So your doctor has told you that not enough foreskin was removed during your son’s circumcision. A circumcision revision surgery or “recircumcision” has been recommended. As a parent, you love your son and you just want what’s best for him. You may be asking yourself, is this surgery really necessary? Warning: clicking hyperlinks in this article may take you to nude images. Please click carefully.

For many years, doctors were performing what is known as a "high and tight" circumcision. After the procedure, all of the baby's foreskin was gone and the glans fully exposed, leaving an end result that looked very much like a circumcised adult.

The problem though was that the removal of that much skin was causing complications. Children with high and tight circumcisions were growing up without having enough mobile penile skin to comfortably accommodate erections. So they were experiencing complications such as:

-tight painful erections, 
-penis wildly curving to one side,
-chafing and tearing of the circumcision scar tissue, and
-scrotal skin pulled up onto the shaft of the penis resulting in "hairy shaft".

All of these problems are the result of having too much skin being removed. After a circumcision revision surgery, a child may indeed look more “like daddy” but he is also subject to all of the above complications that come with having a tight circumcision. These complications not only lead to a great deal of discomfort for the circumcised man, but also for his sexual partner(s). Men experiencing these issues can find some relief from stretching the remaining skin using non-surgical foreskin restoration techniques. Foreskin restoration is painless but it is a slow, arduous process to undergo. 

Knowing what we now know about the complications of high and tight circumcisions, many doctors today are doing what is called a "loose circumcision", where more of the foreskin is left behind for the child to grow into. Sometimes initially this makes the child look like he isn't really circumcised, but with time and recession of the fat pad the child grows into the remaining tissue and eventually realizes the expected aesthetic effect of circumcision. 

Unfortunately not all doctors are aware of the shift towards the loose circumcision. Upon encountering a child with today’s loose circumcision, an uninformed doctor may pressure the child’s parents to "revise" something that requires no revision whatsoever. This is why we are seeing a sharp increase in circumcision revision surgeries at this time. Again, these surgeries are overwhelmingly unnecessary and are a result of doctors who are uninformed on this issue.

Risks Associated With Circumcision Revision Surgeries

Because circumcision revision surgery is strictly cosmetic (not medically needed for the health of the child), any complications of the surgery are 100% avoidable by simply not opting for the procedure. Learn more about the lifelong complications caused by circumcisions and circumcision revisions here (graphic):

-Gallery of Botched Circumcisions
-Circumstitions: Complications of Circumcision
-Global Survey of Circumcision Harm: Photo Gallery of Damage
-Historical Medical Quotes on Circumcision: Circumcision Complications

In addition to complications of the circumcision surgery itself, there are also many concerns that go with use of general anesthesia in infants and children. "Examples of side effects are nausea, vomiting, drowsiness, dizziness, sore throat, shivering, aches and pains, discomfort during injection of drugs, and agitation upon awakening from anesthesia... Adverse effects... may include dental trauma, croup (swelling of the windpipe), allergic reactions to drugs or latex products, wheezing, vocal cord spasm or injury, regurgitation of stomach contents with subsequent aspiration pneumonia, injury to arteries, veins or nerves, alterations in blood pressure, and/or irregular heart rhythms. Death and brain damage are the most feared of all anesthetic risks, but fortunately these complications are extremely rare." (Source: Society for Pediatric Anesthesia)

Questionable Motives of Doctors Recommending Recirumcision

A recent study has revealed that surgical repairs are big business for hospitals. In 2010, an unnamed, nonprofit 12-hospital chain in the southern U.S. was paid more than double when treating surgical patients who had complications compared to those who only underwent the initial surgery. There is zero profit to be made in a child that requires no further surgical modification, however there is great profit to be made in convincing parents that their child needs further surgical modification to his penis after the initial circumcision. Which leads you to wonder: are medical professionals looking at your son's loose circumcision and seeing dollar signs?

