But enough with Morris, let's cut to the meat and potatoes and take a look at the abstract. The article is being published on the Journal of Sexual Medicine (how he gets publishers is something we can't really understand).
And what is this "new" research, one would ask? Well, it's nothing but a recycle of the same old papers. In his own words, "A systematic review of published articles retrieved using keyword searches of the PubMed, EMBASE, and Cochrane databases was performed."
From this, 2,675 publications are identified (several of them authored by Morris himself, no doubt), and they are "rated" on their quality level, to conclude that "The highest-quality studies suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation, or satisfaction.". The problem is, what is the criteria for this rating? Which were the "low quality" studies and what did they reveal?
But, at this point we are not even really discussing the meat and potatoes of the subject, are we? Because, how can we evaluate sexual function, sensitivity, sensation and satisfaction, if we don't start by defining what those are and how to measure them? Guess what, Morris didn't.
For being a biologist, Morris willingly overlooks the question of what is sexual function, and skips the topic by going to statistics. Do you see anything wrong there?
Histological studies such as those by John R. Taylor (published in the British Journal of Urology) are evidently ignored, and most likely Sorrells' "Fine-touch pressure thresholds in the adult penis" (also published in BJU) is most likely rated with low quality, given that Morris (and his friend Jake Waskett, a computer programmer) took it upon himself to criticize that paper by distorting, eliminating and reprocessing the data, as pointed out by Hugh Young. In fact in the Daily Telegraph's article, Morris is quoted saying "There are no legitimate studies which have found a lack of sensitivity". Sorry Morris, just because you don't like the findings of Sorrells et al. doesn't mean that it's not legitimate. You can't remove 20,000 soft-touch receptors from an organ and claim that there is no difference in sensitivity.
Circumcision promoters prefer to ignore Sorrells study while paying attention to Payne et al's "Sensation and sexual arousal in circumcised and uncircumcised men" which was based on a similar methodology with a fatal flaw: Payne didn't take sensitivity measures for the foreskin, only for the glans, thus ignoring the main difference between the circumcised and the uncircumcised penis in what can only be called "researcher's bias" or "researcher's prejudice".
Anyway, the question of what constitutes sexual function is not even asked by Morris. Of course that would have to get him to explain about frenulum, ridged band, gliding function (described by Lakshman in the Indian Journal of Surgery in 1980), etc, things that he really doesn't care to talk about... because he doesn't have them.
So let's be clear here.
If sexual function means simply being able to sustain an erection and ejaculate, then, in most cases there would be no difference... except perhaps at an older age (40, 50...) as keratinization of the glans progresses.
But if sexual function means that the penis works as it was intended to work:
- The foreskin glides over the glans and allows the ridged band and the ridge of the corona to stimulate each other,
- Pre-ejaculate collects in the subpreputial space for additional lubrication instead of falling down on a useless liquid thread,
- The intact frenulum and ridged band perceive a lot of sensation and produce tingling sensations and help control the orgasmic threshold,
Then there is no doubt that removing the foreskin changes the function.
Some of the "high quality" studies would have been, no doubt, those by Kigozi et al, in Uganda (including circumcision promoter Ronald Gray) where the men that volunteered for circumcision as part of the "randomized trial" for HIV prevention, were followed up at 6, 12 and 24 months. Participants reported on "sexual satisfaction and function". Of course at 24 months, keratinization wouldn't have been enough to represent a good difference (some men circumcised during the neonatal stage report the effects of keratinization when they are past their 40 or 50 years - but I'm sure Morris would dismiss them as case-studies in the best case, or as being brainwashed by anticircumcision literature on the internet at worse).
But given that this is nothing but a "systematic review" of existing literature, then comes the question of what's the relevance of this paper. Why did Morris even bothered looking for all these articles and writing a new paper based on no new research whatsoever?
Circumcision promoters have suffered some backslash in the recent years. In 2011 the International Journal of Epidemiology published Morten Frisch's "Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark" which concluded 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." In spite of the expected anonymity of reviewers, Morris outed himself as one of the reviewers, as the one reviewer opposing the publication of Frisch's study, when he asked the members of his mailing list to write letters to the editor protesting the publication of the article. Quite unethical on his part.
In 2013 BJU published Bronselaer's "Male circumcision decreases penile sensitivity as measured in a large cohort", a study in Belgium, which concluded that "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". Strangely for a study that suggest negative consequences of male circumcision, Reuters covered the study so it reached several global news outlets. In some of the media, particularly in American news sites, a critique by circumcision promoter Aaron Tobian (Johns Hopkins University college of Ronald Gray) was included in an attempt to "balance" the information (or reduce the impact of the study, we could say).
