{"id":3016,"date":"2016-04-22T18:11:35","date_gmt":"2016-04-22T17:11:35","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=3016"},"modified":"2016-04-26T05:26:41","modified_gmt":"2016-04-26T04:26:41","slug":"circumcision-and-sexual-function-bad-science-reporting-misleads-parents","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2016\/04\/22\/circumcision-and-sexual-function-bad-science-reporting-misleads-parents\/","title":{"rendered":"Circumcision and Sexual Function: Bad Science Reporting Misleads Parents"},"content":{"rendered":"

by Brian D. Earp<\/a>\u00a0\/\u00a0(@briandavidearp<\/a>)<\/p>\n

Introduction<\/strong><\/p>\n

Another day, another round of uncritical media coverage of an empirical study<\/span><\/a> about circumcision and sexual function. That\u2019s including from the New York Times<\/i><\/span><\/a>, whose Nicholas Bakalar has more or less recycled the content of a university press release<\/span><\/a> without incorporating any skeptical analysis from other scientists. That\u2019s par for the course for Bakalar.[1]<\/span><\/p>\n

The new study<\/span><\/a> is by Jennifer Bossio<\/span><\/a> and her colleagues from Queen\u2019s University in Ontario, Canada: it looked at penile sensitivity at various locations on the penis, comparing a sample of men who had been circumcised when they were infants (meaning they had their foreskins<\/span><\/a> surgically removed), with a sample of men who remained genitally intact (meaning they kept their foreskins into adulthood).[2]<\/span><\/p>\n

What did the researchers discover? According to a typical headline from the past few days:<\/span><\/p>\n

\u201cCircumcision does not reduce penis sensitivity<\/span><\/a>.\u201d<\/span><\/p>\n

But that\u2019s not what the study showed. Before we get into the details of the science, and looking just at this claim from the \u201cheadline\u201d conclusion, it might be helpful to review some basic anatomy.<\/span><\/p>\n

Genital Anatomy 101<\/b><\/span><\/p>\n

Lesson #1. The foreskin is part of the penis<\/span><\/a>. It is made up of sensitive tissue (more on this below); so if you remove it, the penis loses sensitivity by definition. Specifically, it loses all of the sensitivity experienced in the foreskin itself<\/span><\/a>, along with all subjective sensations that are unique to having a foreskin.<\/span><\/p>\n

Chief among these sensations is the feeling of rolling the foreskin back and forth over the head of the penis\u2014the \u201cglans\u201d\u2014during sex, foreplay, or masturbation (see this NSFW video<\/span><\/a> to get the idea): that specific feeling does not exist without a foreskin.<\/span><\/p>\n

Lesson #2. Imagine a study that claimed to show that removing a girl\u2019s labia minora<\/span><\/a>\u2014her vaginal \u201clips\u201d\u2014did not reduce the sensitivity of the vulva.<\/span><\/p>\n

\u201cThat doesn\u2019t make any sense,\u201d you might say. \u201cThe labia are part<\/em> of the vulva!\u201d Quite right. And just like the foreskin<\/span><\/a>, they are richly supplied<\/span><\/a> with nerve endings, blood vessels, and sebaceous glands that provide natural lubrication during sexual activity.<\/span><\/p>\n

Depending on one\u2019s sexual preferences, the labia can be tugged, stretched, sucked on, and otherwise \u201cplayed with\u201d as a part of one\u2019s sexual experience; the same thing is true of the foreskin.<\/span><\/p>\n

So if a girl has her labia removed (which is a federal crime<\/span><\/a> in most Western countries),[3]<\/span>\u00a0or if a boy has his foreskin removed, neither one will be able to experience any of the subjective sensations that go along with those specific activities when they grow up and become sexually active.<\/span><\/p>\n

They also won\u2019t be able to \u201ccompare\u201d their sexual experiences with a version of themselves from an alternate universe in which their genitals had been left intact when they were children: this point will become important later on.<\/span><\/p>\n

Lesson #3. The United States is the only developed country<\/span><\/a> that practices routine circumcision on a majority of newborn boys for non-religious reasons. Circumcision in this context is often described as \u201cjust a little snip,\u201d and the foreskin as \u201ca tiny flap of skin.\u201d I won\u2019t go into the details of what a circumcision surgery actually involves (here is a video<\/span><\/a> for those who are not too squeamish), but \u201clittle snip\u201d is not an accurate description.<\/span><\/p>\n