Common Questions Regarding Loose Circumcision

My son’s foreskin is "growing back", covering the head of the penis, stuck, adhered. Won't he have problems if it's not removed?
A naturally intact boy’s foreskin is fused to the head of the penis the same way your fingernail is fused to your finger. Sometimes after a circumcision, the remaining foreskin will adhere back on to the glans in an attempt to heal itself, causing what are called penile adhesions. This is very common. In this situation, we advise parents to just leave the foreskin alone and only clean the outside of it, the same way you would care for an intact boy. Some doctors may insist that the foreskin needs to be removed altogether or at the very least ripped back. This is a harmful act, causing severe pain to the child, bleeding, possible infection, and scarring. Do not allow doctors or other medical professionals to rip the foreskin remnant back if it has readhered. The adhesions will likely break down on their own over time, as they would with an intact child. If they don’t, less invasive procedures can aid the process along. In most cases, surgery is not needed.

But my son doesn’t look circumcised. Won’t he wonder why he doesn't look like daddy?
Neonatal circumcision techniques and results vary greatly because each patient is different, each doctor is different, and there are different circumcision methods utilized. So it’s already likely that no two circumcisions are ever going to look exactly alike. Your son is more likely to notice differences in size or body hair than the appearance of the penis. If he does ask, you can easily explain that there’s nothing wrong, just that dad had a surgery that resulted in his penis looking different from son’s. 

What if other kids make fun of him for not looking circumcised?
Today, the circumcision rate in the United States is roughly 50/50. That means about half of your son’s classmates will be intact and about half of them will be circumcised, and among them all will have varying lengths of foreskin. Your son will not be the odd man out. If bullying is an issue, any incidents should be reported to school authorities so those doing the bullying can be dealt with accordingly. Surgery is not needed.

My doctor said the recircumcision needs to be done. If the doctor said so, he must need it. Right?
Not necessarily. Doctors are human; they do make mistakes. America doctors used to actually recommend cigarettes to their patients. Now it’s common knowledge that cigarettes make you sick and can kill you. Hindsight is always 20/20. That’s why we recommend getting second and third opinions before proceeding with an irreversible surgery. Here’s a list of doctors who may be able to help you.

I'm planning on getting my son circumcised. Should I request a loose circumcision? 
The male foreskin is a highly specialized organ with a number of protective and sexual functions. It is literally the most sensitive part of the penis. Knowing this, there is no such thing as having too little foreskin removed, but there is most certainly such a thing as having too much removed. In other words, the more foreskin a child is left with, the better. 

All circumcision surgeries include risk. Regardless of the amount of tissue removed, you might still be expected to encounter meatal stenosis, skin tags, skin bridges, excessive scarring, MRSA infections, even death as a complication of routine circumcision. For these reasons and others, many parents are choosing not to circumcise their infant sons noawadays. To learn more about circumcision, check out this article written by The WHOLE Network's founder about her own journey of discovery when she was pregnant with her first son. Then go to our website's library to continue your search.

Just published a few days ago in The Journal of Sexual Medicine: "We assessed the association between circumcision status and self-reported history of STI/HIV infection using logistic regressions to explore whether circumcision conferred protective benefit...

Compared with uncircumcised men, circumcised men have accumulated larger numbers of STI in their lifetime, have higher rates of previous diagnosis of warts, and were more likely to have HIV infection. Results indicate that being circumcised predicted the likelihood of HIV infection."

ABSTRACT

Introduction.  Circumcision among adult men has been widely promoted as a strategy to reduce human immunodeficiency virus (HIV) transmission risk. However, much of the available data derive from studies conducted in Africa, and there is as yet little research in the Caribbean region where sexual transmission is also a primary contributor to rapidly escalating HIV incidence.

Aim.  In an effort to fill the void of data from the Caribbean, the objective of this article is to compare history of sexually transmitted infections (STI) and HIV diagnosis in relation to circumcision status in a clinic-based sample of men in Puerto Rico.

Methods.  Data derive from an ongoing epidemiological study being conducted in a large STI/HIV prevention and treatment center in San Juan in which 660 men were randomly selected from the clinic's waiting room.

