Circumcision and sexuality
Perhaps no issue has been more bitterly or emotionally debated than the question of what difference circumcision makes to the experience of sex. Circumcision promoters insist that it makes no difference or even improves a man's sex life and that women prefer circumcised partners. Critics of circumcision point to a considerable body of evidence that circumcision makes a big difference, that there is no evidence that women in general prefer circumcised partners, and that - on the contrary - women may enjoy sex more with uncircumcised men.
For much of the twentieth century enthusiasts for routine circumcision have echoed the sentiments of the Victorian sexual health expert (and chastity advocate) William Acton:
Although it is possible that it [the foreskin] may increase the pleasure derived from the act of sexual congress, there is no evidence that Jews, and those who have undergone circumcision, do not enjoy as much pleasure in the copulatory act as the uncircumcised; – at any rate, the former do not complain.[1]
The claims are clear: first, that circumcision makes no difference to a male’s experience of sex; second, that even if it did men do not complain about what they are missing. An obvious point to note is that Acton’s first assertion directly contradicts the medical knowledge of his own day; throughout history and up to the end of the nineteenth century it was generally held by authorities on medical and sexual matters that the foreskin made a significant contribution to the sexual pleasure of both men and their partners. Far from there being “no evidence”, there is so much that the problem becomes one of selection: from many possible sources we may cite the early eighteenth century surgeon John Marten as representing the orthodox position:
This Nut is … cover’d with the preputium or Fore-skin, which is of a loose texture, for the better covering of the Nut, and furling itself up behind the Ring or Hoop, to uncover it; therefore serves as a Cap to the Nut, and to enlarge the pleasure that attends Enjoyment, for in the act of Coition it flips backwards and forwards, being tied together with a membranous String call’d the Fraenum or Bridle, and causes the greater pleasure thereby, both to the Man and the Woman … The cutting of this Preputium or Fore-skin, is done by the Jews, and call’d Circumcision; by having of which taken away, ‘tis said those People lose much of the pleasure in the act of Copulation.[2]
Acton’s statement is even inconsistent with the medical wisdom of the Victorian period, since it was precisely the erotic significance of the foreskin that led the physicians of that “anti-sensual age” to urge its removal.[3] As the prominent surgeon Jonathan Hutchinson expressed it:
The only function which the prepuce can be supposed to have is that of maintaining the penis in a condition susceptible of more acute sensation than would otherwise exist. It may be supposed to increase the pleasure of coition and the impulse to it. These are advantages, however, which in the present state of society can well be spared, and if in their loss some degree of increased sexual control should result, one should be thankful.[4]
Acton himself acknowledged the contribution of the foreskin to sexual pleasure when he denounced it as “a source of serious mischief” and a constant threat to the strict continence he regarded as essential to both morals and health.[5]
In the twentieth century the Puritanism of the Victorians gradually softened, and sexual pleasure came to be seen as a good thing, even a human right, rather than a menace to health and virtue.[6] Advocates of routine circumcision thus found it necessary to minimise the adverse effects of such surgery on sexuality and to focus strictly on its benefits for health. For this purpose they have relied heavily on a sloppy and irrelevant piece of research that Masters and Johnson claim to have carried out and published in their much-read book on human sexual response.
References
1. Acton, W. The functions and disorders of the reproductive organs in childhood, youth, adult age and advanced life. 3rd edn. Philadelphia: Lindsay and Blakiston, 1865, p 22
2. Marten, J. Gonosologium novum: Or a new system of all the secret infirmities and diseases natural, accidental and venereal in men and women. London, 1709; Facsimile reprint, New York: Garland Publishing, 1985, p 12
3. Moscucci, O. Clitoridectomy, circumcision and the politics of sexual pleasure in mid-Victorian Britain. In: Miller AH and Adams JE ed. Sexualities in Victorian Britain. Bloomington: Indiana University Press, 1996
4. Hutchinson, J. The advantages of circumcision. Medical Review 1900;3:642
5. Darby, R. A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain. Chicago: University of Chicago Press, 2005. chap 6
6. Cook, H. The long sexual revolution: English women, sex and contraception 1800-1975. London: Oxford University Press, 2004
Three questions
We cannot hope to settle the question here, but three points ought to be made. First, it defies common sense and logic to assume that cutting the part of the penis that contains the vast bulk of the pleasure-sensing nerves could not make a difference to sexual function and sensation. The loss of the mobile sheath of tissue must also make a huge difference.
Secondly, although some men who choose circumcision as adults and say that it improved their sex life, you cannot assume that the effects of circumcision in adulthood are the same as the operation in infancy or childhood. If you cover a baby's eyes at birth he will never learn to see properly because he needs the stimulus of light on the optic nerve to activate the neuronal pathways in the brain that control vision. There is evidence (from studies by Immerman and Mackey - both advocates of circumcision, incidentally) that something similar may occur if the foreskin is removed in infancy. It may well be that circumcision did improve the sex lives of some men, but in most cases this would have been because they had severe phimosis that inhibited any movement of the foreskin. Most such problems these days can be fixed by application of steroid cream.
Thirdly, why should men have to prove to the satisfaction of the circumcision promoters that the foreskin makes a significant difference to sexual experience before they are allowed to keep it? The foreskin is a natural part of normal human anatomy (indeed, of all mammals), and the default position should be that it is a useful, beneficial or at least non-injurious structure. If the foreskin was as malevolent as the circumcision promoters claim, you would think that evolution might have abolished it by now.
New research into nerve structure of penis shows foreskin to be the sexually dynamic element
Ken McGrath, Senior Lecturer in Pathology at the Faculty of Health, Auckland University of Technology and Member of the New Zealand Institute of Medical Laboratory Scientists discusses his research into the neural anatomy of the human penis and the physical damages caused by circumcision. McGrath is author of The Frenular Delta: A New Preputial Structure published in Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, Proceedings of the Sixth International Symposium on Genital Integrity: Safeguarding Fundamental Human Rights in the 21st Century, held December 7-9, 2000, in Sydney Australia.
Abstract: Textbooks and papers referring to penile function state that the source of penile sensation is solely the glans and often justify the existence of the prepuce by stating it protects the 'sensitive' glans. These statements are contrary to the neuro-anatomical and physiological facts accumulated over more than a century. This study reviews the findings of Taylor, et al., that the prepuce is the primary sensory platform of the penis, and describes a new preputial structure. This interview was taped in Berkeley, California 2010 and from the Global Survey of Circumcision Harm.
Removal of the male foreskin and the female clitoral hood (female foreskin) are anatomically equivalent. However, neurologically speaking, removal of the male foreskin is as destructive to male sexual sensory experience as removal of the clitoris is for females. This video discussion of penile and foreskin neurology explains why.
Contrary to popular Western myth, many circumcised women do report the ability to feel sexual pleasure and to have orgasm, albeit in a compensatory manner that differs from intact women [suggested reading: Prisoners of Ritual by Hanny Lightfoot-Klein]. Similar compensatory behaviours for achieving orgasm are at work among circumcised men, who must rely on the remaining 50% or less of their penile nerve endings. Just as clitoridectomized girls grow up not knowing the levels of pleasure they could have experienced had they been left intact, so too are men circumcised in infancy unaware of the pleasure they could have experienced had they not had 50% of their penile skin removed. The above video also explains what's really behind the erroneous comment made by some circumcised men that they 'couldn't stand being any more sensitive'.
Watch Ken McGrath's lecture on Youtube.
