The Comparison of Men Circumcised in Adulthood and Circumcised in Childhood in Terms of Self- Esteem, Mood and Sexual Functions

ABSTRACT

Objetive: In this study, we aimed to evaluate the self-esteem, mood, and sexual functions of men who applied to the Urology outpatient clinic voluntarily for circumcision.

Material and Methods: We assessed 20 adult male patients who admitted to our outpatient clin- ic for circumcision and 20 control group patients between 2016 and 2019. All patients were filled out Rosenberg self-esteem scale, Hospital anxiety and depression test and Arizona sexual experienc- es scale forms. Patients circumcised in adulthood were named as Group I and those who were cir- cumcised in childhood were named as Group II. It was investigated whether there was a statistically significant difference between the two groups in terms of Rosenberg self-esteem scale, Hospital anxiety and depression test and Arizona sexual experiences scale (ASEX) scores. P <0.05 was con- sidered significant.

Results: The mean age of 40 patients included in the study was 21.32 ± 1.62. Mean Rosenberg self esteem score was 2.15 ± 2.10, mean anxiety score was 6.70 ± 4.83, mean depression score was 6.27 ±4.21 ant mean ASEX score was 12.37 ± 3.51. Mean Rosenberg self-esteem scores were 1.9+/-1.58 in Group I and 2.4+/-2.54 in Group II. Mean anxiety scores were 6.4+/-5.13 in Group I and 7+/-4.63 in Group II. Mean depression scores were 6.3+/-3.43 in Group I and 6.25+/-4.96 in Group II. Mean ASEX scores were 12.85+/-3.71 in Group I and 11.9+/-3.32 in Group II. There wasno statistically significant difference between the two groups in terms of the Rosenberg self-esteem, anxiety, depression and ASEX scores (p=0.08, p=0.64, p=0.50, and p=0.40; respectively).

Conclusion: The self-esteem of men applying for circumcision in adulthood is not affected. This situation does not affect the emo- tional state and sexual life of the people.

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ABSTRACT

Objetive: In this study, we aimed to evaluate the self-esteem, mood, and sexual functions of men who applied to the Urology outpatient clinic voluntarily for circumcision.

Material and Methods: We assessed 20 adult male patients who admitted to our outpatient clin- ic for circumcision and 20 control group patients between 2016 and 2019. All patients were filled out Rosenberg self-esteem scale, Hospital anxiety and depression test and Arizona sexual experienc- es scale forms. Patients circumcised in adulthood were named as Group I and those who were cir- cumcised in childhood were named as Group II. It was investigated whether there was a statistically significant difference between the two groups in terms of Rosenberg self-esteem scale, Hospital anxiety and depression test and Arizona sexual experiences scale (ASEX) scores. P <0.05 was con- sidered significant.

Results: The mean age of 40 patients included in the study was 21.32 ± 1.62. Mean Rosenberg self esteem score was 2.15 ± 2.10, mean anxiety score was 6.70 ± 4.83, mean depression score was 6.27 ±4.21 ant mean ASEX score was 12.37 ± 3.51. Mean Rosenberg self-esteem scores were 1.9+/-1.58 in Group I and 2.4+/-2.54 in Group II. Mean anxiety scores were 6.4+/-5.13 in Group I and 7+/-4.63 in Group II. Mean depression scores were 6.3+/-3.43 in Group I and 6.25+/-4.96 in Group II. Mean ASEX scores were 12.85+/-3.71 in Group I and 11.9+/-3.32 in Group II. There wasno statistically significant difference between the two groups in terms of the Rosenberg self-esteem, anxiety, depression and ASEX scores (p=0.08, p=0.64, p=0.50, and p=0.40; respectively).

Conclusion: The self-esteem of men applying for circumcision in adulthood is not affected. This situation does not affect the emo- tional state and sexual life of the people.

INTRODUCTION

Male circumcision is an ancient surgical procedure. The main purpose of circumcision is to remove the foreskin to expose the glans penis to make it easier to clean up the smegma produced by the inner surface of the foreskin and maintaining the hygiene of the phal- lus(1).

