Impact of circumcision performed under local or general anesthesia during the phallic stage on Adult Male Genital Self-Image

Impact of circumcision performed under local or general anesthesia during the phallic stage on Adult Male Genital Self-Image | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of circumcision performed under local or general anesthesia during the phallic stage on Adult Male Genital Self-Image Kenan Yalçın, Vildan Kölükçü This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8756159/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The optimal timing of circumcision during childhood and the preferred method of anesthesia remain subjects of ongoing debate. This study aimed to investigate the long-term potential effects of local versus general anesthesia administered during circumcision performed in the phallic stage on adult male genital self-image scores. Methods: A total of 84 male individuals who had undergone circumcision during the phallic stage were included in the study. Participants were divided into two groups based on the anesthesia type administered during the procedure: Group 1 received general anesthesia, while Group 2 received local anesthesia. Sociodemographic characteristics, including age, marital status, and educational background, were recorded. Additionally, body mass index (BMI), age at circumcision, indications for the procedure, and post-circumcision complications were analyzed. Each participant was assessed using the Beck Depression Inventory (BDI), the International Index of Erectile Function (IIEF-15), and the Male Genital Self-Image Scale (MGSIS-7). Results: The mean age of participants did not differ significantly between groups (p > 0.05). Similarly, there were no significant intergroup differences in terms of circumcision age, BMI, indication for the procedure, or complication rates (p > 0.05). Moreover, IIEF-15 and BDI scores also showed no statistical differences between the two groups (p > 0.05). However, the mean MGSIS-7 score was significantly lower in the local anesthesia group compared to the general anesthesia group (p < 0.0001), indicating a less positive genital self-image among those circumcised under local anesthesia. Conclusions: Circumcision performed under local anesthesia during the phallic stage may be associated with a more negative adult male genital self-image compared to procedures performed under general anesthesia. These findings highlight the potential psychological impact of anesthesia type during this sensitive developmental period and warrant further investigation. Phallic stage local anesthesia general anesthesia genital self-image. Figures Figure 1 Introduction Circumcision is one of the oldest and most widely practiced surgical procedures worldwide, performed for religious, cultural, or medical reasons. It is estimated that approximately 30–33% of men aged 15 years and older have undergone circumcision globally [ 1 ]. The procedure involves the surgical removal of the foreskin covering the glans penis. Despite being commonly performed, circumcision should not be regarded as a simple or minor intervention. The accurate identification of excision margins, strict adherence to antiseptic principles, and the provision of adequate analgesia and anesthesia are all essential for ensuring safe and optimal surgical outcomes [ 2 ]. The optimal timing for circumcision remains of topic of ongoing debate in both clinical and sociocultural contexts [ 3 ]. Similarly, there is no universally accepted or standardized protocol regarding the choice of anesthesia [ 4 ]. In Freudian psychoanalytic theory the so-called "phallic stage", between three and six years of age, represents a critical developmental period during which children begin to form their gender identity, establish body awareness, and internalize attitudes toward sexuality and the body [ 3 ]. Although there is a lack of high-level evidence from large-scale studies or meta-analyses, a significant proportion of healthcare professionals express concern about performing circumcision during this stage due to its potential association with castration anxiety, body image disturbances, and adverse psychosexual outcomes [ 1 , 3 ]. Nevertheless, circumcision during this developmental period remains common in many cultures, particularly when performed under local anesthesia for religious or traditional reasons. In pediatric patients within this age group, the procedure may trigger feelings of fear and anxiety, which could potentially contribute to long-term psychological consequences [ 5 , 6 ]. To the best of our knowledge, this is the first study in the English-language literature to examine the long-term effect of the anesthesia type administered during circumcision in the phallic stage on adult male genital self-image. Methods Ethical approval and consent to participate The study was approved by the Local Ethics Committee of Tokat University Faculty of Medicine (Approval No: 25-MOBAEK 241, Date: June 17, 2025). The research protocol adhered to the principles of the Declaration of Helsinki, and written informed consent was obtained from all participants before inclusion in the study. Patient characteristics The prospective observational study was conducted during January and March 2025 in the Department of Urology, Tokat University Faculty of Medicine. A total of 84 young adult males who presented for routine follow-up and had a documented history of circumcision performed during the phallic stage were included. Patients were attending follow-up for urinary system stone disease, renal cystic disease, and benign adrenal lesions. None of the participants had comorbidities known to cause sexual dysfunction. Based on the type of anesthesia administered during their circumcision, participants were categorized into two groups: Group 1 included individuals who had undergone circumcision under general anesthesia, and Group 2 comprised those who had received local anesthesia. Sociodemographic characteristics, including age, marital status, and educational level, were recorded for each participant. In addition, anthropometric data comprising height, weight, and body mass index (BMI) were calculated. Clinical variables included age at circumcision, indication for the procedure, and any post-operative complications were also analyzed. Psychological and sexual function assessments were conducted using three validated tools: the Beck Depression Inventory (BDI), the Male Genital Self-Image Scale (MGSIS-7), and the International Index of Erectile Function (IIEF-15) [ 7 – 10 ]. Surgical technique All circumcision procedures had been performed by an experienced urologist using the dorsal slit technique. In the local anesthesia group, bupivacaine was administered via subcutaneous peripheral infiltration at the base of the penis. In the general anesthesia group, anesthesia was induced using a laryngeal mask airway. Standard intraoperative monitoring included a 3-lead electrocardiogram, non-invasive blood pressure, and peripheral oxygen saturation. In the penile block group (Group-2), following sterile preparation in the supine position, 0.5 mg/kg 0.5% bupivacaine was administered at the base of the penis using a 21G needle, 15 minutes before surgery. For patients under anesthesia group (Group 1), 0.05 mg/kg midazolam, 2 mg/kg propofol, and 0.1 mcg/kg fentanyl citrate were administered intravenously according to the standard anesthesia protocol. After achieving the desired depth of anesthesia, a laryngeal mask airway was inserted, and mechanical ventilation was applied. All data were obtained from the hospital’s electronic medical records and the anesthesia and reanimation department’s patient follow-up forms. All circumcisions were performed by the same surgeon, and the anesthesia procedures were standardized across all cases. None of the patients had any medical conditions necessitating a change in the anesthesia method. Therefore, the choice of anesthesia was primarily determined by the parents of circumcised boys. To ensure data reliability, any cases involving different surgeons or anesthesia protocols were identified through the hospital's electronic archive and were excluded from the study. Follow-up All patients underwent a detailed genital system examination by medical staff. None of the participants presented with unsightly circumcision scars or major cosmetic defects. Following this assessment, the MGSIS-7, IIEF-15, and BDI scores were evaluated. The MGSIS-7 is a psychometrically validated tool comprising seven items designed to assess how men perceive and feel about their genitalia. Participants respond to each item using a four-point Likert scale, and the total score is derived by summing individual item responses. Higher cumulative scores reflect a more positive genital self-image. The Turkish version of the MGSIS-7 was adopted and validated by Koçak et al. [ 10 ] Sexual function was measured using the IIEF-15, a standardized questionnaire consisting of 15 items that evaluate multiple key aspects such as erectile quality, orgasm, sexual interest, satisfaction with intercourse, and overall sexual well-being [ 8 ]. Depressive symptoms were measured using the BDI, a 21-item, self-report rating scale that assesses the presence and severity of depression. Each item is rated on a four-point scale ranging from 0 (not at all) to 3 (severe), with higher total scores corresponding to increased levels of depression [ 7 ]. Participants were excluded if they had not engaged in regular sexual activity within the past six months or had comorbidities affecting sexual function, including neuropsychiatric disorders, hyperlipidemia, diabetes mellitus, coronary artery disease, hypertension, chronic kidney disease, or hypogonadism. Subjects with a history of pelvic surgery or medication use known to affect erectile function were also excluded from the analysis. Statistical analysis Data analysis was conducted using MedCalc statistical