THE CIRCUMCISION REFERENCE LIBRARY

Extraordinarily high rates of male circumcision in

South Korea: history and underlying causes

M.G. PANG and D.S. KIM*

GenDix, Inc. and Institute of Reproductive Medicine and Population, and *School of Physics, Seoul National University.

Seoul, South Korea

Objective To investigate the high circumcision rate in South Korea and its rapid increase in the short period since its introduction. Subjects and methods From January to December 2000, 5434 South Korean males (or their parents) aged 0-92 years were interviewed in detail about their circumcision status, their age at circumcision, and the possible effect of circumcision on their sexuality. In addition, 267 practising medical doctors were surveyed about their basic understanding of circumcision and phimosis. Results Currently the circumcision rate for high-school boys is >90% and for those >70 years old is <10%. The circumcision rate in 1945 was <0.1%. When averaged over the whole population, the present South Korean circumcision rate is ~60%; the rate has increased dramatically with time and particularly in the past 20 years, when the estimated number of male circumcisions has exceeded the number of male births. Although circumcision in South Korea has been strongly influenced by American culture, it has never been predominantly neonatal. The age at circumcision has continued to decrease and boys are now circumcised at ~12 years old. Of those who were circumcised long after they had been sexually active, >80% reported no noticable difference in sexuality, but a man was twice as likely to have experienced diminished sexuality rather than improved sexuality. Of the doctors who were surveyed, 41% carried out circumcision but, unlike in America gynaecologists and paediatricians rarely did so. Among the factors contributing to the high circumcision rate was the mistaken notion held by both doctors and the general public that circumcision is directly correlated with industrialization and general progress of living standards. Many doctors believe the out-dated and sometimes controversial benefits of circumcision, i.e. prevention of cervical cancer and sexually transmitted diseases, and improved sexuality. Thus the vast majority of doctors recommend circumcision regardless of the patient's age Peer pressure was also an important contributing factor. Conclusion South Korea has an unusual history of circumcision. The mistaken and out-dated notions about circumcision and lack of knowledge of phimosis by physicians seem to be a leading contributory factor to the extraordinarily high circumcision rate. Keywords circumcision, South Korea, history, phimosis

Introduction

Male circumcision is undertaken mostly for religious reasons, notably in Moslem and Jewish communities. Starting from the mid-19th century, circumcision began to be adopted in English-speaking countries but at present, only in the USA are half the boys circumcised. In other English-speaking countries the circumcision rate has been declining or is already fairly low. [1,2]. e.g. at ~5.6% for England or ~2% for New Zealand.

We recently reported that South Korea has a surprisingly high circumcision rate [3]; it is the only country among its geographical and cultural neighbors in which most boys are circumcised. No other countries with strong Confucian and Buddist traditions circumcise in this way. Indeed, circumcision is directly against Korea's long and strong tradition of preserving the body as it is given by his or her parents [3]. As throughout its 2000-year history, the recent popularity of Christianity in South Korea, both Prostestant and Catholic, cannot account for the situation either. There are virtually no Muslim and Jewish populations living in South Korea. Thus all circumcisions have supposedly been `medical'. While an indirect American influence was evident in our previous study [3], it was unclear why South Korean circumcision has never been neonatal, in stark contrast with the practice in the USA.

As the supposed initiation of circumcision in South Korea is so well defined (1945-1950 [3]), it is the only country where the first generation of those who are circumcised and those practicing circumcision are still alive. In the present study we investigated how the circumcision rate increased so rapidly in such a short time and why it is still so high.

Subjects and Methods

The study included 5434 males (or their parents), aged 0-92 years, who were questioned as to whether and when they were circumcised; for this information we obtained the present rate with age; the rate as a function of the calendar year, and the mean age at circumcision vs. age. The 712 men who were circumcised long after they had been sexually active were asked what the effect of circumcision was on their sex lives (whether it became better or worse).

In South Korea, most circumcisions are performed in local clinics by practising medical doctors; thus to determine how the present situation arose, 267 practitioners were surveyed to ascertain their basic knowledge of and beliefs about circumcision and phimosis, whether they themselves were circumcised, and why they recommended circumcision.

