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Male circumcision does not result in inferior perceived male sexual function – a systematic review

Authors

Daniel Mønsted Shabanzadeh1, 2, 3, Signe Düring4 & Cai Frimodt-Møller5

1) Digestive Disease Center, Bispebjerg Hospital

2) Research Centre for Prevention and Health, Capital Region of Denmark

3) Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen

4) Mental Health Services of the Capital Region Region of Denmark

5) Department of Urology, CFR Hospitals, Denmark

 
ABSTRACT

INTRODUCTION:

The debate on non-medical male circumcision has gaining momentum during the past few years. The objective of this systematic review was to determine if circumcision, medical indication or age at circumcision had an impact on perceived sexual function in males.

METHODS:

Systematic searches were performed in MEDLINE and EMBASE. The included studies compared longterm sexual function in circumcised and non-circumcised males, before and after circumcision, or compared different ages at circumcision. The quality of the studies was assessed according to the level of evidence (Grade A-D).

RESULTS:

Database and hand searches yielded 3,677 records. Inclusion criteria were fulfilled in 38 studies including two randomised trials. Overall, the only identified differences in sexual function in circumcised males were decreased premature ejaculation and increased penile sensitivity (Grade A-B). Following non-medical circumcision, no inferior sexual function was reported (A-B). Following medical circumcision, most outcomes were comparable (B); however, problems in obtaining an orgasm were increased (C) and erectile dysfunction was reported with inconsistency (D). A younger age at circumcision seemed to cause less sexual dysfunction than circumcision later in life.

CONCLUSIONS:

The hypothesis of inferior male sexual function following circumcision could not be supported by the findings of this systematic review. However, further studies on medical circumcision and age at circumcision are required.

 

Link to full text article (pdf) above.

 

CORRESPONDENCE: Daniel Mønsted Shabanzadeh. E-mail: daniel.moensted.shabanzadeh.01@regionh.dk

ACCEPTED: 5 April 2016

CONFLICTS OF INTEREST: Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk

ACKNOWLEDGEMENTS: We would like to thank PhD student Lin Chia-Hsien from Department of Public Health at the University of Copenhagen for her assistance with the Chinese articles, and Birthe Frimodt-Møller for linguistic assessment

 

 

Bib ref: 
Dan Med J 2016;63(6):A5245
Magazine: 

💬 7 Comments

In this controversial ‘qualitative synthesis’ paper with numerous methodological shortcomings, Shabanzadeh et al seek to inform the ongoing debate over non-therapeutic childhood male circumcision. However, the authors chose to include any study looking at sexual outcomes after circumcision, whether in boys or adult males, whether in healthy individuals or in patients with a foreskin problem, whether in Africa or in Western settings, and whether with a follow-up period of decades or only a few months to years. Such a cacophony of 38 studies, dominated by findings on short-term sexual consequences of voluntary, adult male circumcision has limited relevance, if any, to the authors’ stated research question: how non-therapeutic circumcision in boys affects the sex lives of the adult men they will one day become.

Editor's note: The full commentary by Frisch and Earp is available as a PDF at the following link:
http://ugeskriftet.dk/files/2016-07-01_commentary_frisch_earp_on_paper_by_shabanzadeh_et_al_dmj_1.pdf
Dear Morten Frisch and Brian Earp

We thank you both for the interest in our paper.

We respectfully disagree that the conductance of systematic reviews is unjustified, and we can only emphasize the importance of identifying all available literature for clarity, before drawing conclusions on a delimited objective, such as, whether the exposure of circumcision has an impact on outcomes of perceived sexual function in adult males. The systematic process was performed according to the PRISMA statement and our conclusion reflected the lack of research in specific domains. We therefore, do not feel the need to justify the methodology any further.
You have problematized that we did not include a Canadian study of sexual partners to circumcised males, however, this was not part of our research objective. To answer the objective of the impact of circumcision on sexual partners perceived sexual function would require yet another systematic review process.

Circumcision is performed on both clinical indications such as penile or prepuce pathology and for non-clinical purposes such as cultural practice or with the aim of HIV-prevention. As we have demonstrated in the paper, many studies fail to distinguish these two populations which is major limitation from a clinical perspective, and one should therefore not draw conclusions about either from such studies. Frisch and Earp suggest that a number of other factors besides this clinical perspective may contribute to the outcome of perceived sexual function in males and we do agree. We have risen the issue of heterogeneity and limitations of the available literature in the discussion.

