International Journal of Impotence Research (2007) 19, 424431

& 2007 Nature Publishing Group All rights reserved 0955-9930/07 $30.00

www.nature.com/ijir

ORIGINAL ARTICLE

Effects of childhood circumcision age on adult male sexual

functions
E Aydur1, S Gungor2, ST Ceyhan2, L Taiimaz1 and I Baser2
1
Department of Urology, Gulhane Military Medical Academy, School of Medicine, Ankara, Turkey and 2Department of
Obstetrics and Gynecology, Gulhane Military Medical Academy, School of Medicine, Ankara, Turkey

The effects of childhood circumcision on male sexual function have been debated. However, there
are no studies, to our knowledge, that assess the possible effects of childhood circumcision age on
male sexual function. In an attempt to answer this question, we performed a prospective study to
determine the possible relationship between circumcision age and male sexual function, using
a validated questionnaire, the GolombokRust Inventory of Sexual Satisfaction. We found no
relationship between childhood circumcision age and overall sexual function; however some
specific domains of sexual function (i.e. avoidance and communication) seemed to be affected by the
age at circumcision procedure in this cohort of sexually active males. In addition, prevalence of
sexual dysfunction was higher, with premature ejaculation being the most common dysfunction
in the survey. We concluded that childhood circumcision age might affect some domains of male
sexual function in adulthood, but not the overall function.
International Journal of Impotence Research (2007) 19, 424431; doi:10.1038/sj.ijir.3901545;
published online 22 February 2007
Keywords: circumcision; male sexual function; adult; premature ejaculation; questionnaire

Introduction
Male circumcision has been described since antiquity
and, today, it is the most commonly performed
surgical procedure worldwide.1,2 However, there is
almost no or few surgical procedures that have
generated controversies and war of words as much
as circumcision in the era of modern medicine.2 One
of the well-known debates is on whether circumcision affects male sexual functions or not. Current
literature is replete with conflicting reports over the
relationship between circumcision and sexual function.2,3 Several authors report superior sensitivity and
sexual satisfaction in uncircumcised men and their
partners,3,4 sexual dysfunction associated with circumcision5,6 and important role of foreskin in sexual
performance and satisfaction.7 However, others did
not show any significant effect811 or found the
procedure to be favorable on adult sexual function.12
It has been postulated that childhood circumcision results in some genital and extra-genital
roloji Klinigi, Etlik,
Correspondence: Dr E Aydur, GATA U
Ankara 06018, Turkiye.
E-mail: eaydur@yahoo.com
Received 17 August 2006; revised 30 December 2006;
accepted 5 January 2007; published online 22 February
2007

changes in children. Keratinization of the more

exposed glans penis would lower the sensibility,
hence sexual excitability, of the circumcised males
genitalia. Early lesions of the prepuce/foreskin
tissue would generate a reorganization/atrophy of
the brain circuitry. This reorganization/atrophy, in
turn, is suggested to lower sexual excitability.5,7,1317
Furthermore, the phallic period of childhood
development, between the ages of 3 and 6 years,
plays a major role in development of sexual identity
and adult sexual attitudes. Circumcision is considered to be an important psychological trauma in
neonates and primary school children. Therefore,
circumcision may affect the psychological status of
the child and eventually cause physical, psychological, behavioral and sexual disturbances.3,5,18,19
However, there have been no studies, to our knowledge, that assess the possible effect(s) of childhood
circumcision age on male sexual function. On the
other hand, this subject is an important public
concern, especially in Western countries.20 Thus, a
study to shed light on this subject would provide
useful information for parents on decision-making
process to have their sons circumcised.
Given the alleged relationship of circumcision with sexual dysfunctions, and the postulated
features and the effects of circumcision on sexual
functions, we designed a prospective study to

Circumcision age and sexual function

E Aydur et al

determine the relationship between age of childhood circumcision and male sexual function using
a validated questionnaire.

