The Relationship of Urological and Psychological Problems with Circumcision – A Cross-sectional Study

Emre Tokuc¹, Nazim Yildiz², Zulfu Sertkaya³, Emrah Ozsoy⁴, Ridvan Kayar¹, Fatih Ozkaya⁵

¹Department of Urology, Haydarpasa Numune Training and Research Hospital, Istanbul, Türkiye
²Department of Psychiatry, Medallion Psychiatry Clinic, Istanbul, Türkiye
³Department of Urology, AndroExpertise Clinic, Istanbul, Türkiye
⁴Department of Urology, Private Unye Cakirtepe Hospital, Ordu, Türkiye
⁵Department of Urology, MedicalPark Bahçelievler Hospital, Istanbul, Türkiye

DOI : 10.5505/GJU.2023.40427

Pages : 090-096

Abstract

Objective: Circumcision is one of the most common surgical procedures in the world which is performed for various reasons. The aim is to investigate whether people's satisfaction with circumcision, their perspectives on circumcision, and whether there is a connection between circumcision and psychological/urological problems.

Materials and Methods: Between 21 March 2023- 10 April 2023, 1009 men aged between 18- 50 who volunteered to participate in the survey were included in the study. Demographic structures of the people (age, education, income status), age of circumcision, by whom, where and with what type of anesthesia; problems during circumcision, satisfaction with circumcision, any sexual and psychological problems and the relationship of this problem with circumcision were investigated.

Results: Mean age of 1009 participants was 32.02±9.15 and mean age of circumcision was 6.18±3.10. 269 (26.7%) men stated that they experienced circumcision complications and 145 (14.4%) stated that they were not satisfied with circumcision. 267 men (26.5%) had sexual or urological problems, and 274 (27.2%) had psychological problems, but the relationship of both problems with circumcision was not significant. Both sexual/urological problems and psychological problems were found to be significantly higher in the group satisfied with circumcision (both p:0.000, p<0.05). The relationships between the characteristics of the circumcision performed (circumcision age, anesthesia method, circumcision site and the person performing it) and urological/sexual problems were found to be significant (all p<0.05).

Conclusion: This cross-sectional study supports the hypothesis that circumcision has no relationship with urological/andrological or psychological problems. However, although circumcision is a relatively simple and frequently performed surgical procedure, characteristics such as the age at which the circumcision was performed, the type of anesthesia, the place where it was performed, and the person performing the circumcision are important in order to avoid future urological/sexual problems.

Introduction

Circumcision is the most common surgical procedure in the world, which has been practiced since ancient times, both traditionally and religiously in various societies, and also has medical indications [1]. The World Health Organization (WHO) reported that 30% of men worldwide are circumcised [2]. The positive and negative psychological effects of such a frequently performed surgical procedure on patients and some urological complications have been the subject of discussion in the literature for many years.

Psychologically, the social anxiety of being uncircumcised in a mostly circumcised society can affect men. In this respect, circumcision can be seen as a procedure that can provide positive psychological contributions such as reinforcing the feeling of "being a man", improving body image, and being accepted in society [3,4]. On the other hand, the fact that this age group's ability to decide on its own body is debatable, as it is a procedure that is mostly applied in infancy and childhood, and that parents are often decisive instead of the child, increases the ethical debates about circumcision [5,6].

On the urological aspect, it is an undeniable fact that the circumcision procedure reduces the frequency of urinary tract infections and sexually transmitted infections. In addition, it reduces the risk of cervical cancer in partner women by reducing the incidence of penile human papillomavirus (HPV) [7,8]. In addition, it significantly reduces the risk of penile cancer and eliminates preputial pathologies such as phimosis [9]. However, the sexual effects of circumcision are a popular topic of discussion in the literature.

The aim of this study is to evaluate people's perspectives on their circumcision, to measure their satisfaction, and to investigate whether there is a connection with circumcision if they have psychological and/or urological problems.

Materials and Methods

This observational cross-sectional survey study was approved by the Haydarpasa Numune Training and Research Hospital Clinical Research Ethics Committee on 20.03.2023 with the decision number HNEAH-KAEK 2023/40. Between 21 March 2023 and 10 April 2023, 1009 men between the ages of 18-50 who volunteered to participate in the survey were included in the study. A non-validated, semi-structured questionnaire of 15 questions prepared for the patients was filled out (Figure 1). In the survey questions, demographic structures of the people (age, education, income status), age at which circumcision was performed, by whom, where and with what type of anesthesia; whether there were any problems during circumcision, whether he was satisfied with his circumcision; whether he had any sexual and psychological problems and the relationship of this problem with circumcision were questioned. The study was carried out in accordance with the principles of the Declaration of Helsinki, no personal information was included in the questionnaire and the data was collected completely anonymously.