Our conclusion clearly states the results of the highest quality of available evidence and the lack of high quality studies on consequences of medically indicated circumcision and age at circumcision in order to fully answer our study objectives, and we have specifically stated that a majority of the studies does not take sexual orientation into perspective. We have suggested specific study designs on how to fill the gaps in evidence for future research.
We would like to extend to you both, and all other interested parties, an invitation to collaborate in the future. We can all agree that the field calls for further research, and would be happy to join forces, with contributions from both clinical, epidemiological and physiological angles.
The field of this study is by no means the authors' primary competence. Forthermore the study deals with concepts which are not very well defined.
If you - under such circumstances - out of 3.677 references pick 177 and conclude on only 38 ~ 1 ‰, you may reach EXACTLY the result you are wishing for, whatever it is.
The first requirement of a scientific study is that the study is carried out and described in a way that any scientist would reach the same conclusion if he performed the experiment as described.
I wonder how this highly subjective article passed the peer review?
Response to Dorte Nielsen
Thank you for the interest in our paper.
For how to conduct a systematic review we refer to the PRISMA guidelines. The methodology of the paper has been reported in detail and is reproducible.

Regards,
The Authors
We congratulate the authors on their systematic review. They should have been aware of a systematic review in the world's leading specialist journal in this area that concluded male circumcision has no adverse effect on sexual function, sensitivity or sensation (Morris BJ, Krieger JN. Does male circumcision affect sexual function, sensitivity, or satisfaction?--A systematic review. J Sex Med 2013; 10: 2644-2657) and another by Chinese researchers who also performed a meta-analysis of common forms of sexual dysfunction and concluded there was no difference between circumcised and uncircumcised men (Tian Y, Liu W, Wang JZ, Wazir R, Yue X, Wang KJ. Effects of circumcision on male sexual functions: a systematic review and meta-analysis. Asian J Androl 2013; 15: 662-666). Also pertinent to their review is a systematic review of histological correlates that found the foreskin has no role in sexual pleasure (Cox G, Krieger JN, Morris BJ. Histological correlates of penile sexual sensation: Does circumcision make a difference? (Systematic review). Sex Med 2015; 3: 76-85). That study revealed that the neuroreceptors invoked in sexual sensation reside in the glans (head) of the penis.They also seem unaware of a large study in the UK that came to the same conclusions (Homfray V, Tanton C, Mitchell KR, Miller RF, Field N, Macdowall W, Wellings K, Sonnenberg P, Johnson AM, Mercer CH. Examining the association between male circumcision and sexual function: evidence from a British probability survey. AIDS 2015; 29: 1411-1416). Frisch & Earp (Letter above) clearly do not want to accept the scientific evidence. Doing so would undermine their agenda opposing male circumcision.
Dear Brian J Morris

Thank you for the comments on our paper.

We did not include all systematic reviews on the subject since the objective was to only include original studies. Due to journal restrictions in maximum numbers of references, we were unable to cite all systematic reviews on the subject in the discussion.

The large observational study from the UK (Homfray et al. 2015) was included in our paper.

Regards,
The Authors
Response to Frisch and Earp’s comments on Systematic Review

We thank you both for the comments on our systematic review.

We respectfully disagree that the conductance of systematic reviews is unjustified. We can only emphasize the importance of identifying all available literature for clarity, before drawing conclusions on a delimited objective, such as, whether the exposure of circumcision has an impact on outcomes of perceived sexual function in adult males. The systematic process was performed according to the PRISMA statement and our conclusion reflected the lack of research in specific domains. We therefore, do not feel the need to justify the methodology any further.

You have problematized that we did not include a Canadian study of sexual partners to circumcised males, however, this was not part of our research objective. To answer the objective of the impact of circumcision on sexual partners perceived sexual function would require yet another systematic review process.

Circumcision is performed on both clinical indications such as penile or prepuce pathology and for nonclinical purposes such as cultural practice or with the aim of HIV-prevention. As we have demonstrated in the paper, many studies fail to distinguish these two populations which is major limitation from a clinical perspective, and one should therefore not draw conclusions about either from such studies. Frisch and Earp suggest that a number of other factors besides this clinical perspective may contribute to the outcome of perceived sexual function in males and we do agree. We have raised the issue of heterogeneity and limitations of the available literature in the discussion.
Our conclusion clearly states the results of the highest quality of available evidence

[The full response by the Authors is available as a PDF at the following link: http://ugeskriftet.dk/files/response_to_frisch_and_earp_dmj.pdf]

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