Methods
Subjects and procedures
Following approval of the Institutional Ethics Committee, an extensive survey was conducted at our
institution between December 2005 and March 2006,
to determine the contributing factors to sexual
functions of women, men and couples. This paper
focused on the findings related to childhood circumcision age and sexual function of male subjects.
Accompanying partners of nulliparous or primiparous women attending the outpatient clinics of
the Obstetrics and Gynecology Department were
consecutively identified by filter questions and
asked to complete a demographic survey and an
inventory of sexual function. Accompanying partners of multiparous women, apparently pregnant
women and those with a stillbirth were excluded
from the study to avoid the possible confounding
factors of those conditions. The study protocol was
explained to all participants. Complete privacy was
assured and the voluntary nature of participation
in the study was emphasized. Written informed
consent was obtained from all volunteers before
their participation in the study. The male partners
completed the questionnaires in a separate room
allowing for sufficient privacy. One of the investigators was on hand in the event study participants
had questions relevant to the study. All the questionnaires were coded, recorded daily and kept in
computerized files by the investigators.
Questionnaires
The self-administered questionnaire consisted of two
parts; Part I was designed to collect data about
individual and lifestyle characteristics of males such
as age, weight, height, educational level, employment
status and medical background. Other questions
included duration of marriage, type of marriage,
contraceptive use and female partners obstetric
history. Part I was tested on a male group before start
of the study to ensure that participants would
understand what was required of each question.
Part II of the questionnaire included the GolombokRust Inventory of Sexual Satisfaction (GRISS)
and provides an objective assessment of the quality
of sexual relationships and sexual functioning.2123
The questionnaire has two separate forms: one for
males and the other for females. Each form consists
of 28 items and covers the most frequently occurring
sexual dysfunctions of heterosexual persons with
a steady partner. Male form of GRISS comprises 28
questions each with five possible answers, ranging
from never to always. Each of these 28 items are

scored and 24 of them converted to provide eight

discrete scores, one for overall sexual function and
seven for each specific area of sexual function; that
is frequency of intercourse, communication, degree
of satisfaction, avoidance, sensuality, ejaculatory
function and erectile function. This allows for a
breakdown of specific areas of sexual dysfunction in
males. The final scores on each of the GRISS
subscales range from 1 to 9; scores of 14 indicate
normal sexual function and scores of 59 indicate
increased degrees of sexual dysfunction. GRISS can
be applied as a screening instrument and for the
measurement of therapy outcome.2224 The factor
structure, internal consistency and stability of the
Turkish adaptation have been examined in our
population.25,26 On the basis of the findings, it was
justified to maintain the original subscale structure.
The results of the standardization study indicated
that GRISS could be used in Turkish population
both in clinical practice and in research, as a valid
and reliable scale. In the present study, all internal
calculations of GRISS were carried out electronically using appropriate formulas.

425

Data analysis
The primary outcome of this study was the difference
in overall sexual function score among males who
had undergone circumcision procedure during infancy (02 years of age), preschool period (35 years
of age), childhood period (612 years of age) and
thereafter. Although the primary endpoint of the
study was overall sexual function, the specific areas
of sexual function were also included as secondary
endpoints. This enabled us to assess mens sexual
function in a fuller picture. For the primary analysis,
the sample was divided into three groups according to
age at circumcision. In one sample, the Kolmogorov
Smirnov test was used to analyze the normality of
variable distribution. Levenes test was used to test
the homogeneity of variance for the continuous
variables. Comparisons between proportions were
made using w2-test. Continuous variables were compared by using Students t-test and analysis of
variance, where appropriate. Data are expressed as
mean7s.d. (m7s.d.), number and percentage, according to the variables. Differences were considered
significant when Po0.05 for the two tails. Data
analysis was carried out using SPSS for Windows,
version 10.0.27

Results
Demographics
Of the 107 Caucasian men, all accepted to participate in the study. The mean age was 30.374.4 (95%
CI: 27.731.4, range 2244). Circumcision procedure
was performed in the first 2 years of life in 12 men
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426

Table 1 Sociodemographics and marital characteristics of the participants by the circumcision age groups
Characteristicsa

02 ages (n 12)

35 ages (n 29)

612 ages (n 66)

Age (year)
Body mass index

29.572.9
25.973.0

32.575.1b
24.272.3

29.574.0b
24.372.2

0.008c
0.093c

Educational level
Primary/Secondary
High school
Some college/College

1 (8.3%)
5 (41.7%)
6 (50.0%)

15 (51.7%)
14 (48.3%)

3 (4.5%)
42 (63.6%)
21 (31.8%)

Holding a regular job

Yes

12 (100.0%)

29 (100.0%)

62 (93.9%)

Family income
Low
Middle
High
Age at first coitus (year)
Marriage duration (year)

12 (100.0%)