Scientific studies document harm of circumcision
Two careful studies published in the world's leading jounral of urology, BJU International, demonstrate that circumcision damages the penis and cuts both sexual capacity and sexual satisfaction.
Korea: Worse sex life after circumcision
Two Korean researchers, DaiSik Kim and Myung-Geol Pang, studied 373 sexually active men, of whom 255 were circumcised and 118 were not. They found that circumcision reduced sexual pleasure in most cases and that a significant minority of men reported major injury to their penis, causing bleeding, scarring and chronic pain. Summarizing their results, the authors write:
"There were no significant differences in sexual drive, erection, ejaculation, and ejaculation latency time between circumcised and uncircumcised men. Masturbatory pleasure decreased after circumcision in 48% of the respondents, while 8% reported increased pleasure. Masturbatory difficulty increased after circumcision in 63% of the respondents but was easier in 37%. About 6% answered that their sex lives improved, while 20% reported a worse sex life after circumcision."
Conclusion: There was a decrease in masturbatory pleasure and sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings.
DaiSik Kim and Myung-Geol Pang, The effect of male circumcision on sexuality. BJU Int 99(3):619-22
United States: Circumcision cuts sensitivity of penis
Meanwhile, researchers in the United States have found that circumcision removes the most sensitive part of the penis.
Researcher Dr Morris Sorrells and others enlisted 159 men from the San Francisco Bay area, 91 of them circumcised, and conducted touch-sensitivity tests, using an instrument that presses with calibrated hairs, on 17-19 different places on their penises. The men could not see where they were being touched.
It was found that the most sensitive part of a circumcised penis was on the scar in the middle underneath. But several places on the foreskin were more sensitive than that while the glans of the uncircumcised penis was more sensitive than in the circumcised.
The paper is summarised here:
Objective: To map the fine-touch pressure thresholds of the adult penis in circumcised and uncircumcised men, and to compare the two populations.
Subjects and methods: Adult male volunteers with no history of penile pathology or diabetes were evaluated with a Semmes-Weinstein monofilament touch-test to map the fine-touch pressure thresholds of the penis. Circumcised and uncircumcised men were compared using mixed models for repeated data, controlling for age, type of underwear worn, time since last ejaculation, ethnicity, country of birth, and level of education.
Results: The glans of the uncircumcised men had significantly lower mean ( SEM ) pressure thresholds than that of the circumcised men, at 0.161 (0.078) g ( P = 0.040) when controlled for age, location of measurement, type of underwear worn, and ethnicity. There were significant differences in pressure thresholds by location on the penis ( P < 0.001). The most sensitive location on the circumcised penis was the circumcision scar on the ventral surface. Five locations on the uncircumcised penis that are routinely removed at circumcision had lower pressure thresholds than the ventral scar of the circumcised penis.
Conclusions: The glans of the circumcised penis is less sensitive to fine touch than the glans of the uncircumcised penis. The transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. Circumcision ablates the most sensitive parts of the penis.
Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU International 2007;99:864-9
Full text of article from CIRP
Further discussion, with diagrams and illustrations at Circumstitions
See also a revealing article by Paul Festa in Nerve magazine, How insensitive: A new study confirms a long-time fear: Circumcised men are missing out
See also Historical quotes on circumcision, foreskin and sexual function on this site.
Male circumcision and female sexual pleasure
There is good evidence that male circumcision affects female sexual pleasure - and for the worse, not the better. Circumcision promoters are putting a lot of effort into trying to persuade people that circumcised men make better lovers, or at least that women "prefer" circumcised men. It may be true that in societies where circumcision is widespread, some women say they prefer what they are accustomed to; but it is equally true that in societies that practise female circumcision, men prefer circumcised women because that is what they are accustomed to. It is also true that some women who experience uncircumcised sex for the first time never want to go back. In any case, the imagined sexual preferences of adults are not a valid reason for interfering with children's genitals.
Kristen O'Hara (with Jeffrey O'Hara), Sex as Nature Intended It (Hudson USA, Turning Point Publications, 2001)
See Kristen's website: www.SexAsNatureIntendedIt.com
O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1:79-84.
Bensley GA, Boyle GJ. Effects of male circumcision on female arousal and orgasm. N Z Med J 2003;116(1181):595-6.
Czech women more likely to experience good orgasms than women in the United States
A study published in the Journal of Sexual Medicine has found that Czech women have more a satisfactory experience of sexual intercourse than women in the United States. The researchers conclude that this is because the key factor in whether a woman has an orgasm is the duration of intercourse, and that the average duration intercourse in Czechoslovakia was more than double that in the United States: 16.2 minutes among the Czechs, compared with only 7 minutes among the Americans. As the authors of the study comment, the results could reflect “a greater appreciation of intercourse and sensuality by Europeans than by Americans.” Since Czech men are generally not circumcised and American men are, they may also reflect the harmful effect of male circumcision on women’s sexual enjoyment.T
hese results are in complete contradiction with the story usually told in the popular U.S. media, that circumcised men “can last longer” before climaxing. The study did not consider this factor, but since circumcision is all but known in Czechoslovakia we can be confident that vast majority of the partners of the Czech women were not circumcised. By contrast, given the high incidence of circumcision in the United States, we can also be confident that most of the partners in the U.S. studies were circumcised. The inevitable conclusion is that circumcised men climax sooner, probably because their reduced sensitivity reduces the pleasure they derive from intercourse so severely that the their pleasure is pretty much limited to the orgasm itself. For uncircumcised men, on the other hand, there is as much pleasure in getting there as there is in arriving – a happy situation that clearly benefits women as well.
Source: Petr Weis and Stuart Brody, Women’s partnered orgasm consistency is associated with greater duration of penile-vaginal intercourse but not of foreplay, Journal of Sexual Medicine, Vol 6 (1), January 2009
Circumcision cuts sensitivity and damages sexual response
A new study has found what thousands of circumcised men already know: that circumcision significantly reduces the sensitivity of the penis and has an adverse impact on male sexual functioning. The study, by researchers at the Department of Urology, Ghent University Hospital, Belgium, confirms earlier findings by Kim and Pang, Sorrells, Frisch and others that the foreskin is the principal source of sensation in the penis, that it facilitates all kinds of sexual activity and enhances sexual pleasure.
ABSTRACT
What’s known on the subject? And what does the study add? The sensitivity of the foreskin and its importance in erogenous sensitivity is widely debated and controversial. This is part of the actual public debate on circumcision for non-medical reason. Today some studies on the effect of circumcision on sexual function are available. However they vary widely in outcome. The present study shows in a large cohort of men, based on self-assessment, that the foreskin has erogenous sensitivity. It is shown that the foreskin is more sensitive than the uncircumcised glans mucosa, which means that after circumcision genital sensitivity is lost. In the debate on clitoral surgery the proven loss of sensitivity has been the strongest argument to change medical practice. In the present study there is strong evidence on the erogenous sensitivity of the foreskin. This knowledge hopefully can help doctors and patients in their decision on circumcision for non-medical reason.
Objectives To test the hypothesis that sensitivity of the foreskin is a substantial part of male penile sensitivity. To determine the effects of male circumcision on penile sensitivity in a large sample.
Subjects and methods The study aimed at a sample size of ≈1000 men. Given the intimate nature of the questions and the intended large sample size, the authors decided to create an online survey. Respondents were recruited by means of leaflets and advertising.
