Written by: Teri Mitchell, RNC, BSN, LCCE, IBCLC, SNM
New parents in the United States (US) are often presented with the option of whether they would like their newborn son to be circumcised, or if they would like him to remain intact (uncircumcised). This offer typically comes from the mother’s obstetrician, who has the most contact with the parents before the baby’s birth and who often performs the surgery. The advertised risks of the procedure are limited to the more immediate risks, such as bleeding, infection, injury to the penis, and scarring (American College of Obstetrics and Gynecology [ACOG], 2008). While the potential long term benefits may be offered, such as decreased risk for urinary tract infections, penile cancer, and acquisition of sexually transmitted diseases (Binner, Mastrobattista, Day, Swaim, & Monga, 2002), the long term risks are not included in the discussion when counseling parents on the risks and potential benefits of non-therapeutic neonatal circumcision. In effort to best serve our youngest and most vulnerable patients, healthcare providers should include all potential short-term and long term risks and benefits when providing information to parents considering elective surgery for their newborns.
Since newborn males are many years from sexual maturity, it may be easy for parents and providers to overlook the potential impact of circumcision on penile sensitivity and sexual function during adulthood. However, for the future man himself, this will likely be an important aspect of his life. One topic that has not been included in circumcision educational materials provided by ACOG (2008) is whether or not neonatal circumcision has a correlation with penile sensitivity or sexual dysfunction later in the baby’s life. I believe this is an important topic because parents deserve to be fully informed before giving consent for their newborn boys to be circumcised. The purpose of this paper is to review the literature in order to answer the question: Do circumcised men experience decreased penile sensitivity or greater sexual dysfunction than intact men?
Background and Significance
Circumcision is the surgical amputation of the prepuce of the penile glans. Cold and Taylor (1999) published a detailed explanation of the structure and function of the prepuce. The prepuce plays an important role in sexual function:
The prepuce is primary erogenous tissue necessary for normal sexual function. The complex interaction between the protopathic sensitivity of the corpuscular receptor-deficient glans penis and the corpuscular receptor-rich ridged band of the male prepuce is required for normal copulatory behavior. The increased frequency of masturbation, anal intercourse, and fellatio reported by circumcised men in the USA may possibly be due to the sensory imbalance caused by circumcision. Clearly, amputation of the prepuce causes changes in sexual behavior in human males and females (Cold & Taylor, 1999, p. 41).
This loss of sensory function in the circumcised penis was an important factor in the rising popularity of the surgery in the US, for non-religious reasons (Gollaher, 1994).
Circumcision has a history dating back as far as historians can measure, with Alexander Badaway’s reports of carvings depicting circumcision in Egyptian tombs in 2400 B.C. (as citied in Gollaher, 1994). The reasons for the ritual are highly varied and dependant on the cultural group and the beliefs of the time (Gollaher, 1994). What was once restricted to establishing a covenant with their creator among the Muslim and Jewish faiths, became an encouraged medical practice in the US during the second half of the 19th century (Gollaher, 1994).
Gollaher’s (1994) report chronicled the history of circumcision in the US. In the late 1800’s and early 1900’s, paralysis, insomnia, digestive abnormalities, epilepsy, hernias, scoliosis, insanity, promiscuity, homosexuality, nocturnal enuresis, nightmares, spermatorrhea and masturbation were believed to be cured by circumcising the male with the said affliction. All of the listed indications were believed to be caused by masturbation. The list of seemingly unrelated indications increasingly grew during this era (Gollaher, 1994).
Masturbation became the priority reason for circumcision (Darby, 2003). The premise was that by inflicting pain on and removing the most highly sensitized tissue from the penis, would stop boys and men from using their penis for any other activities besides procreation (Darby, 2003). Physicians specifically promoted the surgery to be performed without anesthesia in order to act as a punishment and leave a painful imprint on the male who was guilty of the prohibited act of sexual self-pleasure (as cited in Darby, 2003).
“Circumcision in male neonates is the most common surgical procedure in the United States. Throughout the rest of the world, except for religious reasons, it is performed infrequently” (Wang, Macklin, Tracy, Nadel, & Catlin, 2010). In the US, today’s parents are choosing circumcision for a variety of reasons not related to religious beliefs or potential medical benefits (Binner et al., 2002). The most prominent reason for choosing circumcision is so that the child will have the same surgical outcome as the child’s father (Binner et al., 2002). We have come to a time in history when researchers are attempting to validate indications for circumcisions that are aligned with the current beliefs and health concerns of today’s society (Gollaher, 1994), while parents are perpetuating the cycle of the procedure for reasons of aesthetics (Binner et al., 2002).