Mainly it is performed in childhood ages (2). Cir- cumcision, which is optional, is infrequently performed in adults compared to children. In adults, cultural re- quirements and social pressure can influence people’s choices and preferences in a predominantly circum- cised society.(3). However, adult circumcision is most- ly performed to prevent HIV infections in sub-Saharan countries (4, 5). In our country, Turkey, circumcision is mainly performed because of cultural pressure and as a religious ritual. This means that uncircumcised men might feel guilty or inadequate in terms of social compliance (6). In predominantly circumcised societ- ies, self-esteem in uncircumcised men may be affected and low self-esteem may influence mood and sexual functions.

In this study, we evaluate men who are admitted to our hospital for circumcision in terms of self-esteem, mood and sexual function utilizing relevant survey scales.

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INTRODUCTION

Male circumcision is an ancient surgical procedure. The main purpose of circumcision is to remove the foreskin to expose the glans penis to make it easier to clean up the smegma produced by the inner surface of the foreskin and maintaining the hygiene of the phal- lus(1).

Mainly it is performed in childhood ages (2). Cir- cumcision, which is optional, is infrequently performed in adults compared to children. In adults, cultural re- quirements and social pressure can influence people’s choices and preferences in a predominantly circum- cised society.(3). However, adult circumcision is most- ly performed to prevent HIV infections in sub-Saharan countries (4, 5). In our country, Turkey, circumcision is mainly performed because of cultural pressure and as a religious ritual. This means that uncircumcised men might feel guilty or inadequate in terms of social compliance (6). In predominantly circumcised societ- ies, self-esteem in uncircumcised men may be affected and low self-esteem may influence mood and sexual functions.

In this study, we evaluate men who are admitted to our hospital for circumcision in terms of self-esteem, mood and sexual function utilizing relevant survey scales.

MATERIAL AND METHODS

After obtaining the approval of the local ethics committee, between 2016 and 2019, 20 patients who applied to our outpatient clinic with a request for circumcision and 20 patients that we selected as the control group were included in the study. All patients underwent a physical examination. Patients with hy- pospadias and balanitis were excluded from the study.

All patients expressed their willingness to get circum- cised after reading the consent form and accepting the pros and cons of the procedure, after being informed about the process by a physician. Local anesthesia was administered, including dorsal penile nerve block and penile ring block as required before the procedure. (7). The Rosenberg self-esteem scale (SES), Hospital anx- iety and depression (HAD) test and Arizona sexual experiences (ASEX) scale were filled out by each pa- tient before the procedure. Similarly, questionnaires were filled out by the control group of men who had already been circumcised in childhood. All of the male patients in the two groups were single and ASEX scores were evaluated through masturbation.

Rosenberg SES was developed in 1965 by Rosen- berg(8). Cuhadaroglu et al. published the Turkish vali- dation of SES (9). Briefly, outcome scores of Rosenberg SES are categorized; 0–1 as “high self-esteem” 2–4 as “mild self-esteem” and 5–6 as “low self-esteem’’. HAD test was developed by Zigmound et al. in 1983 (10). It was validated in the Turkish language by Aydemir et al. (11). Accordingly, the cut-off values of 10 and 7 were taken for the presence of anxiety and depression in the subjects, respectively. ASEX consists of 5 in- dices, quantifying sexual drive, sexual arousal, penile erection, ability to reach orgasm, and satisfaction of orgasm. Soykan et al. adapted the survey into the Turk- ish language in 2004 (12). Scores ranged from 5 to 30, where the higher the score indicates the more sexual dysfunction. The presence of sexual dysfunction was labeled with the criteria as follows; total ASEX score of >19 or any single query item scored 6 or any two query items scored 5 or any three query items scored 4 (13).

We described the Group I as desiring to get circum- cised in adulthood age and Group II as circumcised in childhood. The self-esteem, mood and sexual life scores were compared between these groups.

Statistical analysis was performed with SPSS 17.0 (Chicago, Illinois, USA). The variables were investigat- ed using visual and analytical methods (Shapiro-Wilk’ s test) to determine whether or not they are normally distributed. Since the Rosenberg self-esteem scores, anxiety scores, and depression scores were not normal- ly distributed; nonparametric tests were conducted to compare these parameters. The Mann-Whitney U test was used to compare the variables between the groups. ASEX scores were normally distributed, therefore stu- dents t-test was used to compare the groups. A p-value of less than 0.05 was considered to show a statistically significant result.

