Vol 13 No 01 January-February 2016 2471Vol 13 No 01 January-February 2016 2541 Fear of Circumcision in Boys Considerably Vanishes within Ten Days of Procedure Purpose: To compare fear of circumcision, before, immediately after, and ten days after the operation. Materials and Methods: This was a case-control study in which participants in the operation group consisted of children admitted for circumcision at the outpatient clinics of a hospital. The Children’s Fear Scale and the Ven- ham Picture Test were administered by face-to-face interviews. Results: The sample consisted of 100 boys who were circumcised and 99 who have not been circumcised yet. Children’s Fear Scale scores measured before (P = .000) and immediately after the operation (P = .000) were significantly different from scores obtained on the 10th day after the operation. Total fear scores of the Venham Picture Test of boys whose families were in the higher economic level were higher than those of boys from low-in- come families (P < .05). The primary reason for admission for circumcision was religious, and the reason for the remaining boys was a combination of religious and hygienic factors. The boys who came to have circumcision solely because of religious reasons were found to be less fearful compared with the boys who were brought to surgery for both religious and medical reasons (P < .05). The lowest fear scores were obtained for boys who were six years of age or older. Boys who knew what the circumcision meant were less afraid of circumcision compared with those who were unaware of the procedure. Conclusion: Fear from circumcision does not persist; it considerably vanishes within ten days. It seems reasonable to recommend circumcision for boys six years of age or older. Pre-operative education may help boys to overcome fear originated from circumcision. Keywords: circumcision; male; psychology; health education; health knowledge; attitudes; practice; case-control studies; socioeconomic factors; child behavior. 1 Department of Pediatric Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa 16310, Turkey. 2 Department of Family Medicine, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa 16310, Turkey. 3 Department of Urology, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa 16310, Turkey. 4 Department of Psychiatry, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa 16310, Turkey. 5 Department of Child and Adolescent Psychiatry, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa 16310, Tur- key. *Correspondence: Department of Family Medicine, Bursa Yuksek Ihtisas Training and Research Hospital, Yildirim, Bursa 16310, Turkey. Tel: +90 536 8963330. Fax: +90 224 3660416. E-mail: drhakandemirci@hotmail.com. Received June 2015 & Accepted November 2015 PEDIATRIC UROLOGY Serpil Sancar,1 Hakan Demirci,2* Muhammet Guzelsoy,3 Soner Coban,3 Rustem Askin,4 Mehmet Erdem Uzun,5 Ali Riza Turkoglu3 INTRODUCTION Circumcision in boys is most common in Muslim countries and Israel. However, it has been also widely performed in predominantly non-Muslim pop- ulations such as the United States and the United King- dom. The estimated rate of circumcision in the United States was 80.5%.(1) In recent years, however, there has been a worldwide decline in the rate of circumcision.(2,3) The decision regarding circumcision has been dis- cussed for a long time. Some authors have insisted that circumcision is beneficial, but some have opposed this idea.(4-8) The former group stressed that circumcision is protective against sexually transmitted diseases and, thus, some kinds of cancer (e.g., penile and cervical malignancies) can also be prevented because their caus- ative etiologies have been shown to be associated with these infections.(9-12) There is substantial uncertainty about the psychologi- cal effects of circumcision on boys. The procedure has been blamed for causing psychological trauma that per- sists for a long time.(8,13,14) Research evaluating fear of circumcision has not been tested yet. Fear is a negative emotion. Since it is a subjective complaint, it is hard to document the degree of fear accurately. However, there are two instruments validated to assess the degree of fear in children; these are the Children's Fear Scale (CFS) and the Venham Picture Test (VPT).(15,16) In this study our aim was to measure fear of circumci- Pediatric Urology 2542 Fear of Circumcision-Sancar et al. sion in boys aged 3–11 years just before, immediately after, and the 10th day after the operation. We studied to find out if the fear disappeared within ten days. MATERIALS AND METHODS Study Population The study was designed as a case-control study. Study participants in the operation group consisted of chil- dren who were admitted for circumcision at outpatient clinics of a hospital between June 2013 and September 2013. The control group was composed of children who were interviewed in places other than a hospital. None of the control patients has been circumcised. The CFS and the VPT were administered by face-to-face inter- views. The CFS is a modified version of a test used in adults.