As for the foreskin itself, it is not a \u201cflap of skin,\u201d but rather a double-layered, retractable, invertible sheath of tissue that functions seamlessly with the rest of the penis (here\u2019s another video<\/span><\/a>); and it\u2019s only \u201ctiny\u201d when it\u2019s connected to a baby. The adult foreskin has on average 30 to 50 square centimeters<\/span><\/a> of tissue surface area (roughly the size of a credit card), with numerous specialized nerve endings<\/span><\/a> that respond to tactile stimulation.<\/span><\/p>\n

Another (rough) analogy<\/b><\/span><\/p>\n

So let me try another analogy. Saying that removing the foreskin \u201cdoesn\u2019t reduce penis sensitivity\u201d is a bit like saying that removing the pinky finger doesn\u2019t reduce hand sensitivity. What you really<\/i> mean is that removing the pinky finger (which is part of the hand) doesn\u2019t reduce sensitivity in the remaining fingers<\/i>\u2014although, as we\u2019ll see, it\u2019s not even clear that this part of the analogy holds up in the actual study.<\/span><\/p>\n

In other words, it\u2019s an odd way to frame the hypothesis. To continue the analogy, my guess is that most people\u2014if faced with the claim that removing the pinky finger doesn\u2019t reduce sensitivity of the hand\u2014would say, \u201cBut what about the pinky finger itself?!\u201d<\/span><\/p>\n

And they would be right to say it. The only reason you wouldn\u2019t think to ask a similar question about the foreskin\u2014vis-\u00e0-vis the rest of the penis, of which it is a part\u2014is if you lived in a country where it had become the habit to cut this tissue off at birth, making it seem like something disposable. But that is not<\/span><\/a> how the foreskin is treated in most developed countries, and that\u2019s not how it seems to most men who possess one.<\/span><\/p>\n

Returning to Bossio et al. study<\/b><\/span><\/p>\n

Now that we have some idea of what we are talking about, let\u2019s take a look at the actual study. The researchers recruited 62 men, of whom 30 were circumcised and 32 were intact. The age range of participants was 18 to 37 years, which means that older men\u2014including those ages 40 and up\u2014were excluded. This is a little bit strange from a sampling perspective, since problems with penile sensitivity (and general function) start to pick up around that age<\/span><\/a>: if you\u2019re trying to detect a difference due to circumcision, it is likelier to be more pronounced in older, rather than younger, men.<\/span><\/p>\n

Participants were also pre-selected to be free of sexual dysfunction. So if foreskin removal causes <\/i>sexual dysfunction (on a statistical basis) then this study cannot find it, by design.<\/span><\/p>\n

Right out of the gate, then, we have a couple of limitations: (1) we don\u2019t know if the results of the study\u2014whatever they turn out to be\u2014apply beyond the age of 37, and (2) we don\u2019t know if they generalize beyond men without any sexual problems (which is the very group of men you would think we\u2019d be interested in, given the hypothesis).<\/span><\/p>\n

Another limitation is the size<\/i> of the sample: it\u2019s small. Too small. As a statistician would say, it\u2019s \u201cunderpowered.\u201d Simply put, the study didn\u2019t have enough power to detect a difference between the circumcised vs. intact men (even if one existed) across all of the different tests that the researchers used.<\/span><\/p>\n

What that means is that the absence of a measurable effect for sensitivity doesn\u2019t tell us very much. It would be like attempting to tell the difference between two photographs printed at a horrible resolution (say, 10 pixels), when the differences\u2014if they existed\u2014would be completely obvious at a higher resolution (say, 1000 pixels). You don\u2019t run a \u201c10 pixel\u201d study and conclude \u201cthe photographs are identical.\u201d<\/span><\/p>\n

As it happens, the researchers actually used a computer program to calculate exactly how many participants they would need to detect an effect of circumcision status on penile sensitivity: for their \u201cpain threshold\u201d test (I\u2019ll say more about this later), they found that they would need 122 participants to detect an effect; and for their \u201cwarmth detection threshold\u201d test, they found that they would need 238 participants to detect an effect.<\/span><\/p>\n

So they had about half as many participants as they needed for the first test, and about a quarter as many participants as they needed for the second test.<\/span><\/p>\n

Here\u2019s the bottom line. If you don\u2019t recruit enough participants to detect the effect you\u2019re looking for (in this case, a difference between circumcised men and intact men in terms of their penile sensitivity), it is misleading to say \u201cthere isn\u2019t an effect.\u201d<\/span><\/p>\n

