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Androlog Summary |
From the Division of Andrology, University of Illinois, Chicago, Illinois.
| Received for publication September 25, 2006; accepted for publication October 5, 2006. |
Recently, Jeff Koffler, a psychiatrist from Connecticut, posted on Androlog:
I have recently been consulted (I am a psychiatrist) by an 18 year old who is beginning college, because of depression, social anxiety and need for psychiatric management of his psychotropic medication. As I am by nature and determination a psychotherapist, we have been establishing a rapport and today he told me, before (what was only our 2nd) session ended, something he was eager to share: He was visited by a girl friend who in those two weeks became a girlfriend. They were intimate. He is uncircumcised. One of the girls he has had sex with (I don't know whether it's this one or not) [said] that it is strange. He has `gone on-line and researched' and believes it is also a healthier option to get cut. And he thinks it would be better looking, and that he would be more at ease if he were to go get a circumcision. His primary care MD is Jewish, as am I. I don't see it as necessarily important for him to be circumcised. I don't know whether his PMD would be biased towards circumcision (the young man is not Jewish) and it's my understanding that the foreskin is wonderfully innervated and might be a shame for him to lose! He also told me that he has read that most guys who are circumcised as adults are pleased with the results. What are people's thoughts on this matter?
In the specialty of urology, we are often asked to perform circumcision on adult males. However, much less frequently we face questions dealing with the consequences of this surgery, as the vast majority of adult circumcisions are performed as a treatment of choice to alleviate a specific medical condition, namely phimosis, as opposed to being done for "elective" or "social" reasons.
Dr. Woet L. Gianotten responded:
Regarding the request for non-religious circumcision. What a pity for this young man meeting such a traditional, silly girl. Most probably this girl is not living on the edge. She cannot stand a change and probably everything should be as it always has been in her home, in her bed or in her perception of decent reality. So she was not able to enjoy the advantages of a not-circumcised penis with its different feel, different smell, different taste and different view (or views since the glans can be both dressed and undressed). Those advantages are expressed by sex-enjoying women who are used to uncircumcised partners. Taste and smell are completely different after circumcision and especially the individual smell can become a very strong aphrodisiac in long standing relationships. This is at least the case in our Dutch culture where circumcision is not a rule and is only performed in boys for (Jewish and Muslim) religious reasons.
Bluestein et al (2005) demonstrated that no significant differences exist in penile sensation between circumcised and uncircumcised men with respect to vibration, pressure, spatial perception, and warm and cold sensation in patients with and without erectile dysfunction. These investigators performed neurosensory testing on 125 individuals, 63 of whom had been neonatally circumcised and 62 who had intact foreskins at the time of the study. To evaluate the patients, the group used the Erectile Function Domain of the International Index of Erectile Function. The authors conclude that the decision to circumcise remains a social issue (Bluestein et al, 2005).
In 2002, two groups published data on adult circumcision in the Journal of Urology, in an attempt to resolve the question of possible sexual dysfunction following the procedure. Fink et al (2002) observed worsened erectile function, decreased penile sensitivity, no change in sexual activity, and improved satisfaction following adult circumcision. Collins et al (2002) presented the results of a prospective study of 15 men who were asked to complete sexual function surveys both before and at a minimum of 12 weeks after circumcision. These investigators observed no difference in scores that reflected sexual function (Collins et al, 2002)
The medical benefits of circumcision are often noted. Lower rates of penile and cervical cancer prevail in populations with higher prevalence of circumcision (Castellsague et al, 2002). Investigators have observed a lower incidence of urinary tract infections in boys younger than one year of age who had been previously circumcised (To et al, 1998).
Recently, many researchers have investigated an association between circumcision and the prevention of HIV transmission in Africa. Several cohort studies have shown a lower prevalence of the virus among circumcised males (Simonsen et al, 1988; Urassa et al, 1997). However, some cross-sectional surveys from Africa have shown no association or an inverse association (Van Howe, 1999). O'Farrell and Egger (2000) have examined the data from 33 recent studies in a meta-analysis, and have reported that male circumcision may offer protection from HIV infection, particularly in high-risk groups. They recommend further systematic review of the available evidence and emphasize the heterogeneity of this issue (O'Farrell and Egger, 2000).
Specific antigen-presenting cells have been implicated as the primary entry-point receptors in the pathogenesis of HIV infection (Miller, 1998). The distribution of Langerhans cells, which is one such cell type, has been studied in the male genitalia (Hussain and Lehner, 1995). Szabo and Short (2000) have postulated that HIV receptors on the Langerhans cells located on the inner surface of the foreskin are likely to be the primary points of viral entry into the penis of an uncircumcised man (Szabo and Short, 2000). These investigators have further suggested that male circumcision should be seriously considered as an additional means of preventing HIV in all countries with a high prevalence of HIV infection (Szabo and Short, 2000).