(15) The test consists of 5 images of faces. The first image is normal, followed by images of fearful faces of increas- ing intensity. The children were asked to choose the face that show how scared they were. Children pointing to the first image were given 0 points, and the other im- ages were scored in order as 1, 2, 3 and 4 points. The VPT is another instrument developed to assess anxiety in children.(16) The test consists of eight pairs of pictures, in which one child is afraid, and one child is not afraid. Children choosing the fearful image were given 1 point. Otherwise, no point was given. All eight pictures were shown to each child. The total scores ob- tained for the eight pictured were used in the analysis. The boys’ height and weight were measured when they were wearing light clothes. Body mass index (BMI) values were calculated using these data (BMI = weight/ height2). Data on parental education and self-reported economic status were obtained. Any plan of celebration related to circumcision is noted. The main reason ‘why the child was admitted for circumcision’ was classified as religious, hygienic or both. At the end of the inter- views, the boys were asked (a) if they had been told why they had been taken to hospital, and (b) ‘what cir- cumcision meant?’ Statistical Analysis Statistical analysis of the data was performed by the Statistical Package for the Social Science (SPSS Inc, Chicago, Illinois, USA) version 20. Statistical signif- icance was defined as results with P < .05. The dis- tribution of age, height and weight was similar to the normal distribution. The means and standard deviation were calculated, and analyzes of these measures were made by parametric tests: Student’s t-test and Pearson correlation coefficient. Since the results of the CFS and the VPT were not normally distributed, analyzes of these scales were conducted by nonparametric tests: the Mann-Whitney U test for independent samples; and the Wilcoxon Sign Test for dependent variables. Pearson’s correlation was used to examine a relationship between the variables. The χ² test was used to analyze categori- cal variables. Linear regression analysis was performed to determine the extent to which there is a linear rela- tionship between variables. Ethics Ethical approval for the study was obtained from Sevket Yilmaz Education and Research Hospital. All the par- ticipants were informed about the study, and written permission was obtained from parents. Exclusion Criteria The exclusion criteria excluded boys who underwent another operation at the same time as circumcision. Boys who were not 3–11 years of age, and participants who did not come for the second visit (10th day) were also excluded from the study. RESULTS There were 100 boys in the circumcised group and 99 boys in the control group. Age (Z = 1.229, P = .098), Table 1. Age distribution of participants. Age (years) Boys Circumcised Controls no. % no. % 3 3 3.0 3 3.0 4 5 5.0 5 5.1 5 6 6.0 6 6.1 6 19 19.0 19 19.2 7 24 24.0 24 24.2 8 19 19.0 19 19.2 9 13 13.0 13 13.1 10 8 8.0 8 8.1 11 3 3.0 2 2.0 Total 100 100.0 99 100.0 Variables Religious Religious and Statistical Reasons Medical Reasons Analysis Children’s Fear 1.08 ± 1.35 1.82 ± 1.57 χ2 = 4.71 P = .030 Scale Scores* Venham Picture 2.02 ± 2.43 2.19 ± 2.34 χ2 = .26 P = .612 Test Scores* *Arithmetic Mean ± SD. Table 2. Relationship between reasons for circumcision and pre-op children’s fear scale scores. Vol 13 No 01 January-February 2016 2543 height (Z = .986, P = .285) and weight (Z = .787, P = .566) values of two groups have normal distribution. Mean differences in the ages, heights, and weights were not statistically significant (Student’s t-test, P > .05). Age distribution of the boys was shown in Table 1. The educational levels of parents were similar between boys in the operation and control groups (χ² = 2.110, SD = 4, P = .716). Self-reported economic status was also similar in both groups. (χ² = 3.844, SD = 2, P = .146). The difference between pre-operation and con- trol group scores on the CFS was statistically signifi- cant (P < .001), according to the Mann-Whitney U test, with the boys in the operation group exhibiting more fear than the controls. However, pre-operation scores were not significantly different from scores obtained immediately after the operation (Wilcoxon, Z = -1.34, P = .181). Children’s Fear Scale scores measured be- fore (Wilcoxon Sign Test, Z = -5.59, P = .000) and im- mediately after the operation (Wilcoxon Sign Test, Z = -5.31, P = .000) were significantly different from scores obtained on the 10th day after the operation. The relationship between the CFS scores and the boys’ ages were examined using the Pearson correlation. Age was not correlated with the pre-operation scores of the operation group or the control group’s scores (P > .05). CFS scores right after the operation were negatively correlated with age (rs = -.241, P = .018), with older boys being was less afraid. A similar correlation, which is shown in Figure, was also found between age and fear when the boys were tested on the 10th day (rs = -.249, P = .016), Children’s Fear Scale scores and BMI were positively correlated (rs = .638, P = .000). This association was analyzed by regression analysis and the effect of BMI on fear scores was found to be dependent on age. The BMI alone was not significantly