It is important to remember that the reason why circumcision became popular in the US was because it was known to decrease penile sensation (Darby, 2003; Gollaher, 1994). The topic of circumcision as it relates to penile sensation and sexual dysfunction is important to nurses because expectant and new parents may inquire about the potential risks and benefits. Healthcare providers should consider the historical, cultural, ethical, and medical aspects of non-therapeutic neonatal circumcision when providing information to parents and should encourage an informed independent decision.
Academic Search Complete, CINAHL, and Medline databases were used to search the terms circumcision, male, premature ejaculation, and sexual dysfunction. Limits placed on the search included English language and publication dates ranging from 2002 to 2012. Articles with titles related to the topic of interest were obtained and the abstracts were reviewed. Abstracts that met the inclusion criteria were included in the review. The inclusion criteria consisted of a) published in the preceding 10 years b) quantitative research design c) penile sensitivity, ejaculatory time, erectile dysfunction, orgasm difficulty, or dyspareunia as outcome criteria d) male subjects e) circumcised and intact group assignments. Excluded articles included those that examined the outcomes before and after adult circumcision. These articles were excluded because the premise for this review is to offer informed consent to parents of newborn boys. Furthermore, the outcomes for men circumcised as adults may be different than those circumcised earlier in life, especially in terms of glans keratanization secondary to the loss of the protective sheath of the prepuce (Cold & Taylor, 1999).
Six articles were found that met the inclusion criteria. No systematic reviews were found on this topic in the past 10 years. Each article was outlined in the accompanying Evidence Summary Table, which presents the design, sample description, variables, findings, and limitations of each study. No further statistical tests were run on the data beyond what was presented in each study individually.
Two studies were identified that attempted to objectively measure penile sensitivity, by measuring the “small and large axon fibers” (Bleustein, Fogarty, Eckholdt, Arezzo, & Melman, 2005, p. 774) and the “fine touch pressure thresholds” (Sorrells et al., 2007, p. 864).
Bleustein et al. (2005) operationalized the measurements by using a series of instruments to determine sensitivity upon touch (Semmes-Weinstein monofilament evaluator), vibration (Bio-thesiometer), spatial perception (tactile circumferential discriminator), and thermal thresholds (Physitemp NTE-2A Thermal Sensitivity Tester). The measurements were taken on the dorsal glans of both the circumcised and intact groups. An additional measurement was taken in the same location among the intact subjects with the prepuce covering the glans, for the vibration, pressure, and spatial measurements only. This sample was comprised of men who sought care at a urology clinic, of which 77% had diagnosed erectile dysfunction. Among the 63 circumcised and the 62 intact subjects, there was not a statistically significant difference reported. (Bleustein et al., 2005).
Sorrells et al. (2007) employed strict exclusion criteria to avoid as many conceivable extraneous variables as possible. This study created a 19-point map of penile sensitivity, operationalized by using the Semmes-Weinstein monofilament evaluator. This was the same instrument used to measure sensitivity to touch by Bleustein et al. (2005). A power analysis was conducted and the study was adequately powered. This study contained 163 subjects (68 intact and 91 circumcised) who were volunteers from the community, without a long list of penile or systemic pathologies. Sorrells et al. (2007) found that the circumcision scar (prepuce remnant) was the most sensitive location among circumcised men, particularly the ventral scar. Among intact men, the study concluded that 18 of the 19 locations were more sensitive than the circumcised group. Sorrells et al. (2007) reported that “Five locations on the uncircumcised penis that are routinely removed at circumcision were more sensitive than the most sensitive location on the circumcised penis” (p. 867). While a significant difference was not found in the two location measurements done by Bleustein et al. (2005), the 19 location map created by Sorrells et al. (2007) showed significant differences between circumcised and intact subjects.
Three published studies measuring premature ejaculation (PE), which were conducted in the last 10 years, were reviewed. According to Waldinger et al. (2005), “Premature ejaculation is probably the most prevalent sexual complaint of men” (p.492). This condition is:
characterized by: (i) ejaculation which always or nearly always occurs prior to or within 1 minute of vaginal penetration; (ii) inability to delay ejaculation on all or nearly all vaginal penetrations; and (iii) negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy (Waldinger, McIntosh, & Schweitzer, 2009, p. 2888).