Main Outcome Measures.  We assessed the association between circumcision status and self-reported history of STI/HIV infection using logistic regressions to explore whether circumcision conferred protective benefit.

Results.  Almost a third (32.4%) of the men were circumcised (CM). Compared with uncircumcised (UC) men, CM have accumulated larger numbers of STI in their lifetime (CM = 73.4% vs. UC = 65.7%; P = 0.048), have higher rates of previous diagnosis of warts (CM = 18.8% vs. UC = 12.2%; P = 0.024), and were more likely to have HIV infection (CM = 43.0% vs. UC = 33.9%; P = 0.023). Results indicate that being CM predicted the likelihood of HIV infection (P value = 0.027).

Conclusions.  These analyses represent the first assessment of the association between circumcision and STI/HIV among men in the Caribbean. While preliminary, the data indicate that in and of itself, circumcision did not confer significant protective benefit against STI/HIV infection. Findings suggest the need to apply caution in the use of circumcision as an HIV prevention strategy, particularly in settings where more effective combinations of interventions have yet to be fully implemented.

Rodriguez-Diaz CE, Clatts MC, Jovet-Toledo GG, Vargas-Molina RL, Goldsamt LA, and García H. More than foreskin: Circumcision status, history of HIV/STI, and sexual risk in a clinic-based sample of men in Puerto Rico. J Sex Med

***WARNING: this article contains very graphic material that is not intended to be viewed by children. Some adults may be offended by it, as well. Viewer discretion is advised.***

It is often said that a "Plastibell" circumcision is painless and doesn't involve any cutting or blood. Many people say that it is a more "gentle" circumcision without any risks. All of these statements are false. No circumcision is painless. The foreskin contains thousands of concentrated, specialized nerve endings. It is the most sensitive part of the penis. Any cutting on this part of the body is extremely painful, even with anesthetic (which will never provide 100% pain relief).

All circumcisions involve cutting, tearing and blood (even Plastibell methods). From birth, the foreskin is fused to the head of the penis (like a fingernail is fused to a finger). Before any circumcision begins, the foreskin must be ripped away from the glans. With a Plastibell circumcision, typically the foreskin is slit down the top to allow the insertion of the Plastibell. When in place, a string is tightly tied to necrotize the foreskin. After everything is secured, the excess skin is removed with scalpel or scissors.

A video of a Plastibell infant circumcision can be seen below:

The Plastibell procedure also has many dangers. It is not "safer" or "without risk". In fact, there are studies surrounding the complications of this method. Below are some photos involving just a few complications from Plastibell circumcisions:

(Above) Plastibell ring which has migrated proximally onto the penile shaft 8 days after circumcision. Patient experienced extensive skin loss over penile shaft. Read more about this story here.

We present the case of a 4-year-old boy who, shortly after a Plastibell circumcision, with the ring still in situ, experienced trauma to his glans, resulting in complete amputation. The second photo shows removal of dressing 7 days post injury. Read more about this story here.

Retained Plastibell ring from the University of Florida Pediatrics

(Above) A term, 10-day-old infant was brought to the hospital for evaluation of tenderness and swelling involving his penis, scrotum, and lower abdomen 2 days after he had undergone Plastibell circumcision. He was diagnosed with Necrotizing Fasciitis. Read more about this story here.

A 2.6-kg male infant was born by normal vaginal delivery after 39 weeks gestation. He was circumcised without incident by the Plastibell technique at age 3 days. Two days later, his mother noticed slight penile swelling and a small amount of blood and pus on the diapers. Later in the day, the penis and scrotum turned black-purple in color. The Plastibell was removed at another hospital and he was transferred to our institution. Read more about this story here.