software (version 20.009; Ostend, Belgium). The Kolmogorov–Smirnov test was used to assess the normality of data distribution. Continuous variables were presented as mean ± standard deviation (SD) or as median (interquartile range, IQR), depending on distribution. For group comparisons, the Independent Samples t-test was used for normally distributed variables, and the Mann–Whitney U test was applied to non-normally distributed data. Categorical variables were summarized using frequencies and percentages and evaluated using the Chi-square (χ²) test. The Kruskal-Wallis test was used for comparison of more than two groups. Numerical data of the groups were visually displayed using box-whisker graphs, and extreme values were indicated as points. Logistic regression was used to identify age, BMI, MGSIS-7, IIEF-15, and BDI parameters as risk factors for circumcision during the phallic stage, according to the type of anesthesia. Odds ratios (OR) and corresponding 95% confidence intervals (CI) for each parameter are reported. A p-value less than 0.05 was considered statistically significant. Sample size was determined using G*Power software (v3.1.2). The statistical power of the study, expressed as 1-β (where β represents the probability of a Type II error), was set at 80%. According to Cohen’s effect size conventions, and assuming a large effect size (d = 0.7) for comparisons between two independent groups, it was calculated that a minimum of 34 participants per group would be required to achieve 80% power at a significance level α = 0.05. Results The mean age of participants was 29.65 ± 4.38 years, with no statistically significant difference observed between the two groups (p > 0.05). The most common indication for circumcision was religious in nature, and the majority of individuals in both groups had a university-level education. There were no significant differences between the groups regarding sociodemographic variables or reasons for urology visits (p > 0.05). No participant experienced a complication classified as Grade 3 or higher according to the Modified Clavien-Dindo classification. The mean age at circumcision was 5 years, and this did not differ significantly between the groups (p > 0.05). In Group 1 (general anesthesia), the mean BMI was 20 kg/m2, and 33 participants (89.2%) were married. These characteristics were also similar to those in Group 2 (p > 0.05) (Table 1 ). When MGSIS-7 scores of circumcised individuals were compared according to the reasons for circumcision, no significant difference was found between the groups (p > 0.05). Table 1 Comparison of demographic data and scores between groups Variable Groups P -Value Group 1 (General anesthesia), N = 37 Group 2 (Local anesthesia), N = 47 Age of circumcision (years) , Median (IQR) 5.0 (5–6) 5.0 (5–6) 0.724 BMI (kg/m 2 ) , Median (IQR) 20.0 (19–20) 20.0(19–21) 0.787 MGSIS-7 , Median (IQR) 28.0 (27–28) 22.0 (19–25) < 0.0001* IIEF-15 , Median (IQR) 28.0 (27-28.3) 28.0 (27–29) 0.347 BDI , Median (IQR) 9 (8–10) 9 (8–10) 0.692 Education status High school , n (%) 4 (10.8) 5 (10.6) 0.980 University , n (%) 33 (89.2) 42 (89.4) Reason for circumcision Cultural , n (%) 12 (32.4) 11 (23.4) 0.586 Religious , n (%) 22 (59.5) 33 (70.2) Social , n (%) 3 (8.1) 3 (6.4) Post-circumcision complications None , n (%) 35 (94.6) 43 (91.5) 0.860 Minimal bleeding , n (%) 1 (2.7) 2 (4.3) Penile edema , n (%) 1 (2.7) 2 (4.3) Marital Status Single , n (%) 4 (10.8) 5 (10.6) 0.980 Married , n (%) 33 (89.2) 42 (89.4) * Significant difference at the 0.05 level according to the Mann-Whitney U test. Medians are presented, and the IQR represents the interquartile range. Abbreviations: BMI: Body Mass Index MGSIS-7: Male Genital Self-Image Scale-7 IIEF-15: International Index of Erectile Function-15 BDI: Beck Depression Inventory The median IIEF-15 and the BDI scores in Group 1 were 28 and 9, respectively, showing no significant difference compared to Group 2 (p > 0.05) (Table 1 ). However, the median MGSIS-7 score was significantly lower in Group 2 (local anesthesia) compared with Group 1 (general anesthesia) (22 vs. higher in Group 1, p < 0.0001) (Table 2 , Fig. 1 ). In the logistic regression analysis performed to determine age, BMI, MGSIS-7, IIEF-15 and BDI parameters in terms of risk factors according to the type of anesthesia in circumcision during the phallic period, it was found that the MGSIS-7 score of patients who received general anesthesia increased (OR: 3.11, p < 0.0001) (Table 3 ). Table 2 Distribution of MGSIS-7 score questions according to groups Item Response option Groups P -Value G1 (General anesthesia) N = 37 (%) G2 (Local anesthesia) N = 47 (%) Q1 = I feel positively about my genitals. 1- Strongly disagree , n (%) 0 (0.0) 18 (38.3) < 0.0001* 2- Disagree , n (%) 0 (0.0) 0 (0.0) 3- Agree , n (%) 0 (0.0) 0 (0.0) 4- Strongly agree , n (%) 37 (100.0) 29 (61.7) Q2 = I am satisfied with the appearance of my genitals. 1- Strongly disagree , n (%) 0 (0.0) 10 (21.3) 0.016* 2- Disagree , n (%) 1 (2.7) 2 (4.3) 3- Agree , n (%) 1 (2.7) 0 (0.0) 4- Strongly agree , n (%) 35 (94.6) 35 (74.5) Q3 = I would feel comfortable letting a sexual partner look at my genitals. 1- Strongly disagree , n (%) 0 (0.0) 12 (25.5) 0.006* 2- Disagree , n (%) 1 (2.7) 0 (0.0) 3- Agree , n (%) 1 (2.7) 2 (4.3) 4- Strongly agree , n (%) 35 (94.6) 33 (70.2) Q4 = I am satisfied with the size of my genitals. 1- Strongly disagree , n (%) 0 (0.0) 11 (23.4) 0.006* 2- Disagree , n (%) 1 (2.7) 2 (4.3) 3- Agree , n (%) 2 (5.4) 0 (0.0) 4- Strongly agree , n (%) 34 (91.9) 34 (72.3) Q5 = I think my genitals work the way they are supposed to work. 1- Strongly disagree , n (%) 0 (0.0) 16 (34.0) 0.000* 2- Disagree , n (%) 2 (5.4) 0 (0.0) 3- Agree , n (%) 0 (0.0) 0 (0.0) 4- Strongly agree , n (%) 35 (94.6) 31 (66.0) Q6 = I feel comfortable letting a healthcare provider examine my genitals. 1- Strongly disagree , n (%) 0 (0.0) 14 (29.8) 0.001* 2- Disagree , n (%) 1 (2.7) 2 (4.2) 3- Agree , n (%) 2 (5.4) 0 (0.0) 4- Strongly agree , n (%) 34 (91.9) 31 (66.0) Q7 = I am not embarrassed about my genitals. 1- Strongly disagree , n (%) 0 (0.0) 18 (38.3) 0.000* 2- Disagree , n (%) 1 (2.7) 3 (6.4) 3- Agree , n (%) 0 (0.0) 0 (0.0) 4- Strongly agree , n (%) 36 (97.3) 26 (55.3) * Significant difference at < 0.05 level according to chi-square test, N [%] presented. Q: question. Abbreviations: MGSIS-7: Male Genital Self-Image Scale-7 Table 3 Results of logistic regression analyses between the MGSIS-7 score and other variables Dependet variable= Type of anesthesia General anesthesia 37 Local anesthesia 47 Overall Model Fit P-Value < 0.0001 Cox & Snell R 2 0.5685 Nagelkerke R 2 0.7617 Hosmer & Lemeshow test P-Value 0.8827 Variables OR OR (%95 CI) P Age (years) 0.63 (0.17–2.37) 0.494 BMI (kg/m 2 ) 1.45 (0.64–3.31) 0.374 MGSIS-7 3.11 (1.86–5.17) < 0.0001* IIEF-15 0.61 (0.26–1.43) 0.255 BDI 0.75 (0.44–1.27) 0.285 Significance at <0.05 level according to regression analyses Abbreviations: Note: MGSIS-7 = Male Genital Self-Image Scale; IIEF-15 = International Index of Erectile Function; BDI = Beck Depression Inventory; OR = Odds ratio; CI = Confidence interval. Discussion The phallic stage, as described by Sigmund Freud, represents one of the pivotal stages of psychosexual development in childhood. According to the psychoanalytic theory, children between three and six years of age begin to establish their gender identity and become increasingly aware of sexual and anatomical differences. During this period, attention to one's own genitalia typically reaches its peak [ 11 , 12 ]. For these reasons, there is concern that circumcision performed during the phallic stage may lead to adverse psychological consequences or behavioral disturbances in later life. Consequently, circumcision performed during the phallic stage has long been associated with concerns regarding potential psychological distress, behavioral changes, or the development of castration anxiety [ 13 ]. Currently, there is no established consensus regarding the optimal anesthesia method during circumcision performed at this particularly sensitive developmental stage. In the present clinical study, we observed that individuals circumcised under local anesthesia during the phallic stage exhibited significantly lower genital self-image scores than those circumcised under general anesthesia. This finding may be attributed to the heightened genital awareness in this developmental period, combined with the child’s cognitive ability to perceive and remember the surgical process, which may amplify anxiety and negatively influence later genital self-perception. Circumcision remains one of the oldest and most common surgical interventions performed in males [ 14 ]. Despite its prevalence, the choice between local and general anesthesia remains debated in modern clinical practice [ 4 ]. For many children, circumcision represents a major psychological stressor, often related to pain and the perceived threat to genital integrity [ 14 , 15 ]. Proponents of local anesthesia cite advantages such as shorter recovery times and fewer systemic risks, whereas general anesthesia is considered to provide a calmer operative setting and reduced perioperative distress, potentially yielding better psychological outcomes [ 4 , 14 ]. The psychosexual consequences of circumcision and their relationship with anesthesia type remain complex and inconsistently reported. For example, Güzelsoy et al. reported that the circumcision process and the hospital setting itself contribute to elevated stress levels in children, particularly when local anesthesia is used [ 14 ]. Conversely, Kozanhan et al found that general anesthesia was associated with higher post-traumatic stress scores in children than local anesthesia [ 1 ]. Suleyman et al explored the relationship between adult surgical anxiety and the anesthesia type used during childhood circumcision, and no significant association was found [ 16 ]. Similarly, Tokuc et al. argued