Results

The number of interviewees in age groups is summarized in Fig. 1 Their present (year 2000) circumcision status is summarized in Figure 2. The circumcision rate is >90% for ~18-year-olds and continues to decrease until it becomes <10% for those >70 years old. Circumcision is predominantly carried out long after birth, because <10% of infants are circumcised. There were no noticable variation in circumcision rate with educational or economic background, geographic origin or where the survey was conducted. Also, older men had lower circumcision rates regardless of where the survey was conducted. The distribution of the circumcision rate was deduced for the same population in 1970, when the polled group was 30 years younger. The resulting distribution is also shown in figure 2.The peak circumcision rate in 1970 was in those aged ~28 years, at 35%. Within 30 years the circumcision rate for 16-year-olds increased 20 fold; furthermore, the neonatal circumcision rate in 1970 was practically zero.

In the survey over 1400 males were born before 1945 but only one person was circumcised before then, the year of the start of the American trusteeship of South Korea. He was circumcised in 1943 and was a student of a medical school originally established by American missionaries. Therefore it can be concluded that, while there might have been isolated instances of circumcision before 1945, the vast majority of circumcisions occurred afterwards. The abrupt start of circumcision is shown clearly in Fig. 3, where each circumcised male amongst the interviewees is represented by a point whose horizontal and vertical locations indicate respectively, his age and the year of his circumcision. Three things are apparent; circumcision started in 1945, mass circumcision began in the 1960s and circumcision has been mostly after birth.

Currently most boys are being circumcised at ~12 years old; as shown in Fig. 4, the prevalent age of circumcision is 9–14 years. Also shown in Fig. 4 is the distribution of age at circumcision for those aged 45-50 years; the distribution is wider and the mean age at circumcision greater; at ~27 years. Figure 4 suggests that the mean age at circumcision continued to decrease since circumcision started in 1945. Figure 5 shows the mean age at circumcision of circumcised males plotted against their present age. While circumcision is rare amongst older men aged >70 years, they were circumcised on average after the age of 30 years.

Figure 6a shows the circumcision rate of then-20-year-old men as a function of the calendar year. Using Census Bureau data (http://www.nso.gov.kr) for the population structure over time, the circumcision rate averaged over the entire population was estimated for the past 50 years (Fig. 6b); the present estimated rate is ~60%, whereas in 1960 it was ~3%. The steepest increase in the rate was between 1980 and 1995, with the rate for the entire population increasing at ~2.9% per year between 1985 and 1995%. With a birth rate of ~1.5% and death rate of ~0.5%, the number of male circumcisions must have far exceeded the number of male births during this period. Considering the actual death rate of each age group with time, the number of circumcisions performed each year can be estimated; the results are shown in Fig. 7. As expected, the circumcision rate has been >100% for the last 10-15 years.

More than 80% of the 593 men who were circumcised long after they had been sexually active reported no noticeable difference in sexuality, but a man reporting a change was twice as likely to have experienced diminished than improved sexuality (78 vs 41 respondents). The most common complaints were painful erections, resulting presumably from the removal of too much prepuce, and diminished sexual pleasure. A few respondents complained of penile curvature on erection.

Overall, 41% of the doctors polled (267) practised circumcision; the percentage in each speciality using circumcision was: urology (92%), general surgery (88%), general practice (80%), dermatatology (80%), thoracic, orthopaedic and plastic surgery (72%), family physician (58%), anaesthesiology (50%), obstetrics and gynaecology (28%), and internal medicine (2%). No paediatricians reported using circumcision.

Of the doctors using circumcision, 72% were circumcised themselves (52 of 72%). However, 56% of those who did not circumcise were circumcised themselves. (49 of 88); this difference is statistically significant (P<0.05). Of the two major circumcisers (urologists and general surgeons) 91% were circumcised (31 of 34) and 92% practised circumcision. In sharp contrast, among internists and paediatricians who rarely, if ever, practise circumcision, 51% were circumcised (20 of 39); these differences are also statistically significant (P<0.001).