Auvert et al (2005) have reported the results of the first randomized trial assessing the effects of circumcision as a possible medical intervention in the prevention of HIV spread. The trial involved 3274 uncircumcised males aged 18–24 years. The authors conclude that the degree of protection that circumcision would offer is equivalent to that offered by a high efficacy vaccine (Auvert et al, 2005).
However, Hill and Denniston (2003) rebutted many of the conclusions drawn by Auvert and colleagues, questioning some of the studies' designs, urging investigators to consider new factors in HIV transmission in Africa, and highlighting the medical, political, and bioethical consequences of instituting national policies using circumcision as a preventive measure in HIV transmission in Africa. They point out in particular that the heterosexual mode only accounts for 30% of transmission (approximately 33% of previous estimates) (Hill and Denniston, 2003). Thus, using circumcision in an attempt to prevent HIV would not account for what is arguably the largest confounding factor – iatrogenic transmission of the virus. In fact, to the contrary, a program of mass circumcision would possibly increase the risk of transmission through unsafe medical practices (Hill and Denniston, 2003).
When one considers circumcision, any real or imagined potential benefits should be weighted carefully against the well-described and real complications, such as infection, bleeding, penile and urethral trauma, and the risk of anesthesia. The literature to date seems to support the notion that circumcision, if not performed for medical indications, remains a procedure that is performed largely for social or religious reasons. Therefore, the responsibility remains with the patient, and in the case of young patients, their parents, to evaluate the risks and benefits of this surgery. It is our duty as physicians to assist patients and families to make the correct decision by providing the available objective scientific data.
References
Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Setta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PloS Med. 2005;2: 1112 –1122.
Bluestein CB, Fogarty JD, Eckholdt H, Arezzo J, Melman A. Effect of neonatal circumcision on penile neurologic sensation. Urology. 2005;65: 773 –777.[CrossRef][Medline]
Castellsague X, Bosch FX, Munoz N, Meijer CJLM, Shah KV, de Sanjose
S, Eluf-Neto J, Ngelangel CA, Chichareon S, Smith JS, Herrero R, Franceschi S,
for the International Agency for Research on Cancer Multicenter Cervical
Cancer Study Group, Male circumcision, penile human papillomavirus infection,
and cervical cancer in female partners. NEJM. 2002; 346: 1105
–1112.
Collins S, Upshaw J, Rutchik S, Ohannessian C, Ortenberg J, Albertsen P. Effects of circumcision on male sexual function: debunking a myth? J. Urol. 2002; 167: 2111 –2112.[CrossRef][Medline]
Fink KS, Carson CC, DeVellis RF. Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. J. Urol. 2002; 167: 2113 –2116.[CrossRef][Medline]
Hill G, Denniston GC. HIV and circumcision: new factors to
consider. Sex Transm Infect. 2003; 79: 495
–496.
Hussain LA, Lehner T. Comparative investigation of Langerhans' cells and potential receptors for HIV in oral, genitourinary and rectal epithelia. Immunology. 1995; 85: 475 –484.[Medline]
Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. JAMA. 1997;277: 1052 –1057.[Abstract]
Miller CJ. Localization of simian immunodeficiency virus-infected cells in the genital tract of male and female Rhesus macaques. J. Reprod. Immunol. 1998;41: 331 –339.[CrossRef][Medline]
O'Farrell N, Egger M. Circumcision in men and the prevention of HIV
infection: a `meta-analysis' revisited. Int J. STD
AIDS. 2000;11: 137
–142.
Simonsen JN, Cameron DW, Gakinya MN, Ndinya-Achola JO, D'Costa LJ, Karasira P, Cheang M, Ronald AR, Piot P, Plummer FA. Human immunodeficiency virus infection among men with sexually transmitted diseases. Experience from a center in Africa. NEJM. 1988; 319: 274 –278.[Abstract]
Szabo R, Short R. How does male circumcision prevent against HIV
infection? BMJ. 2000; 320: 1592
–1594.
To T, Agha M, Dick P, Feldman W. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet. 1998;352: 1813 –1816.[CrossRef][Medline]
Urassa M, Todd J, Ties Boerma J, Hayes R, Isingo R. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS. 1997;11: 73 –80.[Medline]
Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J. STD AIDS. 1999; 10: 8 –16.[CrossRef][Medline]
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