But actually, there\u2019s more to the story. Somewhat confusingly, immediately after explaining that 238 participants would be needed \u201cto obtain a significant effect\u201d on the warmth detection test\u2014which, again, the researchers didn\u2019t have (they had 62 participants)\u2014the authors went ahead and reported a statistically significant effect of p<\/i> = .02.[4]<\/span><\/p>\n

What could be going on here?<\/span><\/p>\n

Surprising findings<\/b><\/span><\/p>\n

To understand the meaning of this \u201ceffect\u201d (I\u2019ll say what it was in just a moment), you have to remember that there are two different comparisons the researchers were interested in. The first comparison is between circumcised and intact men\u2014in terms of their respective sensitivity\u2014at each location on the penis being tested<\/i>. For this comparison, you needed 238 participants.<\/span><\/p>\n

The second comparison is between different locations on the penis itself<\/i>\u2014in terms of their<\/i> respective sensitivity\u2014collapsing across the circumcision status of the men. For this comparison, you can get away with fewer participants.<\/span><\/p>\n

Now, there were four different locations on the penis that the researchers tested: two on the shaft (same location for both circumcised and intact men), one on the head of the penis (same location for both circumcised and intact men, but with the foreskin rolled back in the intact group), and one on the foreskin (intact men only).<\/span><\/p>\n

Just to clarify: the researchers tested one<\/i> spot on the outside<\/i> of the foreskin, versus three spots on the rest of the penis. Previous research<\/span><\/a> suggests<\/span><\/a>, however, that different parts of the foreskin have different distributions of nerve endings, and that it is the inside<\/i> of the foreskin (the part that becomes exposed when the foreskin is rolled back, like it does during sex) that is especially sensitive.<\/span><\/p>\n

The researchers didn\u2019t test this part, which means that their study design was stacked against the sensitivity of foreskin from the get-go.<\/span><\/p>\n

So what did the researchers find? Given what I\u2019ve just said, and given the way this study has been written up in the media so far, you will be surprised to learn that the \u201cstatistically significant finding\u201d\u2014comparing all of the penile locations just mentioned\u2014was actually still<\/i> in favor of the foreskin: the part of the penis removed by circumcision.<\/span><\/p>\n

Specifically, the foreskin was found to be (significantly) more sensitive to warmth than the head of the penis, regardless of circumcision status, and (numerically) more sensitive than all other testing sites including the forearm, which was used as a \u201ccontrol.\u201d Take a look at Figure C from the study (reproduced below), and remember that a lower bar means more<\/i> sensitive. What do you notice?<\/span><\/p>\n

\"Figure<\/a><\/p>\n

A similar result was found on a \u201ctactile threshold\u201d test. For this test, the researchers applied a series of thin filaments to different parts of the penis (the same four locations described above), and wrote down how much pressure was needed before the participants could actually feel the stimulus (see here for a video demonstration<\/span><\/a>).<\/span><\/p>\n

Again, you will be surprised to learn\u2014I am quoting directly from the paper<\/span><\/a> now\u2014that \u201cTactile thresholds at the foreskin (intact men) were significantly lower (more sensitive) than all<\/i> [other] genital testing sites\u201d including the sites in circumcised men (emphasis added).[5]<\/span><\/p>\n

Let me just repeat this: for the one test the researchers used that measured actual tactile sensitivity (which is what most people think of when they hear the word \u201csensitive\u201d in this context), they found that <\/span>the foreskin was more sensitive than any other part of the penis, including all parts of the penis that remain in circumcised men<\/span>.<\/span><\/p>\n

This is consistent with a previous finding<\/span><\/a> by other researchers from 2007, who concluded<\/span><\/a> that \u201cCircumcision ablates [removes] the most sensitive parts of the penis.\u201d<\/span><\/p>\n

Take a look at Figure A, below (again, the lower the bar, the more sensitive):<\/span>\"Figure<\/a><\/p>\n

Mystery conclusion<\/b><\/span><\/p>\n

So how do we get from a finding, replicating previous research, that the foreskin is the most sensitive part of the penis to tactile stimulation, as well as a new finding showing that it is more sensitive to warmth than the glans … to the conclusion that circumcision (which removes the foreskin) \u201cdoes not reduce penis sensitivity\u201d?<\/span><\/p>\n

I reached out to Jennifer Bossio to ask for clarification. As far as I can tell, her conclusion is based on the fact that the foreskin was not shown to be \u201cmore sensitive\u201d than other penile sites on two additional tests her group used: (1) a \u201cheat pain\u201d test (this is the same as the \u201cwarmth detection\u201d test, only turned up until it got hot enough to hurt), and (2) the underpowered \u201cpain threshold\u201d test that I already mentioned (which is the same as the \u201ctactile threshold\u201d test using the filaments, just pressed down harder until the participant felt pain).<\/span><\/p>\n