Results The analysis sample consisted of 1059 uncircumcised and 310 circumcised men. For the glans penis, circumcised men reported decreased sexual pleasure and lower orgasm intensity. They also stated more effort was required to achieve orgasm, and a higher percentage of them experienced unusual sensations (burning, prickling, itching, or tingling and numbness of the glans penis). For the penile shaft a higher percentage of circumcised men described discomfort and pain, numbness and unusual sensations. In comparison to men circumcised before puberty, men circumcised during adolescence or later indicated less sexual pleasure at the glans penis, and a higher percentage of them reported discomfort or pain and unusual sensations at the penile shaft.
Conclusions This study confirms the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning. Furthermore, this study shows that a higher percentage of circumcised men experience discomfort or pain and unusual sensations as compared with the uncircumcised population. Before circumcision without medical indication, adult men, and parents considering circumcision of their sons, should be informed of the importance of the foreskin in male sexuality.
Source: Bronselaer GA, Schober JM, Meyer-Bahlburg HF, T'sjoen G, Vlietinck R, Hoebeke PB. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. 2013 Feb 4. doi: 10.1111/j.1464-410X.2012.11761.x. [Epub ahead of print]
Foreskin has important sexual function: New research
Research by scientists in Slovenia has confirmed previous research, common knowledge and much personal testimony that the foreskin has an important sexual function. A paper by Simon Podnar, published in BJU International – the world’s leading urological journal – found that a reflex action known as the “penilo-cavernosus reflex” is rarely experienced by circumcised men. What this means in ordinary language is that circumcision, by excising the most important nerves of the penis, makes it less sensitive and less functional. The is result that men who retain their foreskins experience greater sexual excitability, better orgasm control and more pleasure. Writing in response to the article, Australia’s Greg Boyle welcomed the article for further developing the work of the late John Taylor and actually doing some objective, scientific investigation of the functions of the foreskin. This was a refreshing change from the ideologically-driven propaganda that pours out of the United States, more interested in exterminating foreskins than in understanding them. In fact, the foreskin is such a miracle of biological engineering that to destroy one without genuine need is an act of wanton vandalism. As Professor Podnar comments, “I see the prepuce as an ingenious device engineered to provide a strong sensory stimulation in a slippery environment”, the evolutionary purpose of which is to maximise the desire to reproduce.
New research on the sexual function of the foreskin: The penilo-cavernosus reflex
“It is known that foreskin, but not glans penis, contains a high density of fine-touch mechanoreceptors. Clinically the penilo-cavernosus reflex provides information on function of the sacral nerves. The study demonstrated that in the majority of circumcised men this reflex cannot be elicited clinically, but can be measured neurophysiologically.”
Research by scientists in Slovenia has confirmed previous research by Dr John Taylor and others, common knowledge and much personal testimony that the foreskin plays an important role in male sexual response. A paper by Simon Podnar, published last year in BJU International – the world’s leading urological journal – found that a reflex action known as the “penilo-cavernosus reflex” is rarely experienced by circumcised men. What this means in ordinary language is that circumcision, by excising the most important nerves of the penis, makes it less sensitive and less functional; the result is that circumcised men experience less sexual excitability, less orgasm control and less pleasure. As Podnar writes, “The present study confirmed my previous observations that the penilocavernosus reflex is more difficult to elicit clinically in circumcised men. … The probable reason for this finding in circumcised men is the elimination of the most sensitive part of the penis (i.e. the foreskin), and to a lesser extent, desensitization of sensory receptors in the penile glans.” While the nerves of the foreskin are highly sensitive to light touch and gentle manipulation, those of the glans respond only to strong pressure, heat and pain.
These findings have significance for treatment of male sexual dysfunction, including premature ejaculation, as well as urinary and bowel control.
Source: Podnar S. Clinical elicitation of the penilo-cavernosus reflex in circumcised men . BJU Int 2012; 109: 582–5.
Commentary on Podnar’s research
Writing in response to the article, Australia’s Greg Boyle welcomed the article for further developing the work of the late John Taylor and actually doing some objective, scientific investigation of the functions of the foreskin. It was refreshing to find a government sponsoring research aimed at improving our (highly inadequate) understanding of the anatomy and physiology of the foreskin, instead of merely cooking up yet more justifications for cutting it off. We will never understand the biology of the mature foreskin unless we can observe and study it in operation, as it were, and this will not be possible if it is routinely amputated in infancy.
The full text of Greg Boyle’s letter and Simon Podnar’s reply follows:
1. Greg Boyle’s letter
In a recent issue of the BJUI, Professor Podnar [1] reported his findings concerning the clinical elicitation of the penilo-cavernosus reflex in genitally intact men as compared with circumcised men. Previously, Taylor [2] had reported that, “Almost certainly, removal of the prepuce and its ridged band distorts penile reflexogenic functions but exactly how and to what extent still remains to be seen”. While Podnar’s study attempted to ascertain the magnitude of this reflexogenic disability, it is notable however that he used different stimulatory techniques in genitally intact vs circumcised men. As reported in his paper, Podnar tested the penilo-cavernosus reflex in intact men by squeezing the glans through the overlying foreskin, thereby stimulating the sensory receptors both within the foreskin itself as well as in the glans, whereas in circumcised men, the stimulus necessarily could only be applied to the glans (which is relatively devoid of fine-touch sensory receptors as compared with the inner foreskin with its dense innervation of Meisners’ corpuscles) [2–6]. This procedural discrepancy raises questions as to the validity of Podner”s clinical findings reported for circumcised and genitally intact men respectively.
Circumcision and premature ejaculation
In regard to PE, Podnar [1] repeated the common myth that “the glans is too sensitive”. To the contrary, PE with little or no sensation/feeling would suggest that the glans is not very sensitive at all. Many circumcised young men ejaculate prematurely but feel very little pleasurable sensation [7]. It would appear that PE may occur before there is much build-up of sexual excitement/tension, so that ejaculation is pretty much a “non-event”. Anecdotally, in the USA where most males have been subjected to routine neonatal circumcision, many young women have commented to their male partner, “Is that it?” Is it not more likely that it is precisely the lack of neurological control over the timing of ejaculation resulting from the severed neuronal circuitry after circumcision that is a major causal factor in PE? Indeed, Bollinger and Van Howe [8] pointed out that, “circumcised men are 2.56 times more likely to suffer from premature ejaculation, and, when the data were adjusted to include erectile dysfunction, that risk rose to 4.88 times”[9]. Moreover, “A recent multinational population survey using stopwatch assessment of the intravaginal ejaculation latency time (IELT) found that in Turkish men, the vast majority of whom are circumcised, had the shortest IELT [10,11].
This report is yet another small piece of the puzzle regarding the adverse effects of circumcision on sexual function [12,13], but cross-validation on much larger samples would seem important. There appears to be a paucity of research funds available to objectively investigate foreskin neurology, physiology, anatomy and sexual function, whereas formidable research resources appear to go to projects aimed at finding “justifications” for ablating the male foreskin. The whole area is still shrouded in myths and distorted by the fact that so much research is carried out in “foreskin-free zones” such as the USA.
