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Introduction
Circumcision, a surgical procedure known since
ancient times, is performed in many countries due
to cultural, religious, or medical reasons; and its frequency is surprisingly high. In the United States, 77
to 85 of every 100 boys are circumcised (1,2). The circumcision rate in newborns has increased in parallel
to the increase in the number of hospital delivery.
Previous studies have revealed lower frequency of urinary tract infection in circumcised infants compared
to those who are not circumcised (3,4), and similarly,
lower frequency of sexually transmitted disease in
circumcised adults compared to those who are not
circumcised has been reported (5,6).
On the other hand, there are conflicting results regarding to the effect of circumcision on the quality of
sexual life in men. Several studies have suggested that
circumcision leads to diminished penil sensitivity as
well as sexual arousal, and therefore, improves ejaculation control (7,8), whereas others did not report
such a change in penil sensitivity (9). Besides, patient
complaints have led to the application of a surgical
procedure to revert circumcision in those who were
unsatisfied with being circumcised (10).
Two separate studies evaluating sexual activity in
men who were circumcised in adulthood have reported that circumcision per se did not alter sexual activity but permitted a retardation in ejaculation time
(11,12).
However, despite numerous studies which have reported various results regarding to sexual activity in
men circumcised in adulthood, there is no study on
the influence of circumcision performed in adulthood on body cathexis appraisal. The present study
was designed to prospectively assess the influence of
adulthood circumcision on body cathexis appraisal
in a group of men.
* Department of Urology, Gulhane Military Medical Faculty Haydarpasa
Training Hospital
**Department of Psychiatry, Gulhane Military Medical Faculty Haydarpasa
Training Hospital
Reprint request: Dr. Cüneyt Adayener, Department of Urology, Gulhane
Military Medical Faculty Haydarpasa Training Hospital, Üsküdar-34668,
İstanbul
E-mail: cuneytadayener@yahoo.com
Date submitted: March 30, 2010 • Date accepted: June 09, 2010186 • September 2010 • Gulhane Med J Adayener et al.
Material and Methods
A total of 40 adult men were circumcised by guillotine method under local anesthesia. Those with
penil dermatological disorders such as phimosis, balanitis, or condyloma were excluded. All patients declared that they were not able to have this procedure
in childhood due to various reasons, and expressed
their willingness to be circumcised due to religious or
sociocultural reasons.
All patients were asked to fill out informed consent
form and QBCs, which were first developed by Secord
and Jourard (13) and subsequently adapted in Turkish
by Hovardaoglu (14) (Table I). Patients were asked to
score their satisfaction (1 for “none”, and 5 for “very
satisfied”) about 40 different parts of their body, the
highest score being 200. The patients who were unable to understand some of the questions were helped
by the surgeon.
The pre-and post-circumcision QBC scores as well
as total scores of four items related to sexuality were
assessed and then compared to those in a group of
age-, body mass index-, and socioculturally-matched
40 men who were circumcised in childhood (Mean
age at circumcision were 6). Single and married patients were evaluated at the 12th week visits in our clinic, respectively regarding their new penile appearance and sexual activity.
Differences in the QBC scores were analized
using Mann Whitney U test, whereas pre-and postcircumcision total scores of four items related to sexuality and those in the control group were analized
with independent variables t test. A p value equal or
less than 0.05 was accepted as statistically significant.
Results
The mean age of the patient group was 21.4 (ranging between 20 to 24) years. All patients were army
recruits from East and Southeast Anatolia who were
performing their military service in the western part
of the country. None, except eight who were married, had a regular sexual life. Eleven patients declared
that they had no previous sexual intercourse. Most
of them had been raised in large families in distant
rural areas and used to work in farms before military
service. Unfortunately, education and income leves
were very low, which for them, was the main reason
for not being circumcised in childhood. The demographical features of both groups are given in Table II.
Circumcision was performed by guillotine method
under local anesthesia and all patients were discharged on the day of procedure following coban bandage
and were administered prophylactic antibiotics (500
mg ciprofloxacin two times a day) orally for five days.
No complication was noted on the 5th day visit.