And this would be the reason why circumcision promoters needed some "new" publication to "find" that circumcision "does not affect -or actually increases- sexual satisfaction", even if it means just recycling all the old articles, even the old and utterly debunked excuse of a "study" by Masters and Johnson from 1966 (here explained and refuted by Hugh Young).
So this is the issue. Awareness of the consequences of male circumcision has been growing. It was already reported in 1997-1999 by Tim Hammond. The past two years have seen two European articles denouncing the reported loss of sensitivity and sexual consequences of circumcision for European males and their partners. 2012 also saw the results of the Global Survey of Circumcision Harm. There is also growing awareness of the possibility of Non-Surgical Foreskin Restoration for men who feel harmed by their circumcision and wish to recover some of the function of their lost foreskin.
So obviously, circumcision promoters are not happy, especially when African men are not rushing to get circumcised as they expected them to. Aaron Tobian prepared the path for the AAP's new Policy Statement on Circumcision by publishing his "findings" (actually a computer simulation applying premises from African data to the United States) that healthcare cost would increase if circumcision rates continue decreasing. Of course even if this was true, this unethical paper is only putting a price tag on a valuable part of the male genitalia, and most of the public could see through it. More was needed, so Professor Morris did what he knows how to do: review old information to produce new publications, while denying everything that doesn't fit his model of the world.
Well, Professor Morris, it doesn't work that way. You can't deny the changes in function by simply refusing to discuss function. Good try though.
One thing we appreciate of Morris "study", and it would be pointing us to his coauthor, Krieger JN. Professor John Krieger from the University of Washington. We'll definitively be learning more about Krieger's work, such as his previous 2008 study on "Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya", which no doubt is one of the studies reviewed in this new publication, it's not like Morris has been known for self-referencing his own publications, what's the cost of sharing that trick with his coauthor?
One final thought is, why is it that European males report sexual difficulties related to their circumcision while African males don't? And why is it that the perception of African males would be more relevant to English speaking countries than the perception of European males?
But let's listen to Brian Morris for a moment, let his words give you an idea of his character. He would be quite amusing if he didn't think he was being serious.
"So obviously, circumcision promoters are not happy, especially when African men are not rushing to get circumcised as they expected them to." Men are not stupid in Africa, or America, or Europe, or anywhere in the world. That's why the circumcisers' Holy Grail is baby circumcision... no choice, no fuss, no problem.
ReplyDeleteOne correction to the article: John Krieger is NOT from the Washington University. He is from the University of Washington (Seattle, WA). He is listed as adjunct professor in the Department of Global Health. This is repugnant, because Global Health at the UW has been swallowing lots of funding and what do they do? Promote circumcision in Africa?
ReplyDeleteThank you for your correction!
DeleteYou do yourself no credit by repeating urban myths ("20,000 soft-touch receptors", "keratinization") or ignoring the critiques of the various studies you cite - like Bronselaer's study in which 22.6 % of his men were circ'd as opposed to only 15 % of the Belgian population. 12.1 % of them were gay. No way was this a representative sample. It was compromised by participant bias (a similar problem applies to Frisch's study). Why do you not mention the recent meta-analysis by Tian et al (http://www.ncbi.nlm.nih.gov/pubmed/23749001) that found that circ has no adverse effect on male sexual function? It was NOT by Morris, so you'll find it harder to ad hominem its authors.
ReplyDeleteIf "European males report sexual difficulties related to their circumcision while African males don't" perhaps it is because African men have less internet access so have mostly not encountered, and been misled by, intactivist propaganda.
The review by Tian did not take into account penile sensitivity and the possible presence of pain. The review itself warns "these results should be evaluated in light of the low quality of the existing evidence and the significant heterogeneity across the various studies". The problem with evaluating adult circumcision is that it is mostly performed because of some medical condition that was likely to induce pain. The results of any such study need to be analyzed extremely carefully. Also, keratinization is likely to take a few years until it kicks in. It makes more sense to compare adults circumcised at birth with adults left intact. This was done in a study by Dan Bollinger which found that circumcision increases erectile dysfunction by 4-5 fold: http://www.mensstudies.com/content/2772r13175400432/?p=a7068101fbdd48819f10dd04dc1e19fb&pi=4
DeleteOn a side note, you mentioned a couple of times:
Delete"African men have less internet access so have mostly not encountered, and been misled by, intactivist propaganda"
"If some circ’d guys are angry about their circumcision perhaps it is because they have been lied to by intactivists and thereby tricked into believing they have lost something significant and are now sexually crippled as a result."