that circumcision does not contribute to later andrological or psychological problems [ 17 ]. Our findings suggest that local anesthesia during the phallic stage may have subtle long-term effects on genital self-image perception, even in the absence of overt psychological or sexual dysfunction. Genital self-image refers to an individual's emotional and psychological perception and awareness of their own genitalia, particularly in relation to sexual function and satisfaction [ 18 ]. This perception may be influenced by multiple factors, including circumcision status, BMI, body image satisfaction, mood, and the presence of conditions such as phimosis [ 19 , 20 ]. Genital identity, which plays a critical role in shaping sexual orientation, is largely rooted in one’s genital self-perception [ 21 ]. A positive genital self-image has been shown to correlate with improved psychological well-being [ 22 ]. Despite its importance, research specifically focusing on male genital self-perception remains limited [ 9 , 22 ]. In a study involving 69 patients with phimosis, Czajkowski et al. reported a marked improvement in MGSIS-7 scores following circumcision [ 22 ]. Similarly, Sonbahar et al. observed that lower genital self-image scores were moderately associated with increased levels of depression and anxiety [ 9 ]. In our study, no significant differences were found between the groups in terms of depression scores or erectile function assessments. However, participants who had undergone circumcision under local anesthesia during the phallic stage reported significantly lower genital self-image scores, even though their overall sexual function and psychological status appeared unaffected. We speculate that this may be attributed to the relatively young age of the study population, the majority of whom were under 30 years old. The psychosexual consequences of circumcision remain a subject of ongoing debate, with a limited number of studies and no clear consensus in the literature. Yılmaz et al. evaluated the treatment protocols of 149 children with phimosis (mean age of 4.47 years), and found that children who received topical corticosteroid therapy exhibited lower anxiety scores compared with those who underwent circumcision [ 13 ]. However, the study did not provide detailed information regarding the anesthesia techniques used during the procedures. In contrast, Armağan et al. conducted a study involving 321 cases and reported that circumcision performed during the phallic stage did not appear to negatively influence psychosexual functioning in adulthood [ 3 ]. Notably, nearly all patients (98.4%) in their cohort had undergone the procedure under local anesthesia. Similarly, Yıgman et al. observed no significant differences in sexual function, genital perception, or gender role identification between individuals circumcised during or after the phallic stage [ 23 ]. Aydur et al. also found no significant association between the age at circumcision and adult sexual functioning [ 24 ]. Our findings are consistent with these observations in terms of erectile function. In our study, which included only individuals circumcised during the phallic stage, sexual function was evaluated using the IIEF-15 questionnaire. The mean IIEF-15 scores in both groups were ≥ 26, indicating the absence of clinically significant erectile dysfunction. In another study, Cüceoğlu et al. examined the relationship between circumcision and sexual dysfunction using the Golombok-Rust Inventory of Sexual Satisfaction (GRISS) in a cohort of 80 participants [ 25 ]. Their results showed no significant effect of age at circumcision on subscales such as frequency, communication, satisfaction, avoidance, emotional involvement, or erectile dysfunction. Although the study noted a minor correlation between circumcision during the phallic stage and premature ejaculation, no association with the castration complex was identified. Consistent with these findings, none of the participants in our cohort exhibited clinical signs of premature ejaculation. Although previous studies have generally reported no direct association between circumcision during the phallic stage and adult sexual dysfunction, it is evident that many of these investigations lacked a comprehensive integration of validated psychological assessments. The phallic stage is characterized by heightened awareness of genital anatomy, making any invasive experience, particularly one performed without anesthesia, potentially traumatic [ 26 ]. In a limited case series, Cansever documented that some children perceived circumcision during the phallic period as an act of aggression or symbolic castration [ 15 ]. Similarly, Öztürk examined 50 psychiatric patients presenting with symptoms indicative of castration anxiety, and suggested a potential link between ritual circumcision performed without anesthesia during the phallic-latency phases and the later development of castration-related fears [ 25 ]. Consistent with these psychological perspectives, our study found that circumcision performed without general anesthesia during the phallic stage was associated with more negative genital self-image scores in adulthood, suggesting potential long-term psychosexual implications of the anesthesia method used during this sensitive developmental period. Limitations This study has several limitations. The sample size was relatively small, and data were collected from a single institution, which may limit generalizability. Genital self-image was evaluated using only one standardized scale, and psychosexual outcomes during childhood were not assessed. Parental perspectives on anesthesia choice could not be obtained due to documentation limitations. As a cross-sectional design, our study cannot establish causality. Although an association between local anesthesia and more negative genital self-image was identified, a direct cause-and-effect relationship cannot be inferred. Moreover, our findings may have been affected by potential sources of bias and confounding factors. First, recall bias may pose a significant problem because participants' memories of their childhood circumcision experience may have changed over time or been influenced by later life experiences. Second, there is the possibility of selection bias; the individuals in our study who could recall their childhood circumcision experiences in detail may not be fully representative of the general population. One of the most critical limitations is the possibility of residual confounding. Although we controlled for known confounders such as age, BMI, education level, and marital status in our analyses, other factors we did not measure may explain this association. For example, parent-child relationship quality, the child's pre-circumcision mood, and auxiliary health care workers' communication style may have influenced genital self-image. Conclusions This study investigated the impact of the anesthesia method used during circumcision performed in the phallic stage on adult male genital self-image. Our findings indicated that individuals undergoing circumcision under local anesthesia were associated with more negative genital self-perception in adulthood compared to individuals receiving general anesthesia. We hypothesize that this may be related to the heightened genital awareness typical of the phallic stage and the cognitive ability of children under local anesthesia to perceive and process each step of the surgical experience. Although these findings generate a novel hypothesis regarding the psychological implications of anesthesia choice, prospective, multicenter studies with larger sample sizes and comprehensive psychosexual assessments are needed to confirm the causal mechanisms underlying this association. Abbreviations BMI: Body Mass Index, MGSIS-7: Male Genital Self-Image Scale-7, IIEF-15: International Index of Erectile Function-15, BDI: Beck Depression Inventory Declarations Ethical approval and consent to participate The study was approved by the Local Ethics Committee of Tokat University Faculty of Medicine (Approval No: 25-MOBAEK 241, Date: June 17, 2025). The research protocol adhered to the principles of the Declaration of Helsinki, and written informed consent was obtained from all participants before inclusion in the study. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors` contributions KY developed the study design, performed the statistical analysis, and was responsible for the clinical management of patients. KY also drafted the manuscript and critically revised it for important intellectual content. KY,VK contributed to the development of the study design and provided guidance during the study. KY,VK were involved in the clinical management of patients. KY supervised the study. References Kozanhan B, Kocaoğlu C, Gündüz M, and Akça ÖF. Posttraumatic stress disorder symptoms in children exposed to circumcision under general or local anesthesia. Turk J Pediatr . 2018; 60 (6): 718-725. Şencan A, Çayırlı H, and Şencan A. Circumcision Techniques. CBU-SBED . 2015; 2 (4): 86-90. Armagan A, Silay MS, Karatag T, et al. Circumcision during the phallic period: does it affect the psychosexual functions in adulthood? Andrologia. 2014; 46 (3): 254-257. Altaş C, Küçükosman G, Yurtlu BS, et al. Anesthesia methods used by anesthetic specialists for circumcision cases. National survey study for Turkey. Saudi Med J. 2017; 38 (1): 75-81. Suzan ÖK, Şahin ÖÖ, and Baran Ö. Effect of Puppet Show on Children's anxiety and pain levels during the circumcision operation: A randomized controlled trial . J Pediatr Urol. 2020; 16 (4): 490.e1-490.e8. Wang X, Liu H, Tang G, Sun F, Wu G, Wu J. The Effect of Distraction Techniques on Pain, Fear, and Anxiety in Children Undergoing Circumcision: A Meta-Analysis of Randomized Controlled Trials. Am J Mens Health. 2024 ;18 (1): 15579883241230166. Beck AT, Steer RA, Ball R, Ciervo CA, and Kabat M. Use of the Beck Anxiety and Depression Inventories for Primary Care with Medical Outpatients . Assessment. 