18.572.7b
5.673.1

1 (3.4%)
28 (96.6%)

21.573.7b
5.374.0

5 (7.6%)
60 (90.9%)
1 (1.5%)
20.773.4
4.273.2

0.042c
0.176c

5 (41.7%)
5 (41.7%)
3 (25.0%)

7 (24.1%)
3 (10.7%)
2 (6.9%)

27 (40.9%)
9 (13.6%)
1 (1.5%)

0.272
0.032
0.005

Marriage type
Love marriage
Arranged marriage

12 (100.0%)

24 (82.8%)
9 (17.2%)

54 (81.8%)
12 (18.2%)

Number of children
0
1

1 (8.3%)
11 (91.7%)

11 (37.9%)
18 (62.1%)

37 (56.1%)
29 (43.9%)

8 (66.7%)
2 (16.7%)
2 (16.7%)

18 (62.1%)
10 (34.5%)
1 (3.4%)

46 (69.7%)
17 (25.8%)
3 (4.5%)

6
1
1
4

11
3
3
6
1
5

22
5
6
9
5
19

Lifestyle habits (yes)

Smoking
Coffee consumption
Alcohol

Degree of pleasure for relationship with the spouse

Very good
Good
Neither good nor bad
Bad/very bad
Last method of contraception
Withdrawal
Combined oral contraceptive
IUD
Condom
Other
None

0.469

0.275
0.713

0.516

0.006

0.370

0.438
(50.0%)
(8.3%)
(8.3%)
(33.3%)

(37.9%)
(10.3%)
(10.3%)
(20.7%)
(3.4%)
(17.2%)

(33.3%)
(7.6%)
(9.1%)
(13.6%)
(7.6%)
(28.8%)

Pleasure for the last contraceptive method

Both spouses pleased
Either spouse not pleased
Both spouses not pleased

7 (58.3%)
2 (16.7%)
3 (25.0%)

19 (79.2%)
3 (12.5%)
2 (8.3%)

32 (68.1%)
8 (17.0%)
7 (14.9%)

0.873

Gravidity/delivery mode of wife

Not delivered
Caesarean delivery
Vaginal delivery

1 (8.3%)
5 (41.7%)
6 (50.0%)

12 (41.4%)
5 (17.2%)
12 (41.4%)

37 (56.1%)
11 (16.7%)
18 (27.3%)

Medical background
Chronic medical illness

1 (8.3%)

1 (1.5%)

0.029

0.189

Values are given as mean7s.d. or number (percentage).

The mean difference is significant at the 0.05 level between these two groups according to Bonferroni test.
c
ANOVA; All other P-values are according to w2-test.
b

(11.2%), in preschool years in 29 men (27.1%), and

between the 6 and 12 years of age in 66 men (61.7%).
None of the males was circumcised later than 12
International Journal of Impotence Research

years of age. Sociodemographic and reproductive

characteristics of the three groups are demonstrated
in Table 1.

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E Aydur et al

Overall sexual function and specific domains

Mean scores of overall and specific areas of sexual
function are demonstrated in Table 2, according to
the circumcision age. In all age groups, mean scores
of all subscales were in the normal range, except for
ejaculatory function. The mean scores of ejaculatory
function were similar in all groups; however, all of
the mean scores were abnormal. The mean scores of
frequency of coitus, degree of satisfaction, sensuality and erectile function were worst in the 35 year
age group, whereas this group had the best mean
score of ejaculatory function. However, the differences did not reached to statistical significance for
all comparisons. The only statistically significant
difference among the three groups was in the
avoidance domain. Multiple comparisons between
groups (i.e. 02 vs 35, 02 vs 612 and 35 vs 612)
indicated that the mean score of avoidance was
significantly lower in the infantile circumcision
group, compared with that of the circumcision
group of 35 ages (Po0.05). Further analysis using
binary logistic regression demonstrated that age at
survey, age at first coitus, alcohol consumption and
number of children were not the predictors of
avoidance.

Prevalence of sexual dysfunction is demonstrated

in Table 3, according to study groups. Overall, 28
men (26.2%) demonstrated sexual dysfunction.
Premature ejaculation (PE) was the most common
dysfunction with a prevalence of 49.5% (n 53).
When the mean score of this subscale was taken into
consideration, this was an expected finding. Interestingly, none of the men demonstrated nonsensuality. Prevalence of sexual dysfunction was
23.4% (n 25) in erectile function, 19.6% (n 21)
in communication, 15.9% (n 17) in avoidance,
13.1% (n 14) in frequency of intercourse and
4.7% (n 5) in degree of satisfaction. Prevalence of
sexual dysfunction in overall and specific areas of
GRISS did not demonstrate any statistically significant difference among the three groups.