MEDICAL JOURNAL: Twenty-three injuries resulting from circumcision with the Plastibell device all occurred from prolonged retention of the ring. In each case, the ring was retained and had migrated proximally. There was extensive skin loss in 17 (74%) babies. Urethrocutaneous fistulae were the result in nine (39%) of these cases, while partial necrosis of the glans penis occurred in four (17%).

http://www.ncbi.nlm.nih.gov/pubmed/19570722

A woman discusses how circumcision has had a negative impact on her and her husband's sex life.
Posted With Permission from Author

My 37 year-old cut husband absolutely detests the fact his penis is now severely curved and his skin is so tight that it's overly shiny in spots. After sex, those spots tend to get raw and sore and sometimes even bleed. All because his mom decided she preferred a cut penis. I really get frustrated when people act like it's no big deal.

His father is intact with no issues, but his mom thinks circumcised looks better. So she chose to circumcise my husband in 1975. He has never had a good relationship with her, even as a child, and had a lot of unexplained problems with depression and self worth. He now wonders if it's not linked. 

When we first had intercourse, the first thing I noticed was his penis curved strongly to the one side. We didn't know that was a side effect of circumcision and just laughed about it. Sex has always been good but it also has been painful. The side of his penis that pulls has shiny skin that is very tight and can be painful for him at times. Sometimes after sex he will even bleed a bit and develop raw spots in that area. I've had intact sex before so I know how wonderful it can be, how it works and how pleasurable it is.

Sex with my husband has been difficult. It's good sex but it has drawbacks (which we now know are directly because of him being circumcised.) We are both so bothered by this that it's hard to even want to have sex now. For him, he has the issues of the rawness and for me, it's the fact that it is dry and not the same as intact movement. Another issue is that we are just now aware of WHY he has this problem, and it serves as a reminder that we are left to deal with his mother's decision for his body. Worst part is: she gets to have sex with an intact man!!

He is just entering the early stages of foreskin restoration and the first day he tried to pull enough skin forward for taping, he couldn't squeeze enough to even move down the shaft. He got so frustrated he threw everything down and cursed his mother. He's been trying slowly and is finally able to get enough to put in the cone, but it's not been easy. There have been plenty of moments where he has been so frustrated over this choice his Mom thought she had the right to make so many years ago. Thirty-seven years later- HER preference means absolutely nothing and we suffer with the side effects.

Circumcision and Adult Penile Sensitivity & Sexual  Dysfunction: A Review of the Literature

Written by: Teri Mitchell, RNC, BSN, LCCE, IBCLC, SNM
Questions? teri_mitchell@baylor.edu

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.

Methods

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.

Findings

Penile Sensitivity

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.

Premature Ejaculation

            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).

Orgasm Difficulty

            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.

References

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

A closer look at the use of anesthetic during circumcisions. Is it actually effective?

A large majority of routine infant circumcisions are not performed with any anesthetic. In fact, up to 96 percent of the babies in the United States and Canada receive no anesthesia when they are circumcised, according to a report from the University of Alberta in Edmonton.

This has many parents (and medical professionals) concerned about the pain associated with circumcision, but is a local anesthetic enough?

In this research study, 11 male newborns were circumcised with a local dorsal penile nerve block, and 13 controls were circumcised without anesthetic. When the adrenal cortisol levels were compared, response to surgery was not significantly reduced by the administration of lidocaine.

Some doctors use EMLA cream as an anesthetic. Not only is EMLA cream less effective than a lidocaine injection, but the manufacturer's insert warns against its use on infants and on the genitals of children:

• EMLA is used to temporarily numb the surface of the skin. It is used for pain relief on the skin prior to procedures such as needle insertion and minor skin surgery in adults and children older than 1 year
• When using EMLA Cream, it should NOT be applied to the following areas:
  • cuts, grazes or wounds
  • where there is a skin rash or eczema
  • in or near the eyes
  • inside the nose
  • in the ear
  • in the mouth
  • in the anus (back passage)
  • the genitals of children
• Use on genital skin prior to injections of local anesthetics (adult men only)
• Use on genital skin prior to minor skin surgery (adults only)

Sometimes, seeing is believing. The below video, which can be found on YouTube, is a recent circumcision, performed at a private clinic. It is narrated by the doctor performing the surgery, and is intended as a video for medical professionals.

Anesthetic is used... can you tell?