Waldinger et al. (2005) and Waldinger, McIntosh, and Schweitzer (2009) conducted the same study, only changing the way in which intravaginal ejaculatory latency time (IELT) was operationalized. Waldinger et al. (2005) instructed the subjects to use a stopwatch to measure and a journal to record their sexual encounters during a 4 week period. Waldinger, McIntosh, and Schweitzer (2009) used a blinded timer with a hidden electronic record to obtain the same measurements. Both studies obtained a sample containing heterosexual couples from five countries; the Netherlands, United Kingdom, Spain, Turkey, and the US. Both studies claimed “exactly the same” (Waldinger, McIntosh, & Schweitzer, 2009, p.2891) findings. Waldinger et al. (2005) and Waldinger, McIntosh, and Schweitzer (2009) both reported that men from Turkey had statistically significant shorter IELT compared with the rest of the sample. However, the results from Turkey were not included in the final findings because all Turkish men (Turkish n=130; sample n=500) in the Waldinger et al. (2005) study and all but two Turkish men (Turkish n=124; sample n=474) in the Waldinger, McIntosh, and Schweitzer (2009) study were circumcised. Upon exclusion of this data, there was no significant difference found in IELT among circumcised and intact men in either study (Waldinger, McIntosh, & Schweitzer, 2009; Waldinger et al., 2005).
The most recent study, used surveys to assess PE among a sample obtained from a primary care setting (Tang & Khoo, 2011). The surveys were pretested and deemed reliable. Subjects were operationalized as having PE if their survey score fell into the PE or Probable PE categories. Tang and Khoo (2011) found that circumcised men were nearly five times (OR 4.88) more like to report PE than intact men. This finding was both statistically and clinically significant, considering that PE may be the most frequent sexual complaint among men (Waldinger et al., 2005) and may cause significant personal distress (Waldinger, McIntosh, & Schweitzer, 2009).
Frisch, Lindholm, and Gronbaek (2011) sought to explore the outcomes of circumcision in Denmark, where 95% of the population is intact. The study examined several factors that are potentially linked to circumcision. Information was gathered from a questionnaire. The study concluded that, while there was no statistically significant difference among intact and circumcised men reporting only occasional orgasm difficulties, there was a statistically significant difference between the groups when reporting frequent orgasm difficulties. Circumcised men were more than 3 times (OR 3.26) more likely to report frequent orgasm difficulties than intact men (Frisch, Lindholm, & Gronbaek, 2011).
Interestingly, while not the topic of this paper, this study found several statistically significant differences in sexual satisfaction and experiences among women with circumcised partners and women with intact partners. Women with circumcised partners were two to three times more likely to report overall sexual dysfunction (OR 3.26) and frequent orgasm difficulties (OR 2.66), as well as eight and a half times more likely to report dyspareunia (OR 8.45) than women with intact partners (Frisch, Lindholm, & Gronbaek, 2011). This is an area that warrants more research to fully understand the impact of circumcision on the sexual partners.
Strengths and Limitation
All the subjective measurements of sexual function found highly significant differences, as did the studies with more stringent controls of extraneous variables. The studies varied greatly in the measurement outcomes and data collection methods, with exception of IELT.
While the Bleustein et al. (2005) study did not find a difference among the groups, the sample was taken from a urology clinic. The subjects could have had extraneous variables that impacted the study findings. For example, men seeking care at a urology clinic may have characteristics or health conditions that differ from the general male population. The Bleustein et al. (2005) findings are not generalizable beyond a population of men who seek care at a urology clinic. This study had an inadequate power and a small sample size as well (Bleustein et al., 2005). The Sorrells et al. (2007) study had higher power, extensive controls, and a more thorough examination of penile sensitivity. Sorrells et al. (2007) also provided comprehensive findings of penile sensation by location, including the locations lost due to circumcision. Interesting to note, Cold and Taylor (1999) reported that “The only point of the body with less fine-touch discrimination than the glans penis is the heel of the foot” (p. 37). The most highly innervated region of the penis is the prepuce, which is removed during circumcision (Cold & Taylor, 1999). Sorrells et al. (2007) argue that sensitivity of the glans is of lesser importance because the glans is not amputated during circumcision.
While the objective measurements analyzed by Waldinger et al. (2005) and Waldinger, McIntosh, and Schweitzer (2009) did not show a statistically significant difference in IELT among the groups in question, Tang and Khoo (2011) found that circumcised men are much more likely to report a shorter ejaculatory time than desired. Regardless of objective measurements, subjective reports demonstrate the desire for longer ejaculatory time among circumcised men. This raises the question: Is there a characteristic unique to circumcised men that lend them to report a need for longer ejaculatory time in order to experience full sexual satisfaction? Do men who report premature ejaculation also have a shortened IELT, upon objective measurement? This is certainly an area in need of further research.
Another limitation to note is that all the men or couples in the study had to volunteer to participate in the studies. Quantifying findings as personal as penile sensitivity and sexual function is certainly threatened by the characteristics of the type of individuals who are willing to participate (selection bias), the impact of having this aspect of one’s life evaluated (evaluation apprehension), and the expectations of the researchers (experimenter expectancies). The researchers did not disclose their own circumcision status, their feelings about their status, the circumcision status of their own sons, or their bias for or against the procedure.