related to the fear scores (R2 = .107, t = 1.785, P = .080). When the answers about the reasons for circumcision were analyzed, the boys who came to have circumcision solely because of religious reasons were found to be less fearful compared with the boys who were brought to surgery for both religious and medical reasons (P < .05) (Table 2). The celebration program for circumci- sion was not associated with fear of the child (P > .05). Paternal education also was not associated with the boys’ fear (P > .05). Total fear scores of the VPT of boys whose families were in the higher economic level were higher than those of boys from low-income families (P < .05) (Ta- ble 3). There was no significant difference between the operat- ed group and the control group on the VPT (P > .05). A comparison of fear before the operation and right after the operation revealed a statistical significance differ- ence, as measured by the VPT (Wilcoxon Sign Test, Z = -2.35, P = .019). Fear on the 10th day after circumcision was significantly lower than it was before the operation (Wilcoxon Sign Test, Z = -5.76, P = .000) or immedi- ately after the operation (Wilcoxon Sign Test, Z = -5.30, P = .000), as measured by the VPT. The VPT scores were not associated with the BMI values of the boys (rs = -.044, P = .735). The fear scores of boys who knew the reason were not different from the scores of boys who did not know the reason (P > .05). Boys who knew what circumcision were less afraid of the operation compared with those Variables Self-Reported Income (Low) Self-Reported Income (Moderate to High) Statistical Analysis Children’s Fear Scale Scores* 0.77 ± 1.16 .93 ± 1.33 χ2 = 3.04 P = .081 Venham Picture Test Scores* 1.24 ± 1.63 1.92 ± 2.19 χ2 = 4.80 P = .028 *Arithmetic Mean ± SD. Table3. Effect of economic status on pre-op children’s fear scale scores. Variables Aware Unaware Statistical Analysis Children’s Fear Scale 0.96 ± 1.34 1.83 ± 1.53 U = 717.0 P = .003 Venham Picture test 1.47 ± 2.19 2.90 ± 2.42 U = 709.5 P = .002 Table 4. Relationship between pre-op fear scores and awareness about circumcision. Figure. The relationship of 10th day fear scores and age of boys. Fear of Circumcision-Sancar et al. who did not know anything about the procedure (Table 4). DISCUSSION We have found that fear of circumcision vanished in ten days. Boys who were circumcised had similar fear scores on the 10th day as the controls, who were in- terviewed outside of hospital settings and were not cir- cumcised. These results indicate that circumcision does not cause a long-lasting fear for the children. Children who knew ‘what the circumcision meant’ were less fearful compared with the rest of the study group. This result supports the idea that pre-operative educational information helps to overcome patients’ anxiety.(17-19) The information on circumcision can be provided by families, doctors or other educated healthcare stuff. Obesity has been shown to be related to psychologi- cal problems such as anxiety and depression.(20-22) In the present study, we have shown that there was a link between fear and BMI. But, this relation was found to be age dependent. Further investigations are needed to evaluate if there were a relationship between obesity and frightfulness in children. In Western countries, circumcision is performed mainly for hygienic reasons. Sahin and colleagues have shown that circumcision in Turkey was mainly preferred be- cause of religious and traditional beliefs.(23) In our study, the primary reason for admission for circumci- sion was also religious, and the reason for the remain- ing boys was a combination of religious and hygienic factors; no admissions were made solely for medical reasons among the participants. Boys admitted for cir- cumcision partially for medical reasons had higher fear scores, which could be associated with previous medi- cal treatments. For example, boys suffering from phi- mosis might have experienced painful treatments such as forcing the foreskin to retract. The fear scores of boys ≥ 6 years of age were the lowest compared with other age groups. Thus, a recommenda- tion to perform circumcision at ages six years of age or older seems more reasonable. Circumcision at earlier ages is preferred in most of the countries like the United States, but boys may be more fearful if the procedure is performed at these earlier ages. Even in the absence of crying, body signals show that neonates experience pain during circumcision.(24) Hence, it may be better to delay circumcision until the school-age years. CONCLUSIONS In conclusion, fear of circumcision is not a persistent problem, and it decreases significantly within ten days. Pre-operative educational information about the proce- dure may help children to be less afraid of circumcision. CONFLICT OF INTEREST None declared. REFERENCES 1. Introcaso CE, Xu F, Kilmarx PH, Zaidi A, Markowitz LE. Prevalence of circumcision among men and boys aged 14 to 59 years in the United States, National Health and Nutrition Examination Surveys 2005-2010. Sex Transm Dis. 2013;40:521-5. 2. Owings M, Uddin S, Williams S. Trends in circumcision for male newborns in US hospitals. 1979-2010. 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