The mean pre-circumcision QBC score was significantly lower than that in the control group (150.4
and 161.2, respectively, p<0.0001), whereas the mean
post-circumcision QBC score was similar (164.8,
Table I. Questionnaire of body cathexis which were first
developed by Secord and Jourard
Name and surname :
Date :
I like so
much
(5)
I like quite
much (4)
Not sure
(3)
I don’t
like (2)
I don’t
like it at
all (1)
My
Hair ( ) ( ) ( ) ( ) ( )
Face ( ) ( ) ( ) ( ) ( )
Appetite ( ) ( ) ( ) ( ) ( )
Hands ( ) ( ) ( ) ( ) ( )
Body hair ( ) ( ) ( ) ( ) ( )
Nose ( ) ( ) ( ) ( ) ( )
Physical strength ( ) ( ) ( ) ( ) ( )
Order of urination and
defecation
( ) ( ) ( ) ( ) ( )
Muscle strength ( ) ( ) ( ) ( ) ( )
Waist ( ) ( ) ( ) ( ) ( )
Level of energy ( ) ( ) ( ) ( ) ( )
Back ( ) ( ) ( ) ( ) ( )
Ears ( ) ( ) ( ) ( ) ( )
Age ( ) ( ) ( ) ( ) ( )
Chin ( ) ( ) ( ) ( ) ( )
Body build ( ) ( ) ( ) ( ) ( )
Profile ( ) ( ) ( ) ( ) ( )
Height ( ) ( ) ( ) ( ) ( )
Sharpness of senses ( ) ( ) ( ) ( ) ( )
Resistance to pains ( ) ( ) ( ) ( ) ( )
Shoulder wideness ( ) ( ) ( ) ( ) ( )
Arms ( ) ( ) ( ) ( ) ( )
Chest ( ) ( ) ( ) ( ) ( )
Eyes ( ) ( ) ( ) ( ) ( )
Digestive system ( ) ( ) ( ) ( ) ( )
Appearence of thighs ( ) ( ) ( ) ( ) ( )
Resistance to diseases ( ) ( ) ( ) ( ) ( )
Legs ( ) ( ) ( ) ( ) ( )
Shape of teeth ( ) ( ) ( ) ( ) ( )
Sexual power ( ) ( ) ( ) ( ) ( )
Feet ( ) ( ) ( ) ( ) ( )
Sleep order ( ) ( ) ( ) ( ) ( )
Voice ( ) ( ) ( ) ( ) ( )
General health ( ) ( ) ( ) ( ) ( )
Sexual activity ( ) ( ) ( ) ( ) ( )
Knees ( ) ( ) ( ) ( ) ( )
Posture ( ) ( ) ( ) ( ) ( )
Shape of face ( ) ( ) ( ) ( ) ( )
Weight ( ) ( ) ( ) ( ) ( )
Appearence of penis ( ) ( ) ( ) ( ) ( )Volume 52 • Issue 3 Body cathexis appraisal after circumcision • 187
Table II. The demographical features and body cathexis scores
of both groups before and after the circumcision
Circumcision
group n:40
Control group
n:40
Mean age 21.4 22
Place of birth
Southeast of Anatolia 26 24
East of Anatolia 14 16
Place of living
Village 28 24
Town 8 10
Big city 4 6
Occupation
Hard worker 24 18
Farmer 6 6
Other 10 16
Mean number of siblings 9.3 8.5
Education
Uneducated 16 12
Primary school 24 20
Body Mass Index (min-max) 23.5 (20.2-27) 23 (19.1-25.9)
The mean body cathexis
score before circ. (min-max)
150.4 (127-176)* 161.2 (126-193)*
The mean body cathexis
score after circ. (min-max)
164.8 (140-188)** 161.2 (126-193)**
* : The mean pre-circumcision body cathexis score is significantly lower than
that in the control group (p<0.0001)
** : The mean post-circumcision body cathexis score was similar with the
control group (p=0.424)
p=0.424) (Table III). Following circumcision, total
scores of four items related to sexuality increased
from 14.40 to 16.65. The respective score was 17.55
in the control group. Our findings indicated that this
particular score was significantly lower in the patient
group before circumcision, and this difference did no
longer exist following the circumcision. Regarding to
four sexual items, all scores except for the appearance
of thighs (sexual activity, sexual performance, and satisfaction from the appaerance of the penis) increased
after circumcision. However, this score was not different than that of the controls following circumcision
(Table III). Of note, those who were married (8 patients) reported more satisfaction from sexual activity
as well as increased frequency of weekly intercourse.