1997; 4 (3): 211-219. Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology . 1997; 49 (6): 822-830. Sonbahar AE. The impact of male genital self-image on depression, anxiety and sexual functions. Aging Male. 2024; 27 (1): 2363275. Kocak V, Erkal Aksoy Y, and Düğeroğlu S. Turkish validity and reliability study of male genital self-image scale (MGSIS). Urologia. 2023; 90 (2): 278–285. Kupfersmid J. Freud's Clinical Theories Then and Now. Psychodyn Psychiatry . 2019; 47 (1): 81-97. Sauerteig LD. Loss of innocence: Albert Moll, Sigmund Freud and the invention of childhood sexuality around 1900. Med Hist. 2012; 56 (2): 156-183. Yilmaz E, Batislam E, Basar MM, and Basar H. Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids . Int J Urol. 2003;10 (2): 651-656. Güzelsoy M, Türkoğlu AR, Sancar S, et al. Selection of anesthesia to reduce anxiety, worry and fear in male circumcision. New J Urol. 2018; 13 (2): 26-30. Cansever G. Psychological effects of circumcision. Br J Med Psychol . 1965; 38 (4): 321-331. Suleyman S. Impact of Circumcision Experiences on Surgical Anxiety in Adulthood: A Comprehensive Study. International Journal of Scientific Pediatrics . 2023; 2 (7): 253-259. Tokuc E, Yildiz N, Sertkaya Z, Ozsoy E, Kayar R, Ozkaya F. The Relationship of Urological and Psychological Problems with Circumcision – A Cross-sectional Study . Grand J Urol . 2023; 3 (3): 90-96. Koçak V, and Tufan O. Male genital self-image, premature ejaculation, and affecting factors. Sex Med. 2024; 12 (3): 1-5. Selino S, and Krawczyk R. Happiness with Circumcision Status, Not Status Itself, Predicts Genital Self-Image in a Geographically Diverse Sample. Arch Sex Behav . 2023 ;52 (4): 1525-1534. Herbenick D, Schick V, Reece M, Sanders SA, and Fortenberry JD. The development and validation of the Male Genital Self-Image Scale: results from a nationally representative probability sample of men in the United States. J Sex Med. 2013;10 (6): 1516-1525. Saffari M, Pakpour AH, Burri A. Cross-Cultural Adaptation of the Male Genital Self-Image Scale in Iranian Men. Sex Med. 2016; 4 (1): 34-42. Czajkowski M, Czajkowska K, Zarańska K, et al. Male Circumcision Due to Phimosis as the Procedure That Is Not Only Relieving Clinical Symptoms of Phimosis But Also Improves the Quality of Sexual Life. Sex Med . 2021; 9 (2) :100315. Yıgman M, Üntan İ, Yığman F, and Gül H. Avoidance of Circumcision during the Phallic Stage: Myth or Reality? Arch Esp Urol. 2025; 78 (4): 385-391. Aydur E, Gungor S, Ceyhan ST, Taiimaz L, and Baser I. Effects of childhood circumcision age on adult male sexual functions . Int J Impot Res . 2007; 19 (4): 424-431. Cüceloğlu EA, Hoşrik ME, Ak M, and Bozkurt A. The effects of age at circumcision on premature ejaculation. Turk Psikiyatri Derg. 2012; 23 (2): 99-107. Ozturk OM. Ritual circumcision and castration anxiety . Psychiatry. 1973; 36 (1): 49-60. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8756159","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":607556738,"identity":"d6d4fad2-1fa6-460c-b5d0-b3dda5b6bf2b","order_by":0,"name":"Kenan Yalçın","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYBACCTBZwMDDwN7AwEyCFgOgFp4DJGoBshKI1CI5+/gziR8GdjLmkm8MPxdU2DDwt3cn4NUizZdjJtljkMxjOTvHWHrGmTQGiTNnN+DVIsfDwybBY3CAx+B2joE0b9thBgOJXEJa2J9J/gFpuXnG+DdRWqR5GMykwbbc4DEjzhbJHh5jaxmgXwzOpJVZ85xJ4yHoF4kz7A9vvqmwszc4fnjzbZ4KGzn+9l78WoCABRI3DByg2AHGKRGA+QOEZn9AjOpRMApGwSgYgQAAswk8fV/pgXsAAAAASUVORK5CYII=","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Kenan","middleName":"","lastName":"Yalçın","suffix":""},{"id":607556739,"identity":"ff728d57-f574-4f2a-aef7-567e5b7fd8a3","order_by":1,"name":"Vildan Kölükçü","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Vildan","middleName":"","lastName":"Kölükçü","suffix":""}],"badges":[],"createdAt":"2026-02-01 12:38:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8756159/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8756159/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105037915,"identity":"27194812-191d-4b8e-8eb4-e93a70ad8839","added_by":"auto","created_at":"2026-03-20 07:40:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35194,"visible":true,"origin":"","legend":"\u003cp\u003eMGSIS-7 score of the groups\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8756159/v1/5b37bd7dc2a70c241cd170a3.png"},{"id":106558627,"identity":"a1a768de-805a-4bc1-b534-a1440d281891","added_by":"auto","created_at":"2026-04-09 21:09:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1184113,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8756159/v1/1583215f-9c93-4fe9-9146-2cf984bd4dfe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of circumcision performed under local or general anesthesia during the phallic stage on Adult Male Genital Self-Image","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCircumcision is one of the oldest and most widely practiced surgical procedures worldwide, performed for religious, cultural, or medical reasons. It is estimated that approximately 30\u0026ndash;33% of men aged 15 years and older have undergone circumcision globally [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The procedure involves the surgical removal of the foreskin covering the glans penis. Despite being commonly performed, circumcision should not be regarded as a simple or minor intervention. The accurate identification of excision margins, strict adherence to antiseptic principles, and the provision of adequate analgesia and anesthesia are all essential for ensuring safe and optimal surgical outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe optimal timing for circumcision remains of topic of ongoing debate in both clinical and sociocultural contexts [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Similarly, there is no universally accepted or standardized protocol regarding the choice of anesthesia [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In Freudian psychoanalytic theory the so-called \"phallic stage\", between three and six years of age, represents a critical developmental period during which children begin to form their gender identity, establish body awareness, and internalize attitudes toward sexuality and the body [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although there is a lack of high-level evidence from large-scale studies or meta-analyses, a significant proportion of healthcare professionals express concern about performing circumcision during this stage due to its potential association with castration anxiety, body image disturbances, and adverse psychosexual outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Nevertheless, circumcision during this developmental period remains common in many cultures, particularly when performed under local anesthesia for religious or traditional reasons. In pediatric patients within this age group, the procedure may trigger feelings of fear and anxiety, which could potentially contribute to long-term psychological consequences [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first study in the English-language literature to examine the long-term effect of the anesthesia type administered during circumcision in the phallic stage on adult male genital self-image.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e \u003cp\u003e The study was approved by the Local Ethics Committee of Tokat University Faculty of Medicine (Approval No: 25-MOBAEK 241, Date: June 17, 2025). The research protocol adhered to the principles of the Declaration of Helsinki, and written informed consent was obtained from all participants before inclusion in the study.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eThe prospective observational study was conducted during January and March 2025 in the Department of Urology, Tokat University Faculty of Medicine. A total of 84 young adult males who presented for routine follow-up and had a documented history of circumcision performed during the phallic stage were included. Patients were attending follow-up for urinary system stone disease, renal cystic disease, and benign adrenal lesions. None of the participants had comorbidities known to cause sexual dysfunction. Based on the type of anesthesia administered during their circumcision, participants were categorized into two groups: Group 1 included individuals who had undergone circumcision under general anesthesia, and Group 2 comprised those who had received local anesthesia. Sociodemographic characteristics, including age, marital status, and educational level, were recorded for each participant. In addition, anthropometric data comprising height, weight, and body mass index (BMI) were calculated. Clinical variables included age at circumcision, indication for the procedure, and any post-operative complications were also analyzed. Psychological and sexual function assessments were conducted using three validated tools: the Beck Depression Inventory (BDI), the Male Genital Self-Image Scale (MGSIS-7), and the International Index of Erectile Function (IIEF-15) [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical technique\u003c/h3\u003e\n\u003cp\u003eAll circumcision procedures had been performed by an experienced urologist using the dorsal slit technique. In the local anesthesia group, bupivacaine was administered via subcutaneous peripheral infiltration at the base of the penis. In the general anesthesia group, anesthesia was induced using a laryngeal mask airway. Standard intraoperative monitoring included a 3-lead electrocardiogram, non-invasive blood pressure, and peripheral oxygen saturation. In the penile block group (Group-2), following sterile preparation in the supine position, 0.5 mg/kg 0.5% bupivacaine was administered at the base of the penis using a 21G needle, 15 minutes before surgery. For patients under anesthesia group (Group 1), 0.05 mg/kg midazolam, 2 mg/kg propofol, and 0.1 mcg/kg fentanyl citrate were administered intravenously according to the standard anesthesia protocol. After achieving the desired depth of anesthesia, a laryngeal mask airway was inserted, and mechanical ventilation was applied.