Full text with references available from BJUI, 16 August 2012
2. Simon Podnar’s reply
There is a long lasting dispute about the physiological role of the prepuce in human. I see it as a tinny [sic] structure sitting at the evolutionary pinnacle, where our “selfish genes” fight their way into the next generation. Competition here is harsh, with no room for redundancy. I see the prepuce as an ingenious device engineered to provide a strong sensory stimulation in a slippery environment of a copiously lubricated vagina. Evolution achieved this by the tubular prepuce sliding during sexual activity over the conically shaped glans as far as the frenulum allows. Both, the prepuce and the frenulum, have rich mechanoreceptor innervation [1] sending a large sensory input to the brain. The goal of this mechanism is to achieve maximum procreative efficiency of the semen by optimising ejaculation in place and time. To achieve this, the brain also needs to be finely tuned with the genital sensory structures.
Intuitively, removal of the penile most sensitive genital structure would lead not only to reduced sexual sensation [2], but also to more difficult achievement of ejaculation. This reasoning – named by Professor Boyle “common myth”– logically leads to a thought that circumcision might be a useful therapy for premature ejaculation (PE). In line with this, in my paper [3] I cited a report that found a reduction in PE in three of seven patients [4] circumcised due to different penile pathology (e.g., phimosis, balanitis, condyloma, etc.). However, I have to admit that these penile conditions made this empirical support unconvincing. Professor Boyle, by contrast, cites studies showing higher frequency of PE [5] and shorter intravaginal ejaculation latency time (IELT) [6] in circumcised men. Of these, higher frequency of PE in the circumcised seems more convincing, as no effect of circumcision status on IELT could be found in an international study after the exclusion of Turkey [6]. Islamic or Asian background was suggested to be a risk factor for PE irrespective of circumcision status [7]. Nevertheless, anything but lower frequency of PE and longer IELT in the circumcised sounds contra intuitive, and needs explanation. The answer, I believe, is neuroplasticity – changes in the thresholds and connectivity that occur within the CNS after circumcision.
The method of the penilo-cavernosus reflex elicitation I used in my study [3] indeed activated only deep pressure and pain receptors [8] in the glans in the circumcised men. By contrast, in the intact men, the Meisners’ corpuscles [9] within the foreskin were also stimulated. However, I do not share the opinion of Professor Boyle that this reduces validity of my clinical findings. In both, the intact and circumcised men, I activated all the available sensory receptors at the tip of the penis, and I showed unequivocal differences in the elicitability of the penilo-cavernosus reflex in the two populations of men [3]. The finding is relevant both for using the reflex as a clinical test, and also for demonstration of possible functional differences. During sexual activity both the glans and the overlying foreskin are stimulated in intact men, as discussed above. However, I do agree that using this approach I could not differentiate absence of Meisners’ corpuscles in the foreskin or desensitisation of deep pressure and pain receptors in the glans as the reason for the reduced reflex elicitability found in the circumcised men.
Full text with references available from BJUI, 16 August 2012
Denmark study: Circumcision cuts sexual satisfaction in men and partners
Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark.
Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: A survey-based, cross-sectional study in Denmark, International Journal of Epidemiology 40 (5), October 2011, 1367-1381.
ABSTRACT
BACKGROUND: One-third of the world's men are circumcised, but little is known about possible sexual consequences of male circumcision. In Denmark (~5% circumcised), we examined associations of male circumcision with a range of sexual measures in both sexes.
METHODS: Participants in a national health survey (n = 5552) provided information about their own (men) or their spouse's (women) circumcision status and details about their sex lives. Logistic regression-derived odds ratios (ORs) measured associations of circumcision status with sexual experiences and current difficulties with sexual desire, sexual needs fulfilment and sexual functio ning.
RESULTS: Age at first intercourse, perceived importance of a good sex life and current sexual activity differed little between circumcised and uncircumcised men or between women with circumcised and uncircumcised spouses. However, circumcised men reported more partners and were more likely to report frequent orgasm difficulties after adjustment for potential confounding factors [11 vs 4%, OR(adj) = 3.26; 95% confidence interval (CI) 1.42-7.47], and women with circumcised spouses more often reported incomplete sexual needs fulfilment (38 vs 28%, OR(adj) = 2.09; 95% CI 1.05-4.16) and frequent sexual function difficulties overall (31 vs 22%, OR(adj) = 3.26; 95% CI 1.15-9.27), notably orgasm difficulties (19 vs 14%, OR(adj) = 2.66; 95% CI 1.07-6.66) and dyspareunia [painful intercourse] (12 vs 3%, OR(adj) = 8.45; 95% CI 3.01-23.74). Findings were stable in several robustness analyses, including one restricted to non-Jews and non-Moslems.
CONCLUSIONS: Circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment. Thorough examination of these matters in areas where male circumcision is more common is warranted.
Abstract of study available here
Report of study with graphic illustrations
Download study in full as pdf file
Researchers defend Danish study showing that male circumcision has adverse effect on sexual satisfaction
In 2011 Circinfo.org reported a study by Danish researchers which found that circumcision reduces sexual satisfaction not only in circumcised men, but also in their female partners. The study by Morten Frisch et al, published in the International Journal of Epidemiology in October 2011, examined the association of male circumcision with a range of sexual measures in both sexes. It found that circumcision was “associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment.”
Not surprisingly, these conclusions did not please circumcision advocates such as Brian Morris, who has set himself the daunting task of proving not only that circumcision is a “biomedical imperative for the 21st century” for various "health" reasons, but also that that the amputation of the foreskin has no impact at all on sexual function (and may even improve the operation and appearance of of the penis). He fired off a lengthy critique in reply, denouncing Frisch’s motives as much as his methodology. In his response (International Journal of Epidemiology, February 2012), Frisch not only debunks these criticisms, but reveals that following publication Morris sent emails to his supporters, urging them to send letters of complaint about the article to the editors of the journal, and (what is worse) disclosing the fact (meant to be kept confidential) that he was one of the original peer reviewers and had recommended that the paper not be published at all. Compromising the confidentiality of the peer review process in this manner is a serious breach of publication ethics. In his dignified reply to this blatant lobbying, Frisch highlights the implausibility of Morris’s attempts to portray himself as a “neutral and unbiased authority” on the “medical benefits” of circumcision, while attacking anybody who dares to disagree with him as ideology-driven anti-circumcision activists. He points out that Morris obviously has his own agenda, revealed in an impressive record of anti-foreskin activism going back to the 1990s. Frisch defends the conclusions of his own study as supported by good evidence and casting grave doubt on optimistic (?) claims that circumcision has no impact on sexual function.
Full text of Morten Frisch’s reply to Morris et al
Morten Frisch, Author’s Response to: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect?
Novel findings in our population-based survey, which had participation rates of 48% in men and 54% (not 40%, as wrongly mentioned by Morris et al.) in women, suggest, but by no means prove, the existence of non-trivial associations of male circumcision with frequent orgasm difficulties in men and with a range of frequent sexual difficulties in women, including orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment. Morris et al. should not be blamed for feeling unconvinced by our findings. However, as these critics repeatedly refer to Morris’ pro-circumcision manifesto [1] as their source of knowledge, their objectivity must be questioned. Morris et al. express concern over possible overfitting in our logistic regression models because we included a number of potentially confounding variables that differed between circumcised and uncircumcised men and between women with circumcised and uncircumcised spouses. However, as seen in Tables 3–6 of our paper, models with adjustment only for age provided odds ratios (ORs) similar to those obtained in the fully adjusted model, suggesting that this is mostly a theoretical concern. Next, Morris et al. suggest that we should have corrected for multiple testing even though such statistical manoeuvres are, at best, unnecessary and, at worst, deleterious to sound statistical inference in most epidemiological studies. [2] Morris et al. also claim that prevalence ratios would have been more appropriate measures of association than ORs. However, despite Morris et al.’s firm statement to the contrary, there is nothing inherently inappropriate about using ORs in cross-sectional studies, even in situations with common outcomes. In such situations, however, ORs should not be misinterpreted as prevalence ratios. We would have been wrong to claim that our OR of 3.26 implied that frequent sexual difficulties were 3.26 times more common in women with circumcised spouses than in women with uncircumcised spouses. Nowhere in our paper did we interpret ORs in such a flawed manner. In accordance with the cited reference [3] we simply noted that frequent sexual difficulties were more common in women with circumcised spouses and that the associated fully adjusted OR was 3.26.