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MATERIAL AND METHODS

After obtaining the approval of the local ethics committee, between 2016 and 2019, 20 patients who applied to our outpatient clinic with a request for circumcision and 20 patients that we selected as the control group were included in the study. All patients underwent a physical examination. Patients with hy- pospadias and balanitis were excluded from the study.

All patients expressed their willingness to get circum- cised after reading the consent form and accepting the pros and cons of the procedure, after being informed about the process by a physician. Local anesthesia was administered, including dorsal penile nerve block and penile ring block as required before the procedure. (7). The Rosenberg self-esteem scale (SES), Hospital anx- iety and depression (HAD) test and Arizona sexual experiences (ASEX) scale were filled out by each pa- tient before the procedure. Similarly, questionnaires were filled out by the control group of men who had already been circumcised in childhood. All of the male patients in the two groups were single and ASEX scores were evaluated through masturbation.

Rosenberg SES was developed in 1965 by Rosen- berg(8). Cuhadaroglu et al. published the Turkish vali- dation of SES (9). Briefly, outcome scores of Rosenberg SES are categorized; 0–1 as “high self-esteem” 2–4 as “mild self-esteem” and 5–6 as “low self-esteem’’. HAD test was developed by Zigmound et al. in 1983 (10). It was validated in the Turkish language by Aydemir et al. (11). Accordingly, the cut-off values of 10 and 7 were taken for the presence of anxiety and depression in the subjects, respectively. ASEX consists of 5 in- dices, quantifying sexual drive, sexual arousal, penile erection, ability to reach orgasm, and satisfaction of orgasm. Soykan et al. adapted the survey into the Turk- ish language in 2004 (12). Scores ranged from 5 to 30, where the higher the score indicates the more sexual dysfunction. The presence of sexual dysfunction was labeled with the criteria as follows; total ASEX score of >19 or any single query item scored 6 or any two query items scored 5 or any three query items scored 4 (13).

We described the Group I as desiring to get circum- cised in adulthood age and Group II as circumcised in childhood. The self-esteem, mood and sexual life scores were compared between these groups.

Statistical analysis was performed with SPSS 17.0 (Chicago, Illinois, USA). The variables were investigat- ed using visual and analytical methods (Shapiro-Wilk’ s test) to determine whether or not they are normally distributed. Since the Rosenberg self-esteem scores, anxiety scores, and depression scores were not normal- ly distributed; nonparametric tests were conducted to compare these parameters. The Mann-Whitney U test was used to compare the variables between the groups. ASEX scores were normally distributed, therefore stu- dents t-test was used to compare the groups. A p-value of less than 0.05 was considered to show a statistically significant result.

RESULTS

A total of forty men were involved in our survey. Twenty patients who were admitted for circumcision formed the study group(Group I), whereas 20 men who had already been circumcised in childhood formed the control group (Group II). The mean age of all patients

was 21.32+/-1.62. Mean Rosenberg Self-esteem score was 2.15+/- 2.10. Mean anxiety score was 6.70+/-4.83. Mean depression score was 6.27+/-4.21. Mean ASEX score was 12.37+/-3.51 (Table 1). Seventeen of 20 un- circumcised men’s and twelve of 20 circumcised men’s Rosenberg self-esteem was normal. Fifteen of 20 uncir- cumcised men’s and nineteen of 20 circumcised men’s anxiety scores were normal. Twelve of 20 uncircum- cised men’s and twelve of 20 circumcised men’s depres- sion scores were normal (Table 2).

Mean Rosenberg self-esteem scores were 1.9+/- 1,58 in Group I and 2,4+/-2,54 in Group II. When we performed Mann-Whitney U test Rosenberg self-esteem scores were not significantly different be- tween the groups (p=0.08). Mean anxiety scores were 6,4+/-5,13 in Group I and 7+/-4,63 in Group II. Anx- iety scores were not significantly different between the groups (p=0.64). Mean depression scores were 6,3+/-3,43 in Group I and 6,25+/-4,96 in Group II. Depression scores were similar (p=0.50). Mean ASEX scores were 12,85+/-3,71 in Group I and 11,9+/-3,32 in Group II. ASEX scores were the same between the groups(p=0.47) (Table 3).