\u003c/p\u003e \u003cp\u003eAll data were obtained from the hospital\u0026rsquo;s electronic medical records and the anesthesia and reanimation department\u0026rsquo;s patient follow-up forms. All circumcisions were performed by the same surgeon, and the anesthesia procedures were standardized across all cases. None of the patients had any medical conditions necessitating a change in the anesthesia method. Therefore, the choice of anesthesia was primarily determined by the parents of circumcised boys. To ensure data reliability, any cases involving different surgeons or anesthesia protocols were identified through the hospital's electronic archive and were excluded from the study.\u003c/p\u003e\n\u003ch3\u003eFollow-up\u003c/h3\u003e\n\u003cp\u003eAll patients underwent a detailed genital system examination by medical staff. None of the participants presented with unsightly circumcision scars or major cosmetic defects. Following this assessment, the MGSIS-7, IIEF-15, and BDI scores were evaluated. The MGSIS-7 is a psychometrically validated tool comprising seven items designed to assess how men perceive and feel about their genitalia. Participants respond to each item using a four-point Likert scale, and the total score is derived by summing individual item responses. Higher cumulative scores reflect a more positive genital self-image. The Turkish version of the MGSIS-7 was adopted and validated by Ko\u0026ccedil;ak et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Sexual function was measured using the IIEF-15, a standardized questionnaire consisting of 15 items that evaluate multiple key aspects such as erectile quality, orgasm, sexual interest, satisfaction with intercourse, and overall sexual well-being [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Depressive symptoms were measured using the BDI, a 21-item, self-report rating scale that assesses the presence and severity of depression. Each item is rated on a four-point scale ranging from 0 (not at all) to 3 (severe), with higher total scores corresponding to increased levels of depression [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipants were excluded if they had not engaged in regular sexual activity within the past six months or had comorbidities affecting sexual function, including neuropsychiatric disorders, hyperlipidemia, diabetes mellitus, coronary artery disease, hypertension, chronic kidney disease, or hypogonadism. Subjects with a history of pelvic surgery or medication use known to affect erectile function were also excluded from the analysis.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData analysis was conducted using MedCalc statistical software (version 20.009; Ostend, Belgium). The Kolmogorov\u0026ndash;Smirnov test was used to assess the normality of data distribution. Continuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or as median (interquartile range, IQR), depending on distribution. For group comparisons, the Independent Samples t-test was used for normally distributed variables, and the Mann\u0026ndash;Whitney U test was applied to non-normally distributed data. Categorical variables were summarized using frequencies and percentages and evaluated using the Chi-square (χ\u0026sup2;) test. The Kruskal-Wallis test was used for comparison of more than two groups. Numerical data of the groups were visually displayed using box-whisker graphs, and extreme values were indicated as points. Logistic regression was used to identify age, BMI, MGSIS-7, IIEF-15, and BDI parameters as risk factors for circumcision during the phallic stage, according to the type of anesthesia. Odds ratios (OR) and corresponding 95% confidence intervals (CI) for each parameter are reported. A p-value less than 0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003eSample size was determined using G*Power software (v3.1.2). The statistical power of the study, expressed as 1-β (where β represents the probability of a Type II error), was set at 80%. According to Cohen\u0026rsquo;s effect size conventions, and assuming a large effect size (d\u0026thinsp;=\u0026thinsp;0.7) for comparisons between two independent groups, it was calculated that a minimum of 34 participants per group would be required to achieve 80% power at a significance level α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean age of participants was 29.65\u0026thinsp;\u0026plusmn;\u0026thinsp;4.38 years, with no statistically significant difference observed between the two groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The most common indication for circumcision was religious in nature, and the majority of individuals in both groups had a university-level education. There were no significant differences between the groups regarding sociodemographic variables or reasons for urology visits (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). No participant experienced a complication classified as Grade 3 or higher according to the Modified Clavien-Dindo classification. The mean age at circumcision was 5 years, and this did not differ significantly between the groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In Group 1 (general anesthesia), the mean BMI was 20 kg/m2, and 33 participants (89.2%) were married. These characteristics were also similar to those in Group 2 (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). When MGSIS-7 scores of circumcised individuals were compared according to the reasons for circumcision, no significant difference was found between the groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of demographic data and scores between groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup 1 (General anesthesia), N\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup 2 (Local anesthesia), N\u0026thinsp;=\u0026thinsp;47\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge of circumcision (years)\u003c/b\u003e, Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0 (5\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.0 (5\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.724\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e, Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.0 (19\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.0(19\u0026ndash;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.787\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMGSIS-7\u003c/b\u003e, Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.0 (27\u0026ndash;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.0 (19\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIIEF-15\u003c/b\u003e, Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.0 (27-28.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.0 (27\u0026ndash;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.347\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBDI\u003c/b\u003e, Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (8\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (8\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.692\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eEducation status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHigh school\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.980\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUniversity\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (89.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42 (89.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eReason for circumcision\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCultural\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.586\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eReligious\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33 (70.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSocial\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePost-circumcision complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNone\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (94.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43 (91.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.860\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMinimal bleeding\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePenile edema\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSingle\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.980\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMarried\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (89.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42 (89.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* Significant difference at the 0.05 level according to the Mann-Whitney U test. Medians are presented, and the IQR represents the interquartile range.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAbbreviations:\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eBMI: Body Mass Index\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eMGSIS-7: Male Genital Self-Image Scale-7\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eIIEF-15: International Index of Erectile Function-15\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eBDI: Beck Depression Inventory\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe median IIEF-15 and the BDI scores in Group 1 were 28 and 9, respectively, showing no significant difference compared to Group 2 (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). However, the median MGSIS-7 score was significantly lower in Group 2 (local anesthesia) compared with Group 1 (general anesthesia) (22 vs. higher in Group 1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In the logistic regression analysis performed to determine age, BMI, MGSIS-7, IIEF-15 and BDI parameters in terms of risk factors according to the type of anesthesia in circumcision during the phallic period, it was found that the MGSIS-7 score of patients who received general anesthesia increased (OR: 3.11, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of MGSIS-7 score questions according to groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eResponse option\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-Value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eG1 (General\u0026nbsp;anesthesia) N\u0026thinsp;=\u0026thinsp;37 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eG2 (Local\u0026nbsp;anesthesia) N\u0026thinsp;=\u0026thinsp;47 (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eQ1\u0026thinsp;=\u0026thinsp;I feel positively about my genitals.