Next, Morris et al. argue that our finding of considerably higher rates of frequent orgasm difficulties in (partially) circumcised than uncircumcised Danish men (11 vs 4%, OR1/43.26) may not apply in countries where circumcision means complete amputation of the foreskin. This may well be the case. If partial amputation of the foreskin truly entails frequent orgasm difficulties in a noticeable proportion of men (as experienced by 11% of circumcised men in our study), comparable proportions may well be larger and associated ORs even higher in countries where circumcised men experience greater tissue loss due to more extensive circumcision procedures. Obviously, more data are needed from rigorous studies using carefully constructed questionnaires. The questionnaires used to assess potential sexual problems in the two cited randomized controlled trials in Kenya and Uganda were not presented in detail in the original publications. [4,5] Rather than blindly accepting such findings as any more trustworthy than other findings in the literature, it should be recalled that a strong study design, such as a randomized controlled trial, does not offset the need for high-quality questionnaires. Having obtained the questionnaires from the authors (RH Gray and RC Bailey, personal communication), I am not surprised that these studies provided little evidence of a link between circumcision and various sexual difficulties. [4,5] Several questions were too vague to capture possible differences between circumcised and not-yet circumcised participants (e.g. lack of a clear distinction between intercourse and masturbation-related sexual problems and no distinction between premature ejaculation and trouble or inability to reach orgasm). Thus, non-differential misclassification of sexual outcomes in these African trials probably favoured the null hypothesis of no difference, whether an association was truly present or not.
Morris et al. should be commended for their creative attempt to dismiss the higher prevalence of frequent dyspareunia in women with circumcised (12%) than uncircumcised (4%) spouses (ORs between 4.17 and 9.00). They suggest that Danish women with circumcised spouses may be so psychologically troubled by the shape of their spouse’s penis that it might result in painful intercourse. A more plausible explanation would be that reduced penile sensitivity may raise the need among some circumcised men for more vigorous and, to some women, painful stimulation during intercourse in their pursuit of orgasm.
Two of the authors, Morris and Waskett, both internationally recognized circumcision activists, [6,7] forget to declare their conflicts of interest. Even in situations that are out of context, Morris promotes himself as a neutral ‘authority on the extensive medical benefits of this simple surgical procedure’, [8] whereas at the same time he argues that neonatal male circumcision ‘should be made compulsory’ and that ‘any parents not wanting their child circumcised really need good talking to’. [9] In contrast, we conducted our survey without setting up any a priori hypotheses, because the limited and inconclusive literature on possible sexual consequences of circumcision would permit almost any imaginable a priori hypothesis. We had no intent to prove an already known ‘truth’ or disprove its contradiction. It is ironic that Morris et al. question the credibility of our findings, postulating that I have an ‘active involvement in opposition to male circumcision’. I have never expressed any objection, ethical, medical or other, against male circumcision as such. Unlike Morris, who believes that ‘circumcision is a biomedical imperative for the 21st century’, [1] I could not care less whether fully informed, healthy adults choose to get circumcised or not. Likewise, when foreskin pathology is present (which does not include the physiological tightness of the foreskin experienced transiently by most boys), and the problem cannot be treated conservatively, preputioplasty or partial circumcision may be a relevant solution, even in minors and others who are unable to consent to the operation. However, because ethical discussions about ritual circumcision are sometimes distorted by strong personal views, I openly declared that I have participated in national debates over ethical issues surrounding male and female circumcision.
Like in critical letters to the editor following other recent studies that failed to support their agenda, [10–12] Morris et al. air a series of harsh criticisms against our study. As seen, however, the points raised are not well founded. It seems that the main purpose, as with prior letters, is to be able in future writings to refer to our study as an ‘outlier study’ or one that has been ‘debunked’, ‘rejected by credible researchers’ or ‘shown wrong in subsequent proper statistical analysis’. This in spite of the fact that our study was carried out using conventional epidemiological and statistical methods, underwent peer-review and was published in an international top-ranking epidemiology journal.
I would like to thank the IJE editors for withstanding the pressure from one particularly discourteous and bullying reviewer who went to extremes to prevent our study from being published. After the paper’s online publication, I have received emails from colleagues around the world who felt our contribution was useful and potentially important. One colleague informed me that the angry reviewer was the first author of the above letter to the editor. In an email, Morris had called people on his mailing list to arms against our study, openly admitting that he was the reviewer and that he had tried to get the paper rejected. To inspire his followers, Morris had attached his two exceedingly long and aggressive reviews of our paper (12,858 words and 5291 words, respectively), calling for critical letters in abundance to the IJE editors. Breaking unwritten confidentiality and courtesy rules of the peer-review process, Morris distributed his slandering criticism of our study to people working for the same cause. Rather than resorting to such selective distribution among friends, Morris should make both reviews freely available on the internet by posting them in their entirety on his pro circumcision homepage (www.circinfo.net). Alternatively, interested readers should feel free to request them from me at the e-mail address above. Despite poorly founded criticisms and attempts at obstruction our findings suggest that male circumcision may be associated with hitherto unappreciated negative sexual consequences in a non-trivial proportion of men and women. Further carefully conducted studies are needed.
References
1. Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays 2007;29:1147–58.
2. Perneger TV. What’s wrong with Bonferroni adjustments. Br Med J 1998;316:1236–38.
3. Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003;3:21.
4. Krieger JN, Mehta SD, Bailey RC et al. Adult male circumcision: effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med 2008;5:2610–22.
5. Kigozi G, Watya S, Polis CB et al. The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU Int 2008;101:65–70.
6. Circleaks. http://circleaks.org/index.php?title1/4Brian_Morr is (8 August 2011, date last accessed).
7. Circleaks. http://circleaks.org/index.php?title1/4Jake_H._ Waskett (8 August 2011, date last accessed).
8. Morris BJ. Renin, genes, and beyond: 40 years of molecular discoveries in the hypertension field. Hypertension 2011;57:538–48.
9. YouTube. http://www.youtube.com/v/7yDvL4hNny4 (8 August 2011, date last accessed).
10. Morris BJ, Wodak A. Circumcision survey misleading. Aust N Z J Public Health 2010;34:636–37.
11. Waskett JH, Morris BJ, Weiss HA. Errors in meta-analysis by Van Howe. Int J STD AIDS 2009;20:216–18.
12. Waskett JH, Morris BJ. Fine-touch pressure thresholds in the adult penis. BJU Int 2007;99:1551–52.
SOURCE: Morten Frisch, Author’s Response to: Brian Morris et al, Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? International Journal of Epidemiology 41 (1), February 2012, 312-314. Morris’s letter in reply can be read in the same issue of the journal.
The original article was Morten Frisch, Morten Lindholm and Morten Grønbæk, Male circumcision and sexual function in men and women: A survey-based, cross-sectional study in Denmark, International Journal of Epidemiology 40 (5), October 2011, 1367-1381.