427

Comparison of normal sexual functioning and

sexually dysfunctional groups
When the males were divided into two groups,
sexually functional and dysfunctional groups,
according to overall sexual function, and compared
with the mean age at circumcision procedure, there
was no difference between the two groups regarding

Table 2 Mean scores of the circumcision age groups in overall and specific areas of sexual functions
Crude scores of GRISS
for normal sexual functioning

02 ages
(n 12)

35 ages
(n 29)

612 ages
(n 66)

Pa

Overall sexual function

p24

17.778.7

21.577.9

18.678.1

0.216

Specific areas of sexual function

Frequency of intercourse
Communication
Degree of satisfaction
Avoidance
Sensuality
Premature ejaculation
Erectile dysfunction

p3
p3
p7
p3
p11
p4
p3

1.971.5
2.271.7
2.872.5
1.771.7
2.972.4
4.972.6
2.271.8

0.270
0.593
0.634
0.016
0.099
0.522
0.527

GRISS Subscales

2.271.2
1.771.9
3.172.5
0.971.3b
2.572.3
5.371.9
2.172.0

2.571.6
2.271.5
3.372.3
2.571.9b
4.072.5
4.472.1
2.772.3

Abbreviation: GRISS, GolombokRust Inventory of Sexual Satisfaction.

a
ANOVA.
b
The mean difference is significant at the 0.05 level between these two groups according to Bonferroni test.
Table 3 Prevalence of overall sexual dysfunction and its specific areas by the circumcision age groups
02 ages (n 12)

35 ages (n 29)

612 ages (n 66)

Pa

Overall sexual dysfunction

3 (25.0%)

9 (31.0%)

16 (24.2%)

0.782

Specific areas of sexual dysfunction

Infrequent intercourse
Noncommunication
Dissatisfaction
Avoidance
Nonsensuality
Premature ejaculation
Erectile dysfunction

1
2
1
1
0
7
4

6
12
3
8
0
32
13

0.118
0.768
0.794
0.124
1.000
0.811
0.484

GRISS Subscales

(8.3%)
(16.7%)
(8.3%)
(8.3%)
(0.0%)
(58.3%)
(33.3%)

7
7
1
8
0
14
8

(24.1%)
(24.1%)
(3.4%)
(27.6%)
(0.0%)
(48.3%)
(27.6%)

(9.1%)
(18.2%)
(4.5%)
(12.1%)
(0.0%)
(48.5%)
(19.7%)

Abbreviation: GRISS, GolombokRust Inventory of Sexual Satisfaction.

a 2
w test.

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428

Table 4 Comparisons of mean circumcision age between sexually normal functioning and dysfunctional men
GRISS Subscales

Circumcision age
Pa

Mean7s.d. (n)
Normal sexual function

Sexual dysfunction

Overall sexual function

6.572.8 (28)

5.573.0 (79)

0.126

Specific areas of sexual dysfunction:

Frequency of intercourse
Communication
Degree of satisfaction
Avoidance
Sensuality
Ejaculatory function
Erectile function

6.472.9
6.573.0
6.372.9
6.372.8
6.372.9
6.272.6
6.472.7

5.372.7
5.272.2
5.273.1
6.273.3

6.373.2
5.773.3

0.179
0.048
0.405
0.906
NA
0.914
0.293

(14)
(21)
(5)
(17)
(107)
(53)
(25)

(93)
(86)
(102)
(90)
(54)
(82)

Students t-test.

overall sexual function. The mean age of these two

groups was similar at survey (30.174.5 vs 31.873.8,
respectively. P 0.339). Among the seven specific
areas of sexual function, only the communication
domain demonstrated a statistically significant
difference between the two groups, showing that
the mean age at circumcision of sexually dysfunctional men was significantly younger than the
normal functioning men (Table 4).