But I still don\u2019t see how the conclusion follows. It sounds like the foreskin is acutely sensitive to the lightest and most gentle of touches (as well as to mild sensations of warmth), while being somewhat less sensitive to outright pain. Is that supposed to count against the foreskin?<\/span><\/p>\n

Misleading headlines<\/b><\/span><\/p>\n

\u201cCircumcision does NOT reduce sensitivity of the penis\u201d (Daily Mail<\/i><\/span><\/a>); \u201cStudy finds no difference in sensitivity between circumcised versus non-circumcised men\u201d (Northern California News<\/i><\/span><\/a>); \u201cForeskin doesn\u2019t make a man more \u2018sensitive,\u2019 study finds\u201d (Vox<\/i><\/span><\/a>); \u201cWe finally know whether or not being circumcised affects sexual pleasure\u201d (Elite Daily<\/i><\/span><\/a>).<\/span><\/p>\n

Who wrote these headlines? They are all false. What the study actually showed was that the average foreskin of a small, non-representative sample of men from Canada, was more sensitive to light touch and mild warmth, and somewhat less sensitive to outright pain, than other parts of the penis. How those differences go on to \u201caffect sexual pleasure\u201d (to jump to the last headline) is a complicated question, and it probably depends on the situation of each individual<\/span><\/a>. Relevant factors would include how he likes to be touched, what kinds of sexual activities he enjoys, and whether those activities are even possible without a foreskin. <\/span><\/p>\n

Notice the word \u201caverage\u201d in the previous paragraph. The individua<\/i>l<\/em> sensitivity scores for each man\u2019s foreskin (in response to the different types of stimuli) were made invisible due to group averaging. And yet it is likely that some men\u2019s foreskins are more sensitive than others, and vice versa\u2014everybody\u2019s different. What that means is that circumcision will affect different people differently: a man with a particularly sensitive foreskin has more to lose by cutting it off, and that\u2019s something you can\u2019t know in advance when you\u2019re looking at an infant.<\/span><\/p>\n

Concluding thoughts<\/b><\/span><\/p>\n

Jennifer Bossio and her colleagues are to be commended for trying to \u201cobjectively\u201d study a complicated issue (although the way they reported their results was woefully misleading). But at the end of the day, sexual experience is largely sub<\/i>jective<\/span><\/a>: different people prefer different things when it comes to sex, and a lot of sexual enjoyment comes down to psychological factors<\/span><\/a>, not penile anatomy.<\/span><\/p>\n

That is why there is a growing movement<\/span><\/a> to leave the \u201ccircumcision decision\u201d to the individual who will be affected by it, so that he can decide\u2014when he\u2019s old enough to understand what\u2019s at stake\u2014if he\u2019d rather experience sex and masturbation with an intact penis (however sensitive his particular foreskin turns out to be), or with a modified one (if he wants to go for surgery).<\/span><\/p>\n

With respect to the specific question of \u201csensitivity,\u201d the latest findings are a lot less definitive than media reports are making them out to be (and they don\u2019t even all point in the same direction as those reports are suggesting). As Bossio and her colleagues state<\/span><\/a> at the end of their paper, \u201creplication of this study is warranted with a larger sample size\u201d and \u201cassociated conclusions should be interpreted as preliminary.\u201d<\/span><\/p>\n

In the meantime, a precautionary approach suggests that we should leave boys\u2019 penises alone until they can assess the sensitivity of their own foreskins as compared to other parts of the penis\u2014as well as their role in sexual experience more generally\u2014in light of their own considered sexual preferences and values.[6]<\/span><\/p>\n

———————————————————————————————————–<\/p>\n

* Note: this article was first published online at\u00a0The Huffington Post<\/em><\/a> with the title: “Does Circumcision Reduce Penis Sensitivity? The Answer is Not Clear Cut.”<\/p>\n

———————————————————————————————————–<\/p>\n

About the author<\/b><\/span><\/p>\n

Brian D. Earp<\/i><\/a><\/span> (<\/i>@briandavidearp<\/i><\/span><\/a>) is a scientist and ethicist with degrees from Yale, Oxford, and Cambridge Universities, including an M.Phil. degree in the history and philosophy of science and medicine, focusing on male and female genital cutting practices. He is currently a Resident Visiting Scholar at <\/i>The Hastings Center<\/i><\/span><\/a>, an independent bioethics research institute in Garrison, New York. He has published widely in the leading journals in his fields.<\/i><\/span><\/p>\n