Let me ask you. Why do you think intactivists would create this propaganda? Why would they trick people into believing things? What do you assume would be the motivation to create such a fiction? And who would be the people to create such fiction?
I just feel that such idea, that intactivists would create fiction to confuse circumcised guys and cripple them, would need to be explained by an ulterior motive, but those who say it (Morris included) never go deeper into why the first intactivists ever appeared.
This is a point that I'm seriously intrigued about.
"Why do you think intactivists would create this propaganda? Why would they trick people into believing things? ..."
DeleteYou tell me, you're the ones doing it. Why do people stir up anti-vaccination hysteria? Why do some deny that HIV causes AIDS (or even that it exists)? Why are wacky alternative medicines like homeopathy so popular?
As most circ'd guys have no experience of 4skins, and have no scientific or medical background, they are not in a position to evaluate intactivists' claims. So when pseudoscientific material is presented to them, full of technical jargon, backed up by people with degrees and selective literature citations, they'll fall for it. How many of them actually bother to check the literature? How many even have access to it (a lot is behind paywalls)? How many would understand it even if they could access it? How many would bother to look at subsequent issues of the journals for rebuttals and counter-rebuttals? How many would know to do a general search on PubMed to find the papers intactivists don't tell them about? How many have even heard of PubMed? I'm lucky. I have experience with & without a 4skin, so I know I am not missing much. I am also a scientist, not medical, but at least familiar with scientific literature, and with access to most of it. I am also a long-standing skeptic, and debunker of various pseudosciences (creationism is my usual target, but I have a go at others sometimes too) so am used to spotting bullsh!t, and there is bullsh!t aplenty in intactivism (and some too on the other side).
There is also a self-propagating aspect to intactivism. Men and boys read intactivist propaganda and become embittered by the “crime” they have suffered. Others repeat to them the mantras about nerves, sensitivity, etc., and the bitterness is reinforced. Thus angry new recruits are drawn in and the cult grows. But it's all bullsh!t. They have not lost 20,000 nerve ends, become keratinized, desensitized, blah, blah, blah. And the bullying nastiness of intactivists drowns out any attempt at countering this pernicious nonsense. A good article in "Slate" on their unpleasantness, and how they have taken over the internet, has just appeared, Google on "How Circumcision Broke the Internet". There is now a huge disparity between what I find in the medical literature, and what I see on intactivist websites. It is immensely damaging to the self-esteem of previously happily circ'd males, and it undermines public health measures. There is a dark side to intactivism, and that needs to be countered, regardless of whether trimming babies is good, bad or indifferent.
"this is consistent with my own personal experience (although I always prefer science over subjective personal experience)."
DeleteWhen it comes to YOUR own sensation, it's your body you should trust. Not Morris, not Sorrells, not Payne, not Frisch... It doesn't matter if 1 million people prefer one thing, if you prefer another thing that's totally up to you. Waskett chose to become circ. as adult, saying he fantisized with that since he was 5 years old; good for him. Those who restore and feel better, good for them.
If people feeling better after restoring is a matter of placebo, then those feeling better after circumcising themselves could also be a matter of placebo. But I digress. I think there are changes, subtle or not, and the result feels better for some and worse for others. Not everybody likes the same thing. So justifying satisfaction of individuals based on p-value of a group, and assuming that those out of the norm are the result of psychological issues, is really missing the point of individual taste.
Nobody, intactivist or procirc, should tell another person HOW they should feel. And this would be a reason to try to prevent infant circumcision, EXCEPT in cases where the life is at risk. Life is obviously more valuable.
I speculate that most circumcised males will be happy and not want to be on the other group, and most uncircumcised males will be happy and not want to be on the other group. It's likely it will be only a minority who will wish to be on the other side. And this is where circumcised males are at disadvantage, and why leaving it as an individual decision will only make things better.
Back to HIV, not everyone will benefit from circumcision even if the science behind it is sound. Some people have lifestyles where they will not benefit from circumcision to prevent HIV, whether they are gay, or celibate, or monogamous. Which is why it should still remain a VOLUNTARY decision, and that means an adult decision (or at least, age of consent decision).
The usual argument that circumcision is easier on babies doesn't really hold true if the promise of the PrePex, Shang-Ring, etc, happens to be true. These devices would make adult circumcision easier, less expensive, less painful and less risky. In fact, they should be certified for use in the United States as well. And the existence of these devices should make infant circumcision less prevalent, focusing instead of making them available to those who want it when they have the age to provide informed consent.