Figure 1. Questionnaire of 15 questions prepared for the patients

Statistical Analysis
After the data in the questionnaires were collected, the results were reported as mean, standard deviation and percentage (%). Distribution normality was evaluated with the Shapiro-Wilks test. Chi-Square, Mann-Whitney U or Kruskal-Wallis tests were used to determine statistical differences according to the type and distribution of variables. Bonferroni-corrected Dunn's test was used as a post-hoc analysis to determine which group was significant in multiple groups that were significant. Statistical significance was taken as p<0.05.

Results

The mean age of 1009 participants were 32.02±9.15 and the mean age of circumcision was 6.18±3.10. Demographic information of the participants is given in Table 1.

Table 1. Demographic data of the participants

Of the participants, 269 (26.7%) stated that they experienced circumcision complications and 145 (14.4%) stated that they were not satisfied with circumcision. 267 of the participants (26.5%) declared that they had sexual or urological problems and 274 (27.2%) of them had psychological problems, but the relationship of both problems with circumcision was not significant (p=0.376 and 0.983, respectively). Data on general circumcision satisfaction, problems experienced and their relationship with circumcision are given in Table 2.

Table 2. General satisfaction and problems encountered concerning circumcision

Considering the participants who had sexual/urological or psychological problems, those who were satisfied with circumcision were statistically significantly higher than those who were not (p=0.000 and p=0.000). There was no significant difference between sexual, urological or psychological problem subtypes in terms of circumcision satisfaction. Data on the relationship between circumcision satisfaction and problems are given in Table 3.

Table 3. The relationship between satisfaction with circumcision and sexual/ urological and psychological problems

When the relationship between the characteristics of circumcision performed on the participants and urological problems was examined, it was seen that circumcision age (p=0.000), anesthesia type (p=0.000), circumcision site (p=0.000) and circumcised person (p=0.001) were statistically significant in the occurrence of urological problems. Circumcision age >12, circumcision under general anesthesia, mass circumcision ceremonies or circumcision performed by general practitioners in the health center and circumcision performed by general practitioners have been found to be stastistically significantly related with urological problems. The relationship between circumcision features and urological problems is summarized in Table 4.

Table 4. The relationship between circumcision features and urological problems

Discussion

Circumcision, which is a surgical procedure applied to almost every man, especially in Muslim and Jewish societies, is also on the agenda in other societies, both for medical indications and for its protection from possible medical consequences. The fact that it is such a frequently performed surgery has led to the fact that the psychological and urological/andrological effects of circumcision are frequently the subject of research in the literature [6,10].

When the answers given by the participants in our study are examined, it is seen that the rate of participants who are not satisfied with circumcision in general is 14%. When the literature is examined, although there is no long-term feedback study on individuals" own circumcision, it was seen in the study conducted by Özen and Eroğlu in 2019 that parents were not satisfied with the circumcision of their children at a rate of 41.2% [11]. In this study, although the parents" satisfaction with circumcision changes significantly with age, it was observed that the lowest dissatisfaction rate (2.1%) was observed in the first month of neonatal period. Although the overall dissatisfaction rate was 14% in our study, this rate reached 37.4% in those with urological or sexual problems and 34.5% in those with psychological problems. This relationship with circumcision is statistically insignificant; possibly due to the vast majority of participants leaving this question unanswered. In addition, when only the respondents were considered, 38-42% reported that these problems could be related to circumcision.

In European and American communities where circumcision is not common, the psychological effects of circumcision, especially on children, have been discussed for years. It has been suggested that the feeling of "difference" caused by circumcision in a mostly uncircumcised society and the trauma to the body and "masculinity" perception caused by the intervention to the male genital organ during circumcision may cause psychosomatic symptoms of future depression, anxiety, and posttraumatic stress disorder [12,13]. On the contrary, it is obvious that being uncircumcised can lead to feelings of exclusion, not being accepted in society, shame and similar feelings in generally circumcised societies. However, the psychological effects of a surgical procedure performed on the genital area in childhood are important, and therefore, providing effective analgesia and anesthesia during the circumcision procedure is extremely important in order to avoid possible psychological effects [14,15]. However, in general terms, it is very unlikely that psychological problems in adulthood, which may be highly multifactorial, are attributed to circumcision performed in childhood.