Complications and harms of circumcision greater than thought
In two recent papers, psychology professor Dr Greg Boyle considers the physical and mental harms of non-therapeutic circumcision. After reviewing the extensive literature in medical and scientific journals, he finds that not only are the risks and complications of the surgery greater than commonly believed, but also that the harms of foreskin loss itself (i.e. without complications) are far more extensive than most people think. These are very harms of circumcision that are completely ignored by circumcision advocates and bureaucratic policy makers (such as the US Centers for Disease Control), who talk narrowly about “risks vs benefits” and ignore the usefulness of the foreskin (contrary to what the Jewish philosopher Maimonides stated) and regard the removal of a healthy foreskin as no different from the removal of a diseased appendix. Professor Boyle particularly rejects recent claims by Morris and Krieger that circumcision “makes no difference” to sexual function as implausible and contradicted by the evidence, and notes that other experts have found serious flaws in their analysis.
Short and long-term effects of infant and childhood circumcision
ABSTRACT Non-therapeutic infant male circumcision is a permanent surgical alteration to the penis that may cause significant physical, sexual and psychological harm. Physical harms include unintended adverse effects of the surgery itself (e.g., complications such as bleeding, infection, excessive removal of foreskin leaving insufficient shaft skin to accommodate erections, etc.), as well as the inherent loss of healthy, functional tissue. Sexual harms that necessarily follow from circumcision include the loss of all sensation in the foreskin itself, and the loss of all sexual functions that involve the physical manipulation of the foreskin. Additional sexual harms that may follow circumcision include reduced sexual sensation in the remaining penile structures, difficulty with masturbation, increased chafing in both the circumcised man and his sexual partner, as well as reduced overall psychosexual/psychological tension relief and subjective satisfaction. Psychological harms include short-term trauma as well as the potential for long-term emotional disturbances, including sadness, frustration, distress, and anger—akin to post-traumatic stress disorder (PTSD). In this paper, the extent and severity of these various harms are considered and it is argued that they are more serious and more widespread than is commonly believed.
Boyle, G. (2015) Circumcision of Infants and Children: Short-Term Trauma and Long-Term Psychosexual Harm. Advances in Sexual Medicine, 5, 22-38. doi: 10.4236/asm.2015.52004.
Fallacies of Morris, Krieger claims about circumcision and sexual satisfaction exposed
A paper in a recent issue of Advances in Sexual Medicine shows that the literature survey in which Morris and Krieger claims to show that circumcision makes no difference to sexual experience is deeply flawed and inconsistent with the full range of the evidence. The abstract reads as follows:
Morris and Krieger (2013) have argued that male circumcision does not impact adversely on sexual sensation, satisfaction, and/or function. In the present paper, it is argued that such a view is untenable. By selectively citing Morris’ own non-peer-reviewed letters and opinion pieces purporting to show flaws in studies reporting evidence of negative effects of circumcision, and by failing adequately to account for replies to these letters by the authors of the original research (and others), Morris and Krieger give an incomplete and misleading account of the available literature. Consequently, Morris and Krieger reach an implausible conclusion that is inconsistent with what is known about the anatomy and functions of the penile foreskin, and the likely effects of its surgical removal.
Gregory J. Boyle, Does Male Circumcision Adversely Affect Sexual Sensation, Function, or Satisfaction? Critical Comment on Morris and Krieger (2013). Advances in Sexual Medicine, 31 March 2015.
Where does the pleasure of penile stimulation come from?
Thoughts on recent research by Bossio et al and their critics
Research by Jen Bossio and colleagues on the nature of penile sensation in circumcised and normal males is to be welcomed. However uncertain or provisional some of their conclusions may be, their work represents a genuine attempt to shed light on an under-researched area of physiology and should stimulate further investigation. In the immediate term their research has provoked a strong dissent from Brian Earp, who argues that their principal conclusion – that circumcision makes little or no difference to penile sensitivity – is neither supported by their own evidence nor consistent with previous research on this question.
A major cause of this disagreement may be that Bossio et al’s research methodology takes the foreskin and penis as separate structures whose properties can be analysed individually, while Earp regards them as elements of a single structure that produce the best results if they work together and which, therefore, should be analysed as a dynamic ensemble. There is sense in this view: when it comes to actual sexual activity, most uncircumcised men are not particularly interested in whether their foreskin, glans or penis shaft is more sensitive to light touch, heat or pain, but rather in the sensations arising from the movement of the foreskin over the glans, or from the friction between the inner foreskin (retracted and everted with erection) and whatever flesh or device is providing the pressure. As nineteenth century advocates of circumcision as a remedy for masturbation warned, it was the mutual stimulation of foreskin and glans that was the problem. The weakness of Bossio’s research methodology is that it examined the penis as a series of static and disconnected objects rather than as a system in motion.
In other words, the problem with these touch tests (and it also affects the Sorrels study, which never got to the heart of the matter) is that they bear no relation to what actually happens during sex. In any sexual activity (wanking, oral, intercourse or whatever) the foreskin is under pressure and stimulated from both sides: from whatever is touching it on the outside, and by the pressure of the glans and shaft on the other side. Since foreskin and glans work together and mutually stimulate each other it is unrealistic to try to separate them and ask which makes the greater contribution to sexual sensation. They need to be studied together in actual situations where sex is taking place.
So where should researchers go from here? One possibility is suggested by an informal experiment conducted by New Zealand pathologist Ken McGrath (University of Technology, Auckland) some years ago. He arranged for several adult volunteers (not circumcised) to masturbate to orgasm. In a subsequent session he deadened their foreskins with a local anaesthetic, got them to masturbate again, and to describe the sensations they experienced in comparison with normal conditions on the previous occasion. The results were striking. All subjects took far longer to reach orgasm and reported:
- severe loss of sensation and pleasure;
- awareness of sensation from the glans (mostly from the frenular attachment and to a lesser extent the corona) of which they were normally unaware and which commenced quite late in the episode (i.e. just prior to orgasm);
- need for more pressure and vigour in stimulation;
- lack of rising pleasure during the period from the onset of tumescence to awareness of orgasmic approach (in contrast to their normal experience of steadily increasing sensation and pleasure);
- a sudden and unanticipated onset of orgasm (a lack of warning which surprised them);
- perception of deepness of sensory origin rather than a surface one as they normally experienced.
All participants found the anaesthetized prepuce experience far less enjoyable, lacking the intense sensation they normally experienced, and rather unsatisfying in comparison.
It could not be claimed that this small experiment to be in any way decisive. The sample size was absurdly small, the methodology was unapproved, and it might not have been possible fully to isolate the nerves of the foreskin in such as way as would correspond to the effects of circumcision. Nonetheless, the exercise is suggestive as a pilot study, and offers a different approach to the question – one that requires no expensive equipment or preparations, and carries no risk of harm to any of the participants. In a university research environment with the full range of medical specialists, including anaesthetists, it should be possible to overcome the methodological difficulties, and recruit sufficient volunteers to secure a robust result.