It would be great if traditional circumcisions in Africa would incorporate these devices and forgo the knives.
Personally, I think the circumcision programmes in Africa would be a non-issue as long as:
a) Proper education is given at the time, to prevent risk compensation. And marketing is not done through shaming uncircumcised males (as the infamous posters that have been used in some places).
b) Do not turn into infant circumcision programmes.
c) Are not funded by American tax dollars. We have enough problems trying to provide healthcare for Americans, to be paying for African circumcisions with money that is needed locally. As far as Bill Gates, it's his money, he can do whatever he wants with it.
The review & meta-analysis by Tian DID take into account pain – dyspareunia was specifically examined, circ had no adverse effect.
ReplyDeleteTian et al also looked at premature ejaculation, ejaculation latency time & orgasm difficulties, finding no adverse effect in each case. As each of these will be linked to sensitivity (how do you get an orgasm if you can’t feel anything?) sensitivity was therefore indirectly assessed.
It was directly assessed in some of the studies included, like Senol’s 2008, and Masood’s 2005 ones. There is also some discussion of sensitivity in the “discussion” section; and in the “conclusions” Tian et al twice say that circ does not adversely affect, “penile sexual function or SENSITIVITY” (my emphasis).
The great majority of circ’d men in the study were NOT circ’d “because of some medical condition that was likely to induce pain”. They were variously infant circs, religious ones, or circ’d as part of African HIV RCTs.
The claim about keratinization is a myth. Got any credible evidence it happens? Let’s see actual measurements on stained sections of glans skin examined down a microscope.
The study you cite by Bollinger & Van Howe is worthless and discredited. It was based on a self-selected, biased sample from an advert with the highly leading title “Male circumcision trauma survey” placed on anti-circ websites, as pointed out by good old Morris. In their reply, Bollinger & Van Howe admitted the potential for bias, but didn’t seem to appreciate just how biased it was likely to be. Their findings that circ is linked to erectile dysfunction (based on Viagra use) flies in the face of multiple other studies, now including Tian et al.
There is no credible evidence that circ, properly done, has any adverse effect on male sexual function. Telling circ’d men the contrary causes them needless angst and is one of the reasons I get fed up with intactivists who seem determined to make circ’d guys feel miserable. It may be a great recruitment ploy, but it is dishonest and unethical.
Orgasm is not necessarily an indicator of the quality of sensitivity. You might get an orgasm after 1/2 hour of thrusting because the glans is so desensitized that you can't orgasm easily. You MUST measure sensitivity directly. Also, male circumcision has been linked to female dyspareunia:
Deletehttp://www.ncbi.nlm.nih.gov/pubmed/21672947
I have no problem if a circumcised guy thinks that everything is fine. I have a problem when it's enforced on innocent babies. There are several "I did not consent" projects on the web, like these:
https://www.facebook.com/events/277946602316816/
http://www.intaction.org/circumcision-i-did-not-consent-petition/
Not all circumcised guys share your opinion. Many are angry at their circumcision. On the other hand, an intact man will never want to give up his foreskin unless he has a serious medical condition or he has strong religious motivations (or he gets bullied into it by very strong social pressure like in Africa). Babies will become men and American society fails to protect them.
It is ignoring that it can have adverse effects on sexuality that is dishonest and unethical. And also, the fact that telling this to circumcised men causes angst is already an indication that there is truth in it. If you told an intact men that being circumcised increases sexual pleasure you would only get a big laugh. Rocco Siffredi calls his adult circumcision the biggest mistake of his life.
Here is a study that discusses the link between circumcision and keratinization and how it decreases sexual function in males:
DeleteA biocultural analysis of circumcision
Author(s): Immerman, RS (Immerman, RS); Mackey, WC (Mackey, WC)
Source: SOCIAL BIOLOGY Volume: 44 Issue: 3-4 Pages: 265-275 Published: FAL-WIN 1997
Abstract: The phenomenon of circumcision may well serve a range of religious and symbolic functions. In addition to these conceptual categories, we argue that circumcision also serves a more mundane, practical function of lowering excitability and distractibility quotients-sexual arousal - of pubescent males, i.e., biasing young males more toward increased tractability which would enhance group efforts and less toward individual goals of amorous exchanges. Neurological data suggest that early lesions of the prepuce/foreskin tissues would generate a re-organization/atrophy of the brain circuitry. This re-organization/atrophy, in turn, is suggested to lower sexual excitability. Epithelial data