Discussion
To our knowledge we report the first prospective
study assessing the relationship between childhood
circumcision age and male sexual function. We
demonstrated no relationship between circumcision
age and overall male sexual function. However,
comparisons of subgroups yielded that, of specific
domains of sexual function, avoidance and communication seemed to be affected by age at circumcision procedure in this cohort of sexually active
males. In addition, prevalence of sexual dysfunction
is higher and PE was the most common dysfunction
in the survey.
Although many have speculated about the effect
of childhood circumcision on sexual function, the
current state of knowledge is based on anecdote
rather than scientific evidence.2830 Myths have
mostly addressed changes in penile sensitivity,5,7,1317 but some have also regarded sexual
activity and satisfaction with appearance.6 Little
has been written about the effect of childhood
circumcision on erectile function5 and, few studies
have investigated the relationship between childhood circumcision and adult sexual function.5,10
Hammond,5 has reported the results of the study
conducted by the National Organization to Halt the
Abuse and Routine Mutilation of Males (NOHARMM) and concluded that circumcision would
International Journal of Impotence Research

result in physical, sexual and psychological adverse

consequences. NOHARMMs study was entirely
based on the poll of participants who were unsatisfied with infantile circumcision and has
claimed that adverse sexual consequences were
secondary to decreased penile sensitivity and
emotional distress. However, there is no evidence
supporting the theory of decreased penile sensitivity
owing to circumcision, though it is plausible.
Furthermore, Masters and Johnson8 and, more
recently Bleustein et al.10 have found no significant
difference in sensation by neurological testing on
the glans of circumcised and uncircumcised men.
On the other hand, emotional distress as a claimed
cause of adult sexual dysfunction after neonatal
circumcision may be, of course, culture, individual
or partner related. For example, an uncircumcised
Turkish man would have emotional distress, because male circumcision is deeply woven into the
fabric of Turkish society and Turks consider that one
is not a man until he is circumcised.31
Laumann et al.12 analyzed data from the National
Health and Social Life Survey and found that
neonatally circumcised men were slightly less likely
to experience sexual dysfunction. Also, several
authors have reviewed the literature and concluded
that circumcision does not interfere with sexual
sensation and satisfaction.2830
Childhood circumcision is reported as a psychological trauma as in all interventions. Furthermore,
infantile circumcision may also cause short-term
behavioral changes. However, long-term psychological effects associated with circumcision are difficult to establish.18 Actually, there is no circumcision
study that demonstrates psychological adverse
effects experienced in adulthood.
We found that the mean score of avoidance was
significantly lower in males who had undergone
circumcision in infancy, compared with that of the
group including men circumcised between 3 and 5
years of age. Also, in the communication domain,

Circumcision age and sexual function

E Aydur et al

there was a statistically significant difference

between the two groups, where the mean age of
sexually dysfunctional men was younger than that
of the normal functioning men. Although NOHARMMs study has reported that many respondents
suffered
physical/emotional
distress
impeding emotional intimacy with partner(s), resulting in sexual dysfunction,5 we could not comment on these findings. The nonsensuality scores
in the study may result from and also represent the
well being of participants, who were at their the
most sexually active period, as sensuality is considered as a yield of endocrine function.32
Men who have undergone circumcision in adulthood have potentially a unique position to assess
the effect of the prepuce on sexual intercourse.6
Therefore, we do not mention findings from adult
circumcision studies. However, the well-known
controversies also continue to exist regarding the
sexual effects of adult circumcision.2,3,6,9
The rationale of the present study is based on the
available literature summarized in the introduction.
Little is known about the effects of male circumcision on male sexual function, even though it is easy
to test their possible relationship, as circumcision
is highly prevalent procedure throughout the
world.1,5,6 Thus, there are many myths surrounding
circumcision, affecting public behavior, particularly
in Western countries.2,20 This study is a part of our
large survey, which was conducted to determine the
contributing factors to sexual functions of women,
men and couples. The present study attempts to
shed light on the circumcision debate by assessing
the possible relationship between childhood circumcision age and sexual function of adult male,
using a validated questionnaire, GRISS.
Several means, including interviews, diaries and
questionnaires, have been developed and commonly
used for assessment of sexual function in both men
and women.6,33 However, few questionnaires have
been cross-validated in multiple samples of sexually
functional and dysfunctional women. Published
data indicate that the GRISS questionnaire is valid,
reliable and responsive to change following standard psychometric testing. Evidence has been
published on all aspects and the questionnaire is
relevant for use with persons with sexual dysfunction.2124 The advantage of the present study is that
we were able to examine the sexual function by the
use of a self-report questionnaire cross-validated
in multiple samples of sexually functional and
dysfunctional men, rather than relying on general
questions about sexual problems or focusing on only
certain types of sexual dysfunction. This provided a
fuller picture of overall sexual function in the study
groups. Considering that sexuality is a complex
entity with physical, emotional, psychological,
cultural and religious dimensions, differing from
person to person, future investigators wishing to
compare sexuality should consider using self-