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RESULTS

A total of forty men were involved in our survey. Twenty patients who were admitted for circumcision formed the study group(Group I), whereas 20 men who had already been circumcised in childhood formed the control group (Group II). The mean age of all patients

was 21.32+/-1.62. Mean Rosenberg Self-esteem score was 2.15+/- 2.10. Mean anxiety score was 6.70+/-4.83. Mean depression score was 6.27+/-4.21. Mean ASEX score was 12.37+/-3.51 (Table 1). Seventeen of 20 un- circumcised men’s and twelve of 20 circumcised men’s Rosenberg self-esteem was normal. Fifteen of 20 uncir- cumcised men’s and nineteen of 20 circumcised men’s anxiety scores were normal. Twelve of 20 uncircum- cised men’s and twelve of 20 circumcised men’s depres- sion scores were normal (Table 2).

Mean Rosenberg self-esteem scores were 1.9+/- 1,58 in Group I and 2,4+/-2,54 in Group II. When we performed Mann-Whitney U test Rosenberg self-esteem scores were not significantly different be- tween the groups (p=0.08). Mean anxiety scores were 6,4+/-5,13 in Group I and 7+/-4,63 in Group II. Anx- iety scores were not significantly different between the groups (p=0.64). Mean depression scores were 6,3+/-3,43 in Group I and 6,25+/-4,96 in Group II. Depression scores were similar (p=0.50). Mean ASEX scores were 12,85+/-3,71 in Group I and 11,9+/-3,32 in Group II. ASEX scores were the same between the groups(p=0.47) (Table 3).

DISCUSSION

Uncircumcised adult males may have impaired self confidence in terms of their sexuality and may be sus- ceptible to depression in a society where the majority of males are circumcised. Since circumcision in our so- ciety is performed for religious and cultural purposes rather than medical reasons, being uncircumcised may create a sense of guilt (6, 14). Accordingly, self-confi- dence may be low. This may cause mood disorders in uncircumcised men. There are also studies suggesting sexual well-being may be different in circumcised and uncircumcised men (15-17).

Adayener et al report an improved appraisal in body cathexis after adult circumcision in a study group similar to ours (6). Also, Kalkan et al suggest that be- ing uncircumcised at puberty has a negative effect on body-esteem and self-esteem (18). On the other hand, Hammond et al report being circumcised is associat- ed with low self-esteem (19). In our study, using the Rosenberg self-esteem scale indices, no difference is apparent between men who are circumcised in child- hood and adult. Since our study group is sampled from a society which is widely circumcised, being uncircum- cised in a generally circumcised society might have different psycho-dynamics compared to being circum- cised in a society where circumcision is not common. We think that it is possibly due to the fact that being circumcised or not is not something that is apparent in everyday social life.

Additionally, the surveys do not include queries on the main purpose of the circumcision. Based on the questioning during physical examinations, all patients in our study were getting circumcised for religious rea- sons, especially before getting married. None of them had medical or hygiene concerns. Accordingly, we were expecting significant mood alteration, however, neither anxiety nor depression scales indicated any sig- nificant impairment.

Some authors demonstrate no difference in cir- cumcised and uncircumcised men in terms of sexual functions, including orgasmic and erectile functions (15, 17, 20-22). Similarly, our study showed no link be- tween circumcision and sexual function.

The main limitation of our study is the low number of patients included in the study. However, in societies

like ours, which are mostly circumcised in childhood, it is difficult to find this number of cases. Although our case number is low, we think that our results may have come out reflecting the universe. Based on the results of our study, we think that randomized, prospective, and even multicentre studies with larger series can yield clearer results.

CONCLUSION
Being circumcised or uncircumcised seems not to affect the self-esteem, mood and the sexual functions in a society like our country, the majority of which are circumcised at a childhood age.

Conflict of interest
All authors declare no conflict of interest.

Financial Disclosure
The authors have declared no financial support.

Ethical Approval
The study was approved by the Ethic Committee of Nevsehir Hacı Bektas Veli University (Approval number: 2020.02.04, 9 Jan,2020) and written informed consent was received from all participants. The study protocol conformed to the ethical guidelines of the Helsinki Declaration.

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