Notes<\/b><\/span><\/p>\n

1. See Bakalar\u2019s equally rote coverage<\/span><\/a> of another paper on circumcision from 2014 written by a controversial<\/span><\/a> Australian researcher; critical perspectives<\/span><\/a> would not have been hard to come by. For more on sloppy science reporting at the New York Times<\/i>, see \u201cThe New York Times Should Seriously Consider Not Writing About Science Anymore<\/span><\/a>.\u201d Or you can read my take here<\/span><\/a>.<\/span><\/p>\n

2. It is probably worth noting that this second group of men is considerably more representative on a global scale: North America has an unusual (and somewhat unsettling<\/span><\/a>) history in adopting male circumcision as a cultural norm\u2014although it appears to be fading away<\/span><\/a> as the years go by\u2014as the science writer Matthew Tontonoz has recently explained<\/span><\/a> in a reader-friendly primer.<\/span><\/p>\n

3. Please note that this would qualify as \u201cfemale genital mutilation<\/span><\/a>\u201c or \u201cFGM<\/span><\/a>.\u201d For a discussion of the similarities and differences between male and female forms of non-therapeutic genital cutting, let me recommend a popular article<\/span><\/a> I wrote on the subject for Aeon<\/i> magazine (by way of a brief introduction), or else a formal paper covering the same ideas<\/span><\/a> (if you have more time).<\/span><\/p>\n

4. For the sake of this discussion I am going to set aside a rather heated debate<\/span><\/a> about whether \u201cp”<\/i>\u00a0values should even be used to make statistical inferences; suffice it to say that a lot of statisticians disagree with this whole approach<\/span><\/a>.<\/span><\/p>\n

5. Remember, they didn\u2019t even test the most sensitive part of the foreskin, so this is a conservative comparison.<\/span><\/p>\n

6. In this article, I\u2019ve focused just on the issue of penile sensitivity, in response to one recent study about circumcision that\u2019s been getting some of traction over the past few days. But there\u2019s a lot more to circumcision than the question of sensitivity. Some readers who are new to this debate\u2014especially if they live in the U.S.\u2014might be thinking, \u201cBut what about health benefits? Aren\u2019t there all sorts of health benefits to circumcision?\u201d As it happens, I\u2019ve written a lot about that question in other contexts, but let me refer you to a nice, accessible summary of the relevant data<\/span><\/a> by Morten Frisch. The upshot is that the balance of medical opinion, on a global scale, is that infant circumcision in developed countries\u2014as opposed to, say, adult circumcision in Sub-Saharan Africa\u2014does not confer<\/span><\/a> any net<\/i> health benefits, when you take into account the countervailing risks and harms<\/span><\/a>. See here<\/span><\/a> for further discussion.<\/span><\/p>\n

Follow Brian D. Earp on Twitter: <\/b>www.twitter.com\/briandavidearp<\/b><\/span><\/a><\/span><\/p>\n

<\/p>\n","protected":false},"excerpt":{"rendered":"

by Brian D. Earp\u00a0\/\u00a0(@briandavidearp) Introduction Another day, another round of uncritical media coverage of an empirical study about circumcision and sexual function. That\u2019s including from the New York Times, whose Nicholas Bakalar has more or less recycled the content of a university press release without incorporating any skeptical analysis from other scientists. That\u2019s par for […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7933,511,394,397],"tags":[395,7969,2611,698,137,7964,578,304,317,2069,7937,787],"class_list":["post-3016","post","type-post","status-publish","format-standard","hentry","category-brian-earps-posts","category-in-the-news","category-methodology","category-research-ethics","tag-bioethics","tag-brian-earp","tag-circumcision","tag-distributive-justice-in-health-care","tag-ethics","tag-female-genital-mutilation","tag-hastings-center","tag-public-health","tag-research","tag-science","tag-sex","tag-sex-education"],"yoast_head":"\nCircumcision and Sexual Function: Bad Science Reporting Misleads Parents - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2016\/04\/22\/circumcision-and-sexual-function-bad-science-reporting-misleads-parents\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Circumcision and Sexual Function: Bad Science Reporting Misleads Parents - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"by Brian D. Earp\u00a0\/\u00a0(@briandavidearp) Introduction Another day, another round of uncritical media coverage of an empirical study about circumcision and sexual function. That\u2019s including from the New York Times, whose Nicholas Bakalar has more or less recycled the content of a university press release without incorporating any skeptical analysis from other scientists. 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