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1- Strongly disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (38.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2- Disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3- Agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4- Strongly agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (61.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eQ2\u0026thinsp;=\u0026thinsp;I am satisfied with the appearance of my genitals.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1- Strongly disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (21.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.016*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2- Disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3- Agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4- Strongly agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (94.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (74.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eQ3\u0026thinsp;=\u0026thinsp;I would feel comfortable letting a sexual partner look at my genitals.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1- Strongly disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.006*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2- Disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3- Agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4- Strongly agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (94.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (70.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eQ4\u0026thinsp;=\u0026thinsp;I am satisfied with the size of my genitals.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1- Strongly disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.006*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2- Disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3- Agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4- Strongly agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (91.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (72.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eQ5\u0026thinsp;=\u0026thinsp;I think my genitals work the way they are supposed to work.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1- Strongly disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (34.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2- Disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3- Agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4- Strongly agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (94.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (66.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eQ6\u0026thinsp;=\u0026thinsp;I feel comfortable letting a healthcare provider examine my genitals.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1- Strongly disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (29.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2- Disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (4.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3- Agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4- Strongly agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (91.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (66.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eQ7\u0026thinsp;=\u0026thinsp;I am not embarrassed about my genitals.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1- Strongly disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (38.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2- Disagree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3- Agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4- Strongly agree\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (97.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (55.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* Significant difference at \u0026lt;\u0026thinsp;0.05 level according to chi-square test, N [%] presented. Q: question.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAbbreviations:\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eMGSIS-7: Male Genital Self-Image Scale-7\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of logistic regression analyses between the MGSIS-7 score and other variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDependet variable= Type of anesthesia\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral\u0026nbsp;anesthesia\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLocal anesthesia\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eOverall Model Fit\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCox \u0026amp; Snell R\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5685\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNagelkerke R\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.7617\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHosmer \u0026amp; Lemeshow test\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8827\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVariables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eOR (%95 CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u0026nbsp;(years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.17\u0026ndash;2.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.494\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.64\u0026ndash;3.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.374\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMGSIS-7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.86\u0026ndash;5.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIIEF-15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.26\u0026ndash;1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.255\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBDI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.44\u0026ndash;1.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.285\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003eSignificance at \u0026lt;0.05 level according to regression analyses\u003c/p\u003e\n\u003cp\u003eAbbreviations:\u003c/p\u003e\n\u003cp\u003eNote: MGSIS-7 = Male Genital Self-Image Scale; IIEF-15 = International Index of Erectile Function; BDI = Beck Depression Inventory; OR = Odds ratio; CI = Confidence interval.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe phallic stage, as described by Sigmund Freud, represents one of the pivotal stages of psychosexual development in childhood. According to the psychoanalytic theory, children between three and six years of age begin to establish their gender identity and become increasingly aware of sexual and anatomical differences. During this period, attention to one's own genitalia typically reaches its peak [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. For these reasons, there is concern that circumcision performed during the phallic stage may lead to adverse psychological consequences or behavioral disturbances in later life. Consequently, circumcision performed during the phallic stage has long been associated with concerns regarding potential psychological distress, behavioral changes, or the development of castration anxiety [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, there is no established consensus regarding the optimal anesthesia method during circumcision performed at this particularly sensitive developmental stage. In the present clinical study, we observed that individuals circumcised under local anesthesia during the phallic stage exhibited significantly lower genital self-image scores than those circumcised under general anesthesia. This finding may be attributed to the heightened genital awareness in this developmental period, combined with the child\u0026rsquo;s cognitive ability to perceive and remember the surgical process, which may amplify anxiety and negatively influence later genital self-perception.