In our study, it was seen that urological problems increase significantly as the age of circumcision increases. In published guidelines and studies, it is shown that circumcision performed especially in the neonatal period has a more effective and faster recovery period compared to other age groups and can be performed with fewer complications [16,17]. In addition, the sense of awareness that develops with advancing age increases the risk of complications, especially in circumcision procedures performed without anesthesia or with local anesthesia [18]. Although there is no data with a high level of evidence, most experts do not recommend circumcision in the age range of 3-6 years, which is called the "phallic" period, when children gain their sexual identity, for fear of sterilization and to avoid psychosexual effects that may occur in the future [19]. In their 2013 publication, Armağan et al. argue that circumcisions performed during the phallic period do not actually cause any sexual or depressive side effects, and that this is nothing more than an anecdote [20].

Unexpectedly, it was found to be significantly higher in the general anesthesia group when the relationship between the type of anesthesia and the urological problem was investigated. There are reports in the literature such as methemoglobinemia due to local anesthetic agents, necrosis of the glans or penis due to vasoconstriction [21-23]. However, there is no study in the literature comparing short or long-term urological complications after circumcision according to anesthesia type, and this study is the first data in the literature on this subject. However, a causeeffect relationship could not be established within the framework of logic on this subject, and it is obvious that there is a need for comprehensive studies on this subject.

In our study, it was observed that the circumcision site and the person performing the circumcision had a significant effect on urological problems. It has been observed that circumcisions performed in places such as general health centers or mass circumcision ceremonies are more open to the risk of urological complications, and circumcisions performed by general practitioners have a higher rate of urological problems. Although circumcision is often seen as a minor surgery, it is a surgery after all and the importance of care and experience cannot be denied. These results are in line with the data found in studies conducted in Nigeria and Turkey comparing medical and non-medical circumcised individuals [24,25]. In addition, it was shown in Özdemir's study that the complication risk rate is higher in mass circumcision ceremonies [26].

When our data were examined, it was seen that the majority of circumcised men were circumcised by a traditional circumciser, the majority of them were circumcised without anesthesia or with local anesthesia, and again, the majority of them were circumcised under household conditions. However, when these participants were questioned about where and by whom they wanted their children to be circumcised; most of them stated that they wanted the procedure to be performed by a specialist doctor and most of them in the hospital. It can be thought that this finding is a useful increase in awareness in order to reduce the urological and psychological complications that circumcision may bring in a constantly developing and changing world. In order to reduce the urological and psychological complications of circumcision, it is of great importance that it is performed preferably in the neonatal period or in infancy, accompanied by any anesthesia and in experienced health institutions.

As being an observational cross-sectional study, a definite judgment from the results obtained is difficult to sustain a causal inference and the association is difficult to interpret. Also, these kinds of studies are known to be susceptible to nonresponse and recall biases. Even though the study is done with a high number of participants, short-time interval and unanswered questions detract the scientific effect of this study. The questionnaire being a semi-structured, non-validated survey also contributes to the limitations of this study. All in all, as defining the key role important factors and features of circumcision that tend to effect possible urological/psychological complications, we believe that this study can shed light on new validation studies of the current questionnaire and also bring new horizons with multicenter collaborative studies with larger sample sizes.

Conclusion

Our study supports the argument that circumcision is not associated with urological/andrological or psychological problems in adulthood. However, although circumcision is a relatively simple and frequently performed surgical procedure, features such as the age at which the circumcision was performed, the type of anesthesia, the place where it was performed, and the person performing the circumcision may be deemed important in order to avoid future urological/sexual problems.

Ethics Committee Approval: The study protocol was approved by the University of Health Sciences, Haydarpasa Numune Training and Research Hospital Clinical Research Ethics Committee on 20.03.2023 with the decision number HNEAH-KAEK 2023/40.

Informed Consent: An informed consent was obtained from all the patients.

Publication: The results of the study were not published in full or in part in form of abstracts.

Peer-review: Externally and internally peer-reviewed.

Authorship Contributions: Any contribution was not made by any individual not listed as an author. Concept – E.T., N.Y.; Design – E.T., N.Y.; Supervision – E.T., N.Y., F.O; Resources – E.O., R.K.; Materials – E.O., R.K.; Data Collection and/or Processing – E.O., R.K.; Analysis and/or Interpretation – E.T., N.Y.; Literature Search – E.O., R.K.; Writing Manuscript – E.T., N.Y.; Critical Review – E.T., F.O.

Conflict of Interest: The authors declare that they have no conflicts of interest.

Financial Disclosure: The authors state that they have not received any funding.