reported and validated questionnaires. It will be

easy to compare studies and increase the ability to
draw clinical inferences from the findings. However,
different questionnaires have been used partly or
entirely in the published studies to assess the effects
of circumcision on male sexual functions, including
nonvalidated and validated questionnaires, such as
the International Index of Erectile Function (IIEF),
Brief Sexual Function Questionnaire, Changes in
Sexual Functioning Questionnaire, Center for Marital and Sexual Health Functioning Questionnaire,
and National Health and Social Life Survey. To our
knowledge, GRISS questionnaire is firstly used in
the study for such a purpose.2,3,6,3438
Male participants were at their most sexually
active period in terms of age, allowing to determine
easily the possible relationship between childhood
circumcision age and sexual functions. The accompanying partners of multiparous women, pregnant
women and those with a stillbirth were excluded
from the study to avoid possible confounding factors.
Our study may have methodological limitation owing
to lack of control (uncircumcised men) group to
compare, but almost all of the men are circumcised in
our country,31 and we, therefore preferred the present
design to test the studys objective.
Of all the dysfunctions, PE was the only specific
dysfunction found in our study, with a mean score
above the normal range. Moreover, it was the most
common problem in accordance with the previous
studies.11 PE has been reported as affecting from 5 to
40% of sexually active men, depending on age.39,40
Prevalence estimates of PE vary widely, probably
because there is no universally accepted definition
of PE and ejaculatory function can be affected by
psychological, physical, financial or partner-related
factors, even in the same man.41 There are few, if
any, large-scale studies providing community-based,
normative data and there is no standardized screening tool to identify PE. Considering the age range of
our study population, the rate of PE was higher than
that reported previously.39,40 There is no evidence
supporting notion that circumcision causes PE.11
In our sample of male participants from a
gynecological outpatient clinic of a University
hospital, a rather high prevalence of sexual dysfunction (26.2%) was found.42 None of the men had
self-presented their sexual dysfunctions before the
present study. This finding corroborates earlier
contentions that the clinician should actively ask
for the existence of sexual dysfunctions, because
patients tend not to disclose their sexual problems
by themselves, usually owing to embarrassment,
despite their apparent need for professional assistance.4244 Although physicians are able to elicit
information regarding sexual function on specific
questioning, patients appear comfortable and willing to discuss their condition with physicians.4244
Some methodological shortcomings may limit the
value of the findings. First, our study consists of

429

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430

small sample size, especially in subscales. Second,

it has no control (uncircumcised men) group to
compare owing to scarce of uncircumcised men in
our country. Third, the study was conducted in a
unique cultural environment, which is a confounding factor in studies regarding circumcision.45 Finally, the female factor in the study was not considered.
However, we cannot know the way in which all the
limitations will affect the studys results.
To our knowledge, we present the first study to
evaluate specifically the relationship between childhood circumcision age and male sexual function.
Although our study has some methodological shortcomings, it contributes to our knowledge about the
effects of childhood circumcision age. We demonstrated that circumcision age does not affect overall
male sexual function, however, some specific
domains of sexual function (i.e., avoidance and
communication) seemed to be affected by the age at
circumcision. In addition, prevalence of sexual
dysfunction was higher and PE was the most
common dysfunction in the survey. Our findings
may help health professionals interested in circumcision better counsel parents on decision-making
process of male circumcision. Prospective studies,
including large cohort studies and those based on
scientifically objective measurements, are needed to
understand better the effects of childhood circumcision on adult life.

Conflict of interest
None.

Acknowledgments
We thank Zuhal Baltaci, PhD, for the assistance in
recruiting women to participate in this study and
Serap Gungor, PhD, for her invaluable advice and
assistance in preparing the questionnaire. We would
also thank Dr Bedreddin Seckin and Dr Kaan Aydos
for their precious reviews and helpful corrections in
the text. We are especially grateful to the participants of the study who so generously gave their time
and support to complete this study.

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