeons of British Columbia (2009). "Circumcision (Infant Male)" (PDF). Retrieved April 22, 2012.
  13. ^ Paediatrics & Child Health Division, The Royal Australasian College of Physicians (2010). "Circumcision of Infant Males" (PDF). Retrieved April 22, 2012. {{cite journal}}: Cite journal requires |journal= (help); Unknown parameter |month= ignored (help)
  14. ^ "Non-therapeutic circumcision of male minors (2010)". KNMG. 12 June 2010.
  15. ^ a b c d Richters, J (2006). "Circumcision in Australia: prevalence and effects on sexual health". International Journal of Sexually Transmissible Diseases and AIDS. 17 (8): 547–554. doi:10.1258/095646206778145730. PMID 16925903. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  16. ^ a b c Krieger JN, Mehta SD, Bailey RC; et al. (2008). "Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya". The journal of sexual medicine. 5 (11): 2610–22. doi:10.1111/j.1743-6109.2008.00979.x. PMC 3042320. PMID 18761593. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  17. ^ a b c d Kigozi, G (2007). "The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda" (PDF). BJU International. 101 (1): 65–70. doi:10.1111/j.1464-410X.2007.07369.x. PMID 18086100. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  18. ^ a b c d e f g h i Kim, DaiSik (2007). "The effect of male circumcision on sexuality" (PDF). BJU International. 99 (3): 619–622. doi:10.1111/j.1464-410X.2006.06646.x. PMID 17155977. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  19. ^ a b c d e f Frisch M, Lindholm M, Grønbæk M (2011). "Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark". Int J Epidemiol. Epub ahead of print. doi:10.1093/ije/dyr104. PMID 21672947. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  20. ^ a b Waldinger, M.D. (2005). "Circumcision in the United States: prevalence, prophylactic effects, and sexual practice". Journal of Sexual Medicine. 2 (4): 492–497. doi:10.1111/j.1743-6109.2005.00070.x. PMID 16422843. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  21. ^ A C Peterson (2010). "Elective, adult circumcision does not affect patient perception of sexual health as defined by the Male Sexual Health Questionnaire (MSHQ)". Journal of men's health. 7 (4): 368–372. doi:10.1016/j.jomh.2010.09.225.
  22. ^ Cortés-González JR, Arratia-Maqueo JA, Gómez-Guerra LS (2008). "[Does circumcision has an effect on female's perception of sexual satisfaction?]". Rev. Invest. Clin. (in Spanish; Castilian). 60 (3): 227–30. PMID 18807735.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unrecognized language (link)
  23. ^ Kigozi G, Lukabwe I, Kagaayi J; et al. (2009). "Sexual satisfaction of women partners of circumcised men in a randomized trial of male circumcision in Rakai, Uganda". BJU Int. 104 (11): 1698–701. doi:10.1111/j.1464-410X.2009.08683.x. PMID 19522862. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  24. ^ a b c d Senol MG, Sen B, Karademir K, Sen H, Saraçoğlu M (2008). "The effect of male circumcision on pudendal evoked potentials and sexual satisfaction". Acta Neurol Belg. 108 (3): 90–3. PMID 19115671. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  25. ^ Yang, DM (April 2008). "Circumcision affects glans penis vibration perception threshold". Zhonghua Nan Ke Xue. 14 (4). China: Nanjing Jun Qu Nanjing Zong Yi Yuan zhu ban, Zhonghua Nan Ke Xue Za Zhi Bian Ji Bu bian ji chu ban: 328–330. PMID 18481425. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
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