Impotence and Adult Circumcision

EXTENSIVE debate on the advisability of circumcision in the neonatal period was initiated by Preston in 1970,¹ who suggested that boys could always elect circumcision later if desired. On the other hand, evaluation of patients undergoing circumcision between the ages of four and seven revealed extensive detrimental psychological effects.² It is the purpose of this report to suggest that greater attention be given to the potential for psychologic problems related to elective circumcision in the adult.

The patients presented as case reports were all on active duty with the United States Air Force and had some problems peculiar to this status. All had complete physical and laboratory examinations,³ including examination of external and internal genitalia, neurological examination, complete blood counts, oral glucose tolerance tests, protein bound iodine and T-4 uptake, serum electrolytes, VDRL, sperm counts, and 2-hour urinary keto-steroids and hydroxysteroids. All were within normal limits with the exception of reactive hypoglycemia in one patient, who had a blood sugar of 40 mg% at three-hours postprandial.

CASE REPORTS

Case 1. W. J., a 23-year-old black father of two, was circumcised at age 22 while on a tour of duty unaccompanied by his wife. His first post-operative attempt at intercourse, which coincided with his first attempt at extramarital intercourse, was a failure. Impotence continued after he returned to his wife. He refused psychiatric consultation, and was treated with Halotestin, 10 milligrams daily, with temporary improvement.

Case 2. J. G., a 31-year-old white father of two (ages 9 and 10) underwent elective circumcision at age 28, and vasectomy at age 30. The latter was done while the patient was separated from his wife, and he noted the onset of impotence as that tour of duty was nearing completion.

Case 3. M. J., a 29-year-old black father of two, had an elective circumcision at age 23. He also gave a history of intermittent low-back pain since the age of 20. impotence was transient, hut recurring. When first seen by the author he complained of impotence accompanied by low-back pain with radiation into the posterior aspect of both thighs. Evaluation by cardiovascular surgeons, neurologists and orthopedic surgeons failed to disclose any physical basis for the pain, and alt symptoms were considered psychological. He was treated at various times with Halotestin 10 to 20 mg. daily, Cytomel 5 to 25 mcg. daily, or Valium 20 mg. daily without any change in the recurrent nature of his impotence or low-back pain.

Case 4. B. A., a 34-year-old white father of three, was circumcised at age 22. He was seen initially because of chronic epigastric pain. Upper GI series, oral cholescystogram and barium enema were normal, as were liver function studies. He was treated with Valium for a functional gastro-intestinal syndrome, and later reported that Valium reduced his libido. Further questioning revealed that impotence had been present periodically for several years.

Case 5. B. S., a 31-year-old white father of two, had elective circumcision and vasectomy while serving a tour of duty requiring separation from his family. On returning home, he learned that his wife had filed for divorce. He had a full-blown psychotic reaction requiring extensive hospitalization and psychotherapy. On return to an acceptable level of function he found himself impotent.

COMMENT

Since the widespread adoption of vasectomy as a means of voluntary-sterilization, follow-up studies have led to the recommendation that pre-operative evaluation include psychologic assessment.⁶ No such recommendation is made for elective circumcision in the adult. While this report cannot claim to show a causal relationship between circumcision and impotence, adult circumcision is the one common thread ill the five patients presented. In addition, two of the men had vasectomies, two first noted impotence during extra-marital intercourse, one had impotence accompanied by low-back pain,⁷ and one noted impotence after a severe psychotic episode. Tile latter had been treated with various psychotropic drugs. There was probably a great deal of interplay between circumcision and these other factors. Nevertheless, it is felt that these case reports are adequate to recommend psychological evaluation prior to elective circumcision, and post-operative psychological counselling when the procedure is done on an emergency basis.

* The opinions expressed in this paper are solely those of the author, and in no way represent the views of the United States Air Force or of its Medical Service.

⁺ Formerly with the Medical Service, USAF Hospital, Holloman Air Force Base, New Mexico.

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