\u003c/p\u003e \u003cp\u003eCircumcision remains one of the oldest and most common surgical interventions performed in males [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Despite its prevalence, the choice between local and general anesthesia remains debated in modern clinical practice [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. For many children, circumcision represents a major psychological stressor, often related to pain and the perceived threat to genital integrity [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Proponents of local anesthesia cite advantages such as shorter recovery times and fewer systemic risks, whereas general anesthesia is considered to provide a calmer operative setting and reduced perioperative distress, potentially yielding better psychological outcomes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe psychosexual consequences of circumcision and their relationship with anesthesia type remain complex and inconsistently reported. For example, G\u0026uuml;zelsoy et al. reported that the circumcision process and the hospital setting itself contribute to elevated stress levels in children, particularly when local anesthesia is used [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Conversely, Kozanhan et al found that general anesthesia was associated with higher post-traumatic stress scores in children than local anesthesia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Suleyman et al explored the relationship between adult surgical anxiety and the anesthesia type used during childhood circumcision, and no significant association was found [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similarly, Tokuc et al. argued that circumcision does not contribute to later andrological or psychological problems [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings suggest that local anesthesia during the phallic stage may have subtle long-term effects on genital self-image perception, even in the absence of overt psychological or sexual dysfunction. Genital self-image refers to an individual's emotional and psychological perception and awareness of their own genitalia, particularly in relation to sexual function and satisfaction [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This perception may be influenced by multiple factors, including circumcision status, BMI, body image satisfaction, mood, and the presence of conditions such as phimosis [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Genital identity, which plays a critical role in shaping sexual orientation, is largely rooted in one\u0026rsquo;s genital self-perception [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A positive genital self-image has been shown to correlate with improved psychological well-being [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Despite its importance, research specifically focusing on male genital self-perception remains limited [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In a study involving 69 patients with phimosis, Czajkowski et al. reported a marked improvement in MGSIS-7 scores following circumcision [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Similarly, Sonbahar et al. observed that lower genital self-image scores were moderately associated with increased levels of depression and anxiety [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In our study, no significant differences were found between the groups in terms of depression scores or erectile function assessments. However, participants who had undergone circumcision under local anesthesia during the phallic stage reported significantly lower genital self-image scores, even though their overall sexual function and psychological status appeared unaffected. We speculate that this may be attributed to the relatively young age of the study population, the majority of whom were under 30 years old.\u003c/p\u003e \u003cp\u003eThe psychosexual consequences of circumcision remain a subject of ongoing debate, with a limited number of studies and no clear consensus in the literature. Yılmaz et al. evaluated the treatment protocols of 149 children with phimosis (mean age of 4.47 years), and found that children who received topical corticosteroid therapy exhibited lower anxiety scores compared with those who underwent circumcision [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the study did not provide detailed information regarding the anesthesia techniques used during the procedures. In contrast, Armağan et al. conducted a study involving 321 cases and reported that circumcision performed during the phallic stage did not appear to negatively influence psychosexual functioning in adulthood [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Notably, nearly all patients (98.4%) in their cohort had undergone the procedure under local anesthesia. Similarly, Yıgman et al. observed no significant differences in sexual function, genital perception, or gender role identification between individuals circumcised during or after the phallic stage [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Aydur et al. also found no significant association between the age at circumcision and adult sexual functioning [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our findings are consistent with these observations in terms of erectile function. In our study, which included only individuals circumcised during the phallic stage, sexual function was evaluated using the IIEF-15 questionnaire. The mean IIEF-15 scores in both groups were \u0026ge;\u0026thinsp;26, indicating the absence of clinically significant erectile dysfunction. In another study, C\u0026uuml;ceoğlu et al. examined the relationship between circumcision and sexual dysfunction using the Golombok-Rust Inventory of Sexual Satisfaction (GRISS) in a cohort of 80 participants [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Their results showed no significant effect of age at circumcision on subscales such as frequency, communication, satisfaction, avoidance, emotional involvement, or erectile dysfunction. Although the study noted a minor correlation between circumcision during the phallic stage and premature ejaculation, no association with the castration complex was identified. Consistent with these findings, none of the participants in our cohort exhibited clinical signs of premature ejaculation.\u003c/p\u003e \u003cp\u003eAlthough previous studies have generally reported no direct association between circumcision during the phallic stage and adult sexual dysfunction, it is evident that many of these investigations lacked a comprehensive integration of validated psychological assessments. The phallic stage is characterized by heightened awareness of genital anatomy, making any invasive experience, particularly one performed without anesthesia, potentially traumatic [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In a limited case series, Cansever documented that some children perceived circumcision during the phallic period as an act of aggression or symbolic castration [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Similarly, \u0026Ouml;zt\u0026uuml;rk examined 50 psychiatric patients presenting with symptoms indicative of castration anxiety, and suggested a potential link between ritual circumcision performed without anesthesia during the phallic-latency phases and the later development of castration-related fears [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Consistent with these psychological perspectives, our study found that circumcision performed without general anesthesia during the phallic stage was associated with more negative genital self-image scores in adulthood, suggesting potential long-term psychosexual implications of the anesthesia method used during this sensitive developmental period.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis study has several limitations. The sample size was relatively small, and data were collected from a single institution, which may limit generalizability. Genital self-image was evaluated using only one standardized scale, and psychosexual outcomes during childhood were not assessed. Parental perspectives on anesthesia choice could not be obtained due to documentation limitations.\u003c/p\u003e \u003cp\u003eAs a cross-sectional design, our study cannot establish causality. Although an association between local anesthesia and more negative genital self-image was identified, a direct cause-and-effect relationship cannot be inferred. Moreover, our findings may have been affected by potential sources of bias and confounding factors. First, recall bias may pose a significant problem because participants' memories of their childhood circumcision experience may have changed over time or been influenced by later life experiences. Second, there is the possibility of selection bias; the individuals in our study who could recall their childhood circumcision experiences in detail may not be fully representative of the general population. One of the most critical limitations is the possibility of residual confounding. Although we controlled for known confounders such as age, BMI, education level, and marital status in our analyses, other factors we did not measure may explain this association. For example, parent-child relationship quality, the child's pre-circumcision mood, and auxiliary health care workers' communication style may have influenced genital self-image.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study investigated the impact of the anesthesia method used during circumcision performed in the phallic stage on adult male genital self-image. Our findings indicated that individuals undergoing circumcision under local anesthesia were associated with more negative genital self-perception in adulthood compared to individuals receiving general anesthesia. We hypothesize that this may be related to the heightened genital awareness typical of the phallic stage and the cognitive ability of children under local anesthesia to perceive and process each step of the surgical experience.\u003c/p\u003e \u003cp\u003eAlthough these findings generate a novel hypothesis regarding the psychological implications of anesthesia choice, prospective, multicenter studies with larger sample sizes and comprehensive psychosexual assessments are needed to confirm the causal mechanisms underlying this association.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI: Body Mass Index, MGSIS-7: Male Genital Self-Image Scale-7, IIEF-15: International Index of Erectile Function-15, BDI: Beck Depression Inventory\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Local Ethics Committee of Tokat University Faculty of Medicine (Approval No: 25-MOBAEK 241, Date: June 17, 2025). The research protocol adhered to the principles of the Declaration of Helsinki, and written informed consent was obtained from all participants before inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors` contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKY developed the study design, performed the statistical analysis, and was responsible for the clinical management of patients. KY also drafted the manuscript and critically revised it for important intellectual content. KY,VK contributed to the development of the study design and provided guidance during the study. KY,VK were involved in the clinical management of patients. KY supervised the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKozanhan B, Kocaoğlu C, Gündüz M, and Akça ÖF. Posttraumatic stress disorder symptoms in children exposed to circumcision under general or local anesthesia.