Table III: The comparison of the mean sexual domain scores of pre-circumcision, post-circumcision and control group
Question The mean pre-circ.
score
The mean post-circ.
score
Control group Precirc-control
group
Postcirc-control
group
Sexual activity 3.40 3.90 4.25 p=0.008 p=0.273
Sexual power 3.40 4.10 4.60 p=0.0001 p=0.022
The appearance of penis 3.65 4.40 4.65 p=0.0001 p=0.221
The appearance of thighs 3.95 4.25 4.05 p=0.732 p=0.486
Total score 14.40 16.65 17.55 p=0.0001 p=0.188
Discussion
In Turkey, male circumcision is both a religious and
sociocultural compulsion. As for the parents and the
society, the medical advantages frequently reported
in the literature such as decreased prevalence of genitourinary infections, does not represent any significance. The usual time of circumcision is early school
ages. However, although being the “prerequisition”
for manhood in Turkey (15), circumcision could not
be performed at these ages due to low income in most
parts of eastern and southeastern Anatolia, most of the
young males awaiting to be recruited by the military
service until they reach medical attention at the military hospitals. Moreover, it is usually very hard for
these men to admit that they are uncircumcised while
obtaining past medical history as this is perceived as
an “imperfection” or “guilt” by the society.
Not surprisingly, only 14 of the patients were able to
admit that he was uncircumcised; 6 out of 8 married
patients admitted that they used every means in order
to make their spouses not be aware of their being uncircumcised; and 12 out of 32 single patients admitted
that they were not allowed to get married, and were
unlikely to do so unless they are circumcised.
In this study, we observed that circumcision not only
improved body cathexis appraisal but had favorable
effects on the attitude of adult men as well. This may
best be represented with the encourage of circumcised
men to report their health status to the nurses at the
outpatient clinic front desk during the 12th week visit.
There are conflicting results about penile sensitivity
and the level of satisfaction from sexual intercourse following circumcision. Several studies have reported diminished sensitivity of the glans penis (16,17), whereas
others reported a more favorable sexual body cathexis
appraisal after circumcision intercourse (9,18). Another
study has revealed no difference between quantified somatic glans sensitivity between circumcised and uncircumcised men (19). The results of a more recent study
indicate that erectile function and penile sensitivity are
diminished but the level of sexual satisfaction is increased in men circumcised for medical reasons (20). Not
surprisingly, the patients have uniformly stated that 188 • September 2010 • Gulhane Med J Adayener et al.
they are now much better satisfied with the appearance of their new penis because of their previous preputial disturbances such as balanitis, phimosis, or chondyloma. Likewise, diminished pain during intercourse
as well as improved penil sensitivity despite unaltered
erectile function scores in patients with preputial disorders may be attributed not only to the surgical procedure itself but the alleviation of the inflammatory disorder of the penis (21). There is another study which
has reported that neither sexual activity nor level of satisfaction were altered following prohylactic circumcision for HIV in over 2000 adult men (22).
In our study, all patients (who did not had any preputial disorder and were circumcised for solely religious reasons) reported “a better looking” penis and this
was further documented with the QBC scores. All of
the post-circumcision QBC scores, except sexual activity, were found to be similar to the control group,
and the reason for this low sexual activity score might
be related to the relatively short time (12 weeks) after
the surgical procedure.
The dramatic improvement in the body cathexis
appraisal that we have observed might be closely related to the cessation of negative feelings about the
perception of overall body appearance. Previous studies have demonstrated that body cathexis appraisal is
negatively correlated with physical and sexual appeal,
sexual activity, frequency of sexual activity, and depression (23).
In our country, men perceive the state of being uncircumcised in childhood as a “misperfection” in their
identity and body, therefore leading to disintegration
of emotional body cathexis appraisal after circumcision stability and disorders of sexual function (24). This
inevitably results in the instinct of “hiding” this personal defect form the spouse, thereby interfering with
a normal and healthy sex life of the couples. Thus, one
might consider that increased number of sexual intercourse as well as enhanced level of sexual satisfaction
is not only related to the new physical appearance of
the penis but to the improved body cathexis appraisal
and self esteem as well.
In conclusion, circumcision in adulthood substantially improves body cathexis appraisal and this procedure must be considered in adult men who were less
fortunate to have this procedure in childhood, particularly in countries like Turkey.