Implications of Findings/Recommendations for practice
The body of evidence on this topic demonstrates that circumcised men are more likely to report greater sexual dysfunction. Objective measurements examining limited variables did not show any difference between the groups, but more extensive objective measurements with tighter controls did show a significant difference between circumcised and intact men. More research is needed to combine subject reports with objective measurements. Researchers need to be sure to include objective measurements of the prepuce in their studies, since that is the removed part.
Over the last 150 years, the healthcare profession has lost sight of normal male anatomy and the outcomes circumcision. “Historically, reduced penile sensitivity was not an unintended side effect of circumcision” (Frisch, Lindholm, & Gronbaek, 2011, p. 9), but today’s nursing schools do not teach the important historical roots, function, and importance of the prepuce, in this writer’s experience. Today’s providers in the US are not taught alternatives to circumcision when an intact male is in need of competent medical care for a condition of the prepuce. The result is providers who are providing ill-informed data to parents attempting decide if they want their son circumcised, a culture that views males with natural anatomy as abnormal, and a lack of intact friendly providers for parents with intact sons.
Normal sexual function must be considered when discussing circumcision with individuals weighing the pros and cons of the surgery for themselves or their children. The prepuce serves many important functions throughout the span of a male’s lifetime, including normal reproductive behaviors (Cold & Taylor, 1999). Omitting the possibility that circumcision may impact the sexual experience of the individual denies parents the opportunity for fully informed consent on the behalf of their sons.
Future practice should include more research, re-evaluation and alteration of informed consent and patient education materials, and more comprehensive education of healthcare providers in the academic setting.
American College of Obstetricians and Gynecologists (2008). Newborn circumcision. [Brochure]. Washington, D.C.: American College of Obstetricians and Gynecologists.
Binner, S., Mastrobattista, J., Day, M., Swaim, L., & Monga, M. (2002). Effect of parental education on decision-making about neonatal circumcision. Southern Medical Journal, 95(4), 457-461. Retrieved from http://ehis.ebscohost.com.ezproxy.baylor.edu/ehost/pdfviewer/pdfviewer?vid=4&hid=121&sid=83be1044-47f9-4e1f-ab62-a08205bba187%40sessionmgr111
Bleustein, C.B., Fogarty, J.D., Eckholdt, H., Arezzo, J.C., Melman, A. (2005). Effect of neonatal circumcision on penile neurologic sensation. Urology, 65, 773-777. doi: 10.1016/j.urology.2004.11.007
Darby, R. (2003). The masturbation taboo and the rise of routine male circumcision: A review of the historiography. Journal of Social History, 36(3), 737-757. Retrieved from http://ehis.ebscohost.com.ezproxy.baylor.edu/ehost/pdfviewer/pdfviewer?vid=4&hid=121&sid=65948ec5-a06c-4b12-8353-6ca93bd7ea71%40sessionmgr113
Gollaher, D. (1994). From ritual to science: The medical transformation of circumcision in America. Journal of Social History, 28(1), 5-36. Retrieved from http://ehis.ebscohost.com.ezproxy.baylor.edu/ehost/pdfviewer/pdfviewer?vid=3&hid=121&sid=461b8f81-a00f-4935-86ea-0bccb807d390%40sessionmgr111
Sorrells, M.L., Snyder, J.L., Reiss, M.D., Eden, C., Milos, M.F., Wilcox, N., Van Howe, R.S. (2007). Fine-touch pressure thresholds in the adult penis. BJU International, 99, 864-869. doi: 10.1111/j.1464-410X.2006.06685.x
Tang, W.S., Khoo, E.M. (2011). Prevalence and correlates of premature ejaculation in a primary care setting: A preliminary cross-sectional study. Journal of Sexual Medicine, 8, 2071-2078. doi: 10.1111/j.1743-6109.2011.02280.x
Waldinger, M.D., McIntosh, J., Schweitzer, D.H. (2009). A five-nation survey to assess the distribution of the intravaginal ejaculatory latency time among the general male population. International Society for Sexual medicine, 6, 2888-2895. doi: 10.1111/j.1743-6109.2009.01392.x
Waldinger, M.D., Quinn, P., Dilleen, M., Mundayat, R., Schweitzer, D.H., Boolell, M. (2005). A multi-national population survey of intravaginal ejaculation latency time. Journal of Sexual Medicine, 2, 492-497. doi: 10.1111/j.1743-6109.2005.00070.x
Wang, M.L., Macklin, E.L., Tracy, E., Nadel, H., & Catlin, E. A. (2010). Updated parental viewpoints on male neonatal circumcision in the United States. Clinical Pediatrics, 49(2), 130-136. doi: 10.1177/0009922809346569