\u003cem\u003eTurk J Pediatr\u003c/em\u003e. 2018; 60\u003c/strong\u003e(6): 718-725.\u003c/li\u003e\n\u003cli\u003eŞencan A, Çayırlı H, and Şencan A. Circumcision Techniques. \u003c/strong\u003e\u003cem\u003eCBU-SBED\u003c/em\u003e. 2015; 2\u003c/strong\u003e(4): 86-90.\u003c/li\u003e\n\u003cli\u003eArmagan A, Silay MS, Karatag T, et al. Circumcision during the phallic period: does it affect the psychosexual functions in adulthood? \u003c/strong\u003e\u003cem\u003eAndrologia.\u003c/em\u003e 2014; 46\u003c/strong\u003e(3): 254-257.\u003c/li\u003e\n\u003cli\u003eAltaş C, Küçükosman G, Yurtlu BS, et al. Anesthesia methods used by anesthetic specialists for circumcision cases. National survey study for Turkey.\u003cem\u003eSaudi Med J. \u003c/em\u003e2017; 38\u003c/strong\u003e(1): 75-81.\u003c/li\u003e\n\u003cli\u003eSuzan ÖK, Şahin ÖÖ, and Baran Ö. Effect of Puppet Show on Children's anxiety and pain levels during the circumcision operation: A randomized controlled trial\u003c/strong\u003e. \u003cem\u003eJ Pediatr Urol.\u003c/em\u003e 2020; 16\u003c/strong\u003e(4): 490.e1-490.e8.\u003c/li\u003e\n\u003cli\u003eWang X, Liu H, Tang G, Sun F, Wu G, Wu J. The Effect of Distraction Techniques on Pain, Fear, and Anxiety in Children Undergoing Circumcision: A Meta-Analysis of Randomized Controlled Trials. Am J Mens Health. \u003c/strong\u003e2024 ;18\u003c/strong\u003e(1): 15579883241230166. \u003c/li\u003e\n\u003cli\u003eBeck AT, Steer RA, Ball R, Ciervo CA, and Kabat M. Use of the Beck Anxiety and Depression Inventories for Primary Care with Medical Outpatients\u003c/strong\u003e. \u003cem\u003eAssessment.\u003c/em\u003e 1997; 4\u003c/strong\u003e(3): 211-219.\u003c/li\u003e\n\u003cli\u003eRosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. \u003c/strong\u003e\u003cem\u003eUrology\u003c/em\u003e. 1997; 49\u003c/strong\u003e(6): 822-830.\u003c/li\u003e\n\u003cli\u003eSonbahar AE. The impact of male genital self-image on depression, anxiety and sexual functions. \u003c/strong\u003e\u003cem\u003eAging Male.\u003c/em\u003e 2024; 27\u003c/strong\u003e(1): 2363275.\u003c/strong\u003e\u003c/li\u003e\n\u003cli\u003eKocak V, Erkal Aksoy Y, and Düğeroğlu S. Turkish validity and reliability study of male genital self-image scale (MGSIS). \u003c/strong\u003e\u003cem\u003eUrologia.\u003c/em\u003e 2023; 90\u003c/strong\u003e(2): 278–285.\u003c/li\u003e\n\u003cli\u003eKupfersmid J. Freud's Clinical Theories Then and Now.\u003cem\u003ePsychodyn Psychiatry\u003c/em\u003e. 2019; 47\u003c/strong\u003e(1): 81-97.\u003c/li\u003e\n\u003cli\u003eSauerteig LD. Loss of innocence: Albert Moll, Sigmund Freud and the invention of childhood sexuality around 1900.\u003cem\u003eMed Hist.\u003c/em\u003e 2012; 56\u003c/strong\u003e(2): 156-183.\u003c/strong\u003e\u003c/li\u003e\n\u003cli\u003eYilmaz E, Batislam E, Basar MM, and Basar H. Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids\u003c/strong\u003e. \u003cem\u003eInt J Urol.\u003c/em\u003e 2003;10\u003c/strong\u003e(2): 651-656.\u003c/li\u003e\n\u003cli\u003eGüzelsoy M, Türkoğlu AR, Sancar S, et al. Selection of anesthesia to reduce anxiety, worry and fear in male circumcision. \u003c/strong\u003e\u003cem\u003eNew J Urol.\u003c/em\u003e 2018; 13\u003c/strong\u003e(2): 26-30.\u003c/li\u003e\n\u003cli\u003eCansever G. Psychological effects of circumcision.\u003cem\u003eBr J Med Psychol\u003c/em\u003e. 1965; 38\u003c/strong\u003e(4): 321-331.\u003c/li\u003e\n\u003cli\u003eSuleyman S. Impact of Circumcision Experiences on Surgical Anxiety in Adulthood: A Comprehensive Study. \u003c/strong\u003e\u003cem\u003eInternational Journal of Scientific Pediatrics\u003c/em\u003e. 2023; 2\u003c/strong\u003e(7): 253-259.\u003c/li\u003e\n\u003cli\u003eTokuc E, Yildiz N, Sertkaya Z, Ozsoy E, Kayar R, Ozkaya F. The Relationship of Urological and Psychological Problems with Circumcision – A Cross-sectional Study\u003c/strong\u003e. \u003cem\u003eGrand J Urol\u003c/em\u003e. 2023; 3\u003c/strong\u003e(3): 90-96. \u003c/li\u003e\n\u003cli\u003eKoçak V, and Tufan O. Male genital self-image, premature ejaculation, and affecting factors. \u003c/strong\u003e\u003cem\u003eSex Med.\u003c/em\u003e 2024; 12\u003c/strong\u003e(3): 1-5.\u003c/li\u003e\n\u003cli\u003eSelino S, and Krawczyk R. Happiness with Circumcision Status, Not Status Itself, Predicts Genital Self-Image in a Geographically Diverse Sample. \u003c/strong\u003e\u003cem\u003eArch Sex Behav\u003c/em\u003e. 2023 ;52\u003c/strong\u003e(4): 1525-1534.\u003c/li\u003e\n\u003cli\u003eHerbenick D, Schick V, Reece M, Sanders SA, and Fortenberry JD. The development and validation of the Male Genital Self-Image Scale: results from a nationally representative probability sample of men in the United States. \u003c/strong\u003e\u003cem\u003eJ Sex Med.\u003c/em\u003e 2013;10\u003c/strong\u003e(6): 1516-1525.\u003c/li\u003e\n\u003cli\u003eSaffari M, Pakpour AH, Burri A. Cross-Cultural Adaptation of the Male Genital Self-Image Scale in Iranian Men. \u003c/strong\u003e\u003cem\u003eSex Med.\u003c/em\u003e 2016; 4\u003c/strong\u003e(1): 34-42.\u003c/li\u003e\n\u003cli\u003eCzajkowski M, Czajkowska K, Zarańska K, et al. Male Circumcision Due to Phimosis as the Procedure That Is Not Only Relieving Clinical Symptoms of Phimosis But Also Improves the Quality of Sexual Life. \u003c/strong\u003e\u003cem\u003eSex Med\u003c/em\u003e. 2021; 9\u003c/strong\u003e(2) :100315.\u003c/li\u003e\n\u003cli\u003eYıgman M, Üntan İ, Yığman F, and Gül H. Avoidance of Circumcision during the Phallic Stage: Myth or Reality? \u003c/strong\u003e\u003cem\u003eArch Esp Urol.\u003c/em\u003e 2025; 78\u003c/strong\u003e(4): 385-391.\u003c/li\u003e\n\u003cli\u003eAydur E, Gungor S, Ceyhan ST, Taiimaz L, and Baser I. Effects of childhood circumcision age on adult male sexual functions\u003c/strong\u003e. \u003cem\u003eInt J Impot Res\u003c/em\u003e. 2007; 19\u003c/strong\u003e(4): 424-431.\u003c/li\u003e\n\u003cli\u003eCüceloğlu EA, Hoşrik ME, Ak M, and Bozkurt A. The effects of age at circumcision on premature ejaculation. \u003c/strong\u003e\u003cem\u003eTurk Psikiyatri Derg.\u003c/em\u003e 2012; 23\u003c/strong\u003e(2): 99-107.\u003c/li\u003e\n\u003cli\u003eOzturk OM. Ritual circumcision and castration anxiety\u003cem\u003e.\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e Psychiatry.\u003c/em\u003e1973; 36\u003c/strong\u003e(1): 49-60.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Phallic stage, local anesthesia, general anesthesia, genital self-image.","lastPublishedDoi":"10.21203/rs.3.rs-8756159/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8756159/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eThe optimal timing of circumcision during childhood and the preferred method of anesthesia remain subjects of ongoing debate. This study aimed to investigate the long-term potential effects of local versus general anesthesia administered during circumcision performed in the phallic stage on adult male genital self-image scores.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA total of 84 male individuals who had undergone circumcision during the phallic stage were included in the study. Participants were divided into two groups based on the anesthesia type administered during the procedure: Group 1 received general anesthesia, while Group 2 received local anesthesia. Sociodemographic characteristics, including age, marital status, and educational background, were recorded. Additionally, body mass index (BMI), age at circumcision, indications for the procedure, and post-circumcision complications were analyzed. Each participant was assessed using the Beck Depression Inventory (BDI), the International Index of Erectile Function (IIEF-15), and the Male Genital Self-Image Scale (MGSIS-7).\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThe mean age of participants did not differ significantly between groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Similarly, there were no significant intergroup differences in terms of circumcision age, BMI, indication for the procedure, or complication rates (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Moreover, IIEF-15 and BDI scores also showed no statistical differences between the two groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, the mean MGSIS-7 score was significantly lower in the local anesthesia group compared to the general anesthesia group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), indicating a less positive genital self-image among those circumcised under local anesthesia.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eCircumcision performed under local anesthesia during the phallic stage may be associated with a more negative adult male genital self-image compared to procedures performed under general anesthesia. These findings highlight the potential psychological impact of anesthesia type during this sensitive developmental period and warrant further investigation.\u003c/p\u003e","manuscriptTitle":"Impact of circumcision performed under local or general anesthesia during the phallic stage on Adult Male Genital Self-Image","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-20 06:58:18","doi":"10.21203/rs.3.rs-8756159/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"283530da-5ab1-43a6-8570-27d28210c6b6","owner":[],"postedDate":"March 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T21:08:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-20 06:58:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8756159","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8756159","identity":"rs-8756159","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}