Letters in urology journal criticise Bossio study
A study by Bossio et al published in the Journal of Urology in June 2016 was widely misreported as showing that circumcision made no difference to the sensitivity of the penis. Even leaving aside the vagueness of this measure (do they mean sensitivity to pain or to pleasure? what about other measures of sexual functionality and satisfaction?) the reports seriously misrepresented the findings of the study, which actually showed that men with foreskins had a lower threshold of sensitivity and circumcised men a higher threshold – in other words, that men with foreskins were more sensitive to touch, and circumcised men less sensitive. As the authors admit in their reply to criticisms of their article published in a later issue of the journal, “the foreskin was observed to be most sensitive to fine touch pressure thresholds.” Of course, there are other issues to be taken into account, some of which are raised in the letters criticising the paper, but there is not the slightest basis for media and other reports that circumcision “makes no difference” to sexual experience.
The following letters criticising the Bossio et al study on circumcision and penis sensitivity were published in the December 2016 issue of the Journal of Urology, with a reply by the original authors.
1. Professor Morten Frisch
Bossio et al assessed penile sensitivity in circumcised and intact males using quantitative sensory measures, and concluded that infant circumcision likely entails only “minimal long-term implications for penile sensitivity.” However, this conclusion does not follow logically from their findings.
Despite a small sample size (62 sexually non-dysfunctional males 18 to 37 years old, of whom 30 were neonatally circumcised and 32 were intact), the study confirmed findings from a prior investigation by Sorrells et al, which revealed significantly lower tactile thresholds (i.e. greater tactile sensitivity) in the foreskin compared to other examined penile sites (the glans and 2 shaft positions). Additionally the current study found significantly greater warmth sensitivity at the foreskin than at the glans (p = 0.02). Finally, the authors assessed thresholds for tactile pain and heat pain, and failed to find any significant evidence that the foreskin is more or less pain sensitive than other parts of the penis.
These results suggest that 1) the foreskin is more sensitive to gentle touch than any other tested penile site, replicating prior research, 2) the foreskin may be more sensitive to subtle variations in temperature, at least compared to the glans, and 3) the foreskin appears to be no more or less sensitive to potentially uncomfortable tactile or temperature induced stimuli leading to sensations of penile pain. From these observations the logical conclusion would be that neonatal circumcision appears to be associated with reduced sensitivity in the adult penis. It is noteworthy that the findings of Bossio et al of greater foreskin sensitivity to tactile and temperature related stimuli emerged despite the fact that the examined outer cutaneous part of the foreskin may not even be the most sensitive part of this complex, double layered structure.
Figure 2 in the article combines individual sensitivity threshold scores from the 30 circumcised and 32 intact males. To better understand the relevance and meaning of the study findings, I kindly urge the authors to repeat their analysis and provide a supplementary figure, in which they divide the results depicted in figure 2 into 2 separate panels (1 for intact and 1 for circumcised males), illustrating each of the 4 sensory threshold graphs as demonstrated for the combined group of 62 males in this figure. An additional simplified 4-graph panel for the 32 intact males may help readers to judge whether and to what extent the foreskin is more sensitive than other parts of the intact penis. Due to the apparent lack of statistically significant differences in sensitivity among the various non-foreskin penile sites, I suggest that Bossio et al recombine the original 5 tested anatomical sites, i.e. the foreskin, other penile sites (including the glans and the 2 penile shaft sites) and the forearm, to gain statistical power. I also would be interested to see the associated p values provided in a manner similar to that used in figure 2.
Morten Frisch, Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
2. Dr Alexandre Rotta
In a study fraught with methodological problems Bossio et al conclude that “circumcision is not associated with changes in penile sensitivity” and believe they have provided “preliminary evidence to suggest that the foreskin is not the most sensitive part of the penis.” However, neither of these assertions is supported by their data. Although nowhere explicitly stated in the article, we assume that all penile sensitivity tests were performed in penises in the flaccid state. Such a testing condition can only provide an indirect hint as to what would occur during sexual arousal, which is the relevant situation to consider when studying penile sensitivity in this context.
For unclear reasons the authors tested only a single site on the foreskin – a location on the dorsal unretracted external skin, somewhat proximal to the more sensitive tip of the penis - that previous research has already indicated may be less sensitive than other parts of the foreskin. Specifically if the authors wanted to determine the sensory thresholds of the foreskin of intact men compared to other penile sites, why would they not test its most sensitive point, or at least include a site representing the (widely considered to be) more sensitive transitional or internal surfaces of the foreskin that become exposed when the structure is pulled back?
Due to differences in erection mechanics in the intact and circumcised penis, the tested sites on the penile shaft may not be comparable between the 2 groups during sexual activity. The penile shaft skin of circumcised males does not move back and forth a great deal during sex, so the penile shaft sites tested by Bossio et al in flaccid circumcised males may serve as a reasonable proxy for what those same subjects will experience while erect but not for their intact counterparts. During intercourse a considerable part of the penile shaft of intact males is covered intermittently by the everted mucosal portion of the foreskin, which rolls back and forth over the glans. During penetration the skin that covered the penile shaft in the flaccid state moves proximally closer to the pubis. Consequently the penile shaft skin measurements by Bossio et al are unlikely to represent analogous penile sites in sexually aroused intact and circumcised males. To provide a more meaningful comparison of penile shaft sensitivities in intact and circumcised males that might serve as a plausible proxy for what occurs in the erect state, penile shaft sensitivity tests in the flaccid state should have been carried out with the foreskin pulled back (as typically will be the case during sexual arousal) in intact males.
Even with its underpowered sample and inadequate choice of cutaneous testing sites the conclusion of the authors that the foreskin is not the most sensitive part of the penis is certainly puzzling in light of figure 2, part A in the article, which shows the foreskin to be significantly more sensitive than any other tested site. The inference that surgical removal of this most sensitive penile segment would not decrease penile sensitivity seems logically and anatomically incoherent.
Alexandre T. Rotta, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
3. Professor Robert Van Howe et al
This study examining penile sensitivity left us with several concerns. The report fails to adequately describe the main outcomes of the study, namely measurements broken down by circumcision status. Instead of average scores and standard deviations, the reader is provided with p values, statements about failing to find a statistically significant difference and a figure that collapses the data from the 2 groups into 1 group. Of interest is whether fine touch sensitivity was reduced in the glans in the flaccid penis of circumcised men, as has been reported in 3 previous studies. However, these results were not provided. Instead, the authors provide what could be characterized as pilot data, along with the number of participants needed for a more definitive study, while failing to report the results that are needed to design such a study.
Several of the conclusions of Bossio et al do not follow from their findings. Although several of their tests were underpowered, and the maximum participant age was only 37 years (mean 24.2), the authors make sweeping generalizations regarding long-term implications of circumcision on penile sensitivity. Similarly they state that “this study challenges past research suggesting that the foreskin is the most sensitive part of the penis,” while at the same time reporting that the “foreskin of intact men was more sensitive to tactile stimulation.” Finally, the authors conclude that they “failed to consistently replicate the findings by Sorrells et al across stimuli” when they did, in fact, replicate our findings along the only dimension that was consistent - and hence even potentially replicable - between the 2 studies, namely assessment of fine touch thresholds.
The authors struggle to explain some of their results but the histology may help. The glans is innervated mainly by free nerve endings, which primarily sense deep pressure and pain, so it is not surprising that the glans was more sensitive to pain. By contrast, the foreskin has a paucity of free nerve endings and is primarily innervated by fine touch neuroreceptors, so it was comparatively less sensitive to pain. On a positive note, it is heartening that the term “intact” has replaced “uncircumcised,” which is considered by many to be a pejorative term.
