Male Circumcision and Sexual Function in Men and Women

A Survey-based, Cross-sectional Study in Denmark

Morten Frisch; Morten Lindholm; Morten Grønbæk


Int J Epidemiol. 2011;40(5):1367-1381. 

In This Article

Materials and Methods

The Health and Morbidity Study is a series of interview surveys that has addressed matters of public health in Denmark since 1987.[13] The surveys are based on nationally representative samples of Danish citizens aged ≥16 years drawn randomly by their unique personal identification number in the continuously updated Danish Civil Registration System.[14] Each identified person received an information letter with an invitation to participate. Upon written informed consent, participants underwent a structured personal interview in their home conducted by a professional interviewer. A total of 10 916 persons were invited to take part in that arm of the 2005 survey, which included questions about sexual health.

The interview covered matters related to health and morbidity, family situation, lifestyle and sociodemographic, cultural and religious background. After the interview, participants were asked to complete a self-administered questionnaire covering more sensitive issues, including questions about circumcision status or, for women, circumcision status of the spouse or steady male partner (referred to hereafter as the spouse), general sexual experiences (age at first sexual intercourse, number of sex partners since age 15 years, perceived importance of having a good sex life, and frequency of sexual activity with a partner in the last year), and experiences in the last year of low or lacking sexual desire, of incomplete fulfilment of sexual needs, or of difficulties in relation to sexual functioning with a partner [men: erectile difficulties, delayed orgasm or complete anorgasmia (hereafter referred to as orgasm difficulties), premature ejaculation or dyspareunia; women: lubrication insufficiency, orgasm difficulties, dyspareunia or vaginismus]. The degree to which a given sexual difficulty was present was rated on a five-point Likert scale ('not at all', 'rarely', 'sometimes', 'often' or 'every time'), as described in detail elsewhere.[15–17]

Statistical Analysis

We used chi-squared tests to evaluate possible differences in background variables between participants and non-participants and differences in background variables and general sexual experiences between circumcised men and men with an intact foreskin (referred to hereafter as uncircumcised), and between women with circumcised and uncircumcised spouses.

Subsequently, by means of logistic regression analyses we calculated two sets of odds ratios (ORs) with accompanying 95% confidence intervals (CIs) for associations between the exposure variable, circumcision and the sexual outcome variables, low or lacking sexual desire, incomplete sexual needs fulfilment and sexual function difficulties, with the latter categorized as either dichotomous outcomes ('not at all' vs any frequency of sexual difficulties) or polytomous outcomes ['not at all' vs 'rarely' or 'sometimes' (i.e. occasional difficulties) vs 'often' or 'every time' (i.e. frequent difficulties)]. Dichotomized outcomes were used when <10% of circumcised men or <10% of women with circumcised spouses reported frequent difficulties for the sexual difficulty in question. One set of ORs was calculated with adjustment only for age (16–29, 30–44, 45–59, ≥60 years), and the other (referred to hereafter as ORadj), included adjustment for age and a number of other potentially confounding differences between circumcised and uncircumcised participants. Specifically, ORadj were adjusted for age (16–29, 30–44, 45–59, ≥60 years), cultural background (Danish vs other; persons with at least one Danish-born parent were considered Danish), membership of religious community (yes vs no), three sociodemographic variables that were recently reported to be associated with sexual dysfunction in Denmark,[15] i.e. marital status (married vs not married), school attendance (≤9, 10–11, ≥12 years) and household income in year 2004 (<400 000 vs ≥400 000 Danish Kroner; 100 000 Danish Kroner ~11 500 UK£ ~13 400 Euros ~18 400 US$), and age at first sexual intercourse (<17 vs ≥17 years), number of sex partners since age 15 years (<4 vs ≥4), and frequency of sexual activity with a partner in the last year (≥weekly vs <weekly).

In 16 supplementary analyses, we examined the robustness of our main findings. First, we restricted the study population to participants whose cultural background was Danish, participants who were not Jews or Moslems, or participants aged 20–69 years (robustness analyses 1–3) to obtain less heterogeneous study populations. Secondly, we evaluated the impact of making various assumptions about men and women who provided no information about their circumcision status or that of their spouse (robustness analyses 4–7). Thirdly, we evaluated the stability of our multivariate statistical model by adding or removing possible health-related, socioeconomic or behavioural confounders in the logistic regression analysis (robustness analyses 8–16).

All ORs express the odds among circumcised men (or women reporting a circumcised spouse) vs the odds among the reference category of uncircumcised men (or women reporting an uncircumcised spouse). ORs were calculated using the LOGISTIC procedure in SAS version 9.1.[18]

The study was approved by the Danish Data Inspection Board (approval nos 2001-54-0894, 2007-41-0022 and 2008-54-0472).


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