To analyse the doctors' perceptions of circumcision rate in developed and neighbouring countries, they were asked, using a multiple-choice format, what the approximate circumcision rates were in Scandinavian countries and which of South Korea's neighbouring countries routinely used mass circumcision; their answers are summarized it Table 1. For the circumcision rates in Scandinavian countries, more than half of the doctors believed that the rate was >50%. More than half of the polled doctors believed that Japan also had circumcision rate of >50%. In contrast only 8% of the doctors believed that North Korea and China had a circumcision rate of >50%. There was no noticeable difference in doctors' perceptions depending on whether they used circumcision or not.

Two multiple-choice questions were also asked about phimosis (Table 1; which also summarizes the doctors' answers); >70% of the doctors defined phimosis as `glans covered by foreskin', `long foreskin', or `foreskin itself', Less than 30% offered the definition accepted by doctors worldwide, i.e. an unretractable foreskin. On the second question, >75% of doctors reported an astonishingly high percentage of phimosis (>40%), consistent with most of the polled doctors having the wrong definition of phimosis. Incidentally of 267 polled doctors, only five answered all four questions correctly.

The vast majority of polled doctors (99%) recommended circumcision regardless of age; as to why they recommended universal circumcision, 75% of doctors cited `prevention of cervical cancer'. Most of the same doctors also cited `improved hygiene and prevention of sexually transmitted diseases'. Other than medical benefits, 18% of doctors also cited parental request as the primary cause for their circumcising their patient.

Discussion

The history of circumcision in Korea was examined by undertaking a large-scale detailed study of >5000 males of all ages up to 92 years, and by questioning 267 practising medical doctors about their basic understanding of circumcision. While this survey was mostly conducted in Seoul, this population comprises about half of the general population, most of whom originate from elsewhere. Therefore it can be assumed that the interviewees are generally representative of the general population of South Korea.

Circumcision in South Korea is unique in several aspects; while most young males are being circumcised for `medical' and not for religious reasons' unlike medical circumcision in the USA, <10% of circumcision is neonatal; interestingly there is no fixed age for circumcision in South Korea. Older men were circumcised when they were older. The dramatic increase in circumcision rate in the short period since circumcision started in 1945 is unprecedented in modern medical history; the mean estimated circumcision rate over the population is ~60%, whereas it was ~3% in 1960. The circumcision rate for young males is high, at >90% for those aged ~18 years. Circumcised boys are the majority and thus boys who resist circumcision until later often face many years of peer and psychological pressure. The circumcision rate has been >100% of male births for the last 15 years. We cannot explain this large increase, even if it is assumed that every boy who is born is circumcised and that every male who dies is uncircumcised. Therefore, the number of male circumcisions must have been far exceeding the number of male births during this period.

As circumcision in South Korea has never been predominantly neonatal, most circumcisions were of boys, adolescents and adults. Currently, as the age at circumcision continues to decrease with time, there can be a situation whereby a father and son who are 30 years apart in age, were circumcised 15 years apart. Consistent with this there were among the interviewees three generations of males circumcised within 20 years. Indeed, there were a few grandfathers among the interviewees who were circumcised after their sons and grandsons, after being urged to do so by their sons and daughters-in-law. Added to such peer pressure has been the `culture of public bath-houses'. Most South Korean men often go to public bath-houses and uncircumcised men tend to feel embarrassed.

Male circumcision removes 33-50% of the penile skin and nearly all of the penile fine-touch neuroreceptors [4]. While there has been debate over whether circumcision affects the sexual sensation of the penis, there have been few relevant studies. Studies on circumcision were mostly found in neonatally circumcised males [5,6]; little difference was found in sexuality in these studies. However, there is a widespread perception in South Korean society that circumcision is good for sex, i.e. the prevention of premature ejaculation and prolonging of intercourse [3]. How these perceptions may have affected the responses of the present interviewees is difficult to guage. While the present study does not answer the large question of circumcision and sexuality, South Korea offers a unique opportunity to study the effect on sexuality, as millions of men were circumcised long after they had been sexually active. In the present study, >80: reported no noticeable difference but a man reporting a change was twice as likely to have experienced diminished than improved sexuality. While the reasons for complaints were specific, those who reported that their sex lives improved after circumcision were less specific; no details were given about how and why their sex lives improved.

The results obtained from the 267 South Korean doctors surveyed were helpful in understanding how a traditionally Confucian country has adopted widespread circumcision in one generation. No paediatrician and relatively few gynaecologists practised circumcision.; this contrasts with the situation in the USA where most circumcisions are neonatal and conducted by those groups. [7]. More than half of the doctors surveyed believed that the circumcision rate in Scandinavia was >50%; this perception is of course wrong, as the circumcision rate there is 1-2% [8]. The possible source of this error is the belief that most males in any medically and economically advanced countries, like the USA should be routinely circumcised. Moer interestingly, more than half the South Korean doctors also considered that Japan used routine male circumcision; in reality, only South Korea among its neighbours practises routine circumcision. What is striking is that none of the doctors considered that North Korea uses mass circumcision. Therefore, it is clear that most South Korean doctors believe in the strong correlation between economic prosperity, medical advance and circumcsion. They tend to think that prosperous countries such as Scandinavia and Japan should be using routine circumcision, while the generally poor North Koreans or Chinese do not. This erroneous yet strong belief in this direct correlation must be important in South Korean doctors recommending indiscriminate male circumcision; mass circumcision is viewed as part of `advancement'.

Phimosis is generally defined as an `unretractablae foreskin': the percentage of phimotic males at ~20 years of age varies depending on the study, but is 0.8–1.5% [9-11]. These males are prime candidates for medical circumcision in most countries outside the USA. In South Korea, >70% of doctors defined phimosis incorrectly and >75% believed that the incidence of phimosis was >40%. Most of the doctors surveyed recommended circumcision (99%); as South Korean doctors define circumcision as a `phimosis operation', and as they believe that most adult males have phimosis, indiscriminate circumcision regardless of patient age seems obvious.

The reasons given by most doctors recommending universal circumcision were `prevention of cervical cancer' and `improved hygiene and prevention of sexually transmitted diseases'. Preventing cervical cancer by circumcision is now an outdated notion, as recent American Association of Paediatricians and American Cancer Society reports unequivocally note [12,13]. Circumcision has been suggested as an effective method of maintaing penile hygiene, but there is little evidence to affirm the association between circumcision status and optimum penile hygiene. There is no clear evidence that circumcision prevents sexually transmitted diseases. The only consistent trend is that uncircumcised men are more prone to genital ulcer disease, while circumcised men are more prone to urethritis [14]. Recently there have been reports on the possible correlation between HIV infection and circumcision status [15-17]. Most of these articles were based on research in African males with generally poor hygiene, and the potential preventive measure of circumcision against circumcision was not intended to be applied to developed countries. However, these results have often been quoted as one of the main causes of the low incidence of HIV infection amongst South Korean males, and another reason for recommending universal circumcision. These recommendations probably stem in part from South Korea's general unawareness that Japanese males are mostly uncircumcised, yet they also have as similarly low incidence of HIV infection.

Recent articles [12,18-20] on UTI suggest that even though the incidence of UTI may be less in circumcised boys, it always occurs in the first year of life; it is also rare (<1 in 100) and easily treatable with antibiotics. However, in South Korea these same articles are quoted or interpreted as recommending universal circumcision not at infancy but at, say, 12 years of age, which in reality has no bearing on preventing UTI.

In conclusion, male circumcision started 50 years ago in South Korea but now the country has one of the highest circumcision rates in the world. The mistaken and outdated notions of South Korean doctors about circumcision, and their lack of knowledge about phimosis, seem to be a leading contributory factor to the extraordinarily high rate of circumcision.

Acknowledgements

We acknowledge helpful discussions with Dr Frederick Hodges.

References