Robert S. Van Howe, Department of Pediatrics, Central Michigan University College of Medicine; with Morris L. Sorrells, James L. Snyder, Mark D. Reiss and Marilyn F. Milos
Reply by authors
Based on a careful review of these letters, we believe that our conclusions have been misconstrued in different ways by the authors (and others, as apparent in media reports and on social media). We will attempt to clarify what our article indicates, what it does not indicate and how the responses to it highlight the need to improve the empirical rigor of research on the impact of circumcision on the sexual lives of men and their partners.
Despite the widespread global practice of circumcision, as well as the public beliefs about the procedure, there is limited objective peer-reviewed research assessing the sexual correlates of circumcision. The purpose of our study was to use objective measures to assess penile sensitivity across circumcision status (intact, circumcised). We examined sensitivity on certain penile areas, as well as on the forearm, with a focus on the glans penis and the foreskin, using touch (punctate or fine touch pressure, pain) and heat (warmth detection, heat pain). The stimulus modalities we used are expected to activate penile nerve fibers more likely associated with sexual pleasure than measuring fine touch pressure thresholds alone. Statistical analyses revealed that the sensory thresholds of intact and circumcised men were remarkably similar - hence, the data were collapsed across the 2 groups. Although presented in graphic format in the full article, we have included a breakdown of descriptive statistics in this response, as requested by Frisch and Van Howe et al (see table).
To reiterate the findings of the study, the foreskin was observed to be most sensitive to fine touch pressure thresholds. Indeed, this finding replicated the results reported by Sorrells et al. However, fine touch pressure, which was only 1 of 4 stimulus modalities assessed, activates nerve fibers that are likely less relevant for sexual pleasure than fibers activated by the other stimuli used in this study (stimuli that did not exhibit significant between group differences). Therefore, we maintain that we “failed to consistently replicate the findings by Sorrells et al across stimuli” (emphasis added). We also urge caution in the over-interpretation of this result (that the fine touch pressure threshold at the foreskin was significantly less than in other areas). This finding alone does not prove that circumcision reduces penile sensitivity, and it also does not prove that circumcision has no impact on the sexual lives of men. Insisting that this finding supports either the pro or anti-circumcision “camp” is not warranted, as it does not take into account the other study findings and ignores the limitations (e.g. small sample size). Instead, we consider the outcome of this study an indication of the need for further examination.
In light of the misinterpretations of our findings we believe it necessary to further clarify what the results of this particular study do not indicate. The results of this series are not to be taken as the definitive answer concerning the circumcision debate. As we discuss in the article, the results do not address the role of the foreskin during sexual activity, nor was the study, as Rotta suggests, an exploration of the biomechanics of the foreskin during intercourse (an interesting question, indeed, but one that would be incredibly difficult to measured and one that we did not examine). This study was not an exploration of the direct impact of circumcision status on sexual function or on the experience of sexual pleasure. Furthermore, and importantly, we do not state whether the findings offer support to either side of the circumcision debate, but instead highlight the need for more empirically rigorous research.
The strong reactions to this self-described preliminary study highlight the need for more research and serve as a “call to arms” for researchers interested in examining the sexual correlates of circumcision. This body of research is plagued by weak study design, such as the inclusion of non-random samples, equating outcomes of adult and neonatal circumcision without evidence to suggest that the 2 are comparable, failure to control for participant expectations of study outcomes and reliance on self-report to the exclusion of objective measures. These shortcomings represent a serious problem in this contentious field because they allow room for participant and author bias. One does not have to search far for these biases in the circumcision literature, such as frequent references to non-peer-reviewed articles and author involvement in anti or pro-circumcision advocacy groups. Are we, as scientists, not responsible for stepping back from questions about which we have a personal stake in the outcome?
Research in this area should be conducted by those who are not personally invested in the circumcision debate. That was our initial goal. But following the severe reactions we have received, we wonder about who would want to continue (or even start) working on this topic without biased motivations. However, that is not what science is about. As comedian John Oliver stated in a recent commentary on the current state of science, “In science you don’t just get to cherry pick the parts that justify what you were going to do anyway.” We will continue to report what the data show, regardless of whether that reflects the popular vote, and hope that others in this field do the same.
Journal of Urology, Vol. 196 (December 2016), 1821-26. References and the table referred to in the authors’ reply have been omitted.
The original article, Examining Penile Sensitivity in Neonatally Circumcised and Intact Men Using Quantitative Sensory Testing by J.A. Bossio, C.F. Pukall and S.S. Steele, was published in Journal of Urology, Vol. 195 (June 2016) 1848-53.
Impact of circumcision on body image and sexual function
ABSTRACT Research exploring the impact of circumcision on the sexual lives of men has failed to consider men’s attitudes toward their circumcision status, which may, in part, help to explain inconsistent findings in the literature. … Men who were circumcised as adults or intact men reported higher satisfaction with their circumcision status than those who were circumcised neonatally or in childhood. Lower satisfaction with one’s circumcision status—but not men’s actual circumcision status—was associated with worse body image and sexual functioning. These findings identify the need to control for attitudes toward circumcision status in the study of sexual outcomes related to circumcision. Future research is required to estimate the number of men who are dissatisfied with their circumcision status, to explore the antecedents of distress in this subpopulation, and to understand the extent of negative sexual outcomes associated with these attitudes.
Jennifer Bossio, Caroline Pukall. Attitude Toward One’s Circumcision Status Is More Important than Actual Circumcision Status for Men’s Body Image and Sexual Functioning. Archives of Sexual Behaviour, early view, 11 September 2017
What this study really found is that men are more likely to be happy with being circumcised if they have freely elected the operation for themselves. In other words, the key issue is not age, but consent.
Tim Hammond writes in response:
The Archives of Sexual Behavior recently published findings by Canadian researchers Bossio and Pukall who identify a subpopulation of men subjected to nontherapeutic circumcision as children who experience distress over this genital modification. I personally consider this a validation of my two "circumcision harm" surveys that were published in 1999 (BJU International) and 2017 (International Journal of Human Rights, with co-author Adrienne Carmack). Although Bossio downplays that the distress might be related to any actual physical or sexual harm, she believes that a man's attitude toward his circumcision plays a larger role in the distress. Many years ago, circumcision advocate Edgar Schoen dismissed men's concerns by saying he thought the problem with these men lies more between their ears than between their legs. At the time, I took great offense to that comment, but I have come to believe that such comments presaged what is now being discussed relative to childhood MGM.
To her credit Bossio consistently refers to the intact penis and to intact men, rather than uncircumcised, and discusses the "loss of the natural foreskin". She also called for more research into the "antecedents" of circumcision distress. I consider that the adverse physical, sexual, emotional and self-esteem consequences of NTC addressed in both of my surveys are among the "antecedents" to which refers. In her present article, Bossio did reference my 1999 survey, but not in relation to harm, rather with regard to the phenomenon of foreskin restoration. The 2017 Hammond/Carmack survey was just published in March of this year, so I'm sure it was not yet on Bossio's radar as she prepared her manuscript. Also to her credit Bossio suggests that this circumcision "distress" experienced by an as yet undetermined number of adult men should be addressed by medical associations when formulating any future policy statements regarding infant circumcision. I heartily agree.
Tim Hammond is founder of the Circumcison Harm Survey.
References
Earp, B. D., & Darby, R. Circumcision, sexual experience, and harm. University of Pennsylvania Journal of International Law, 37(2) 2017, online symposium.
Robert Darby & Laurence Cox. Objections of a sentimental character: The subjective dimensions of foreskin loss.
See also in-depth discussion on this site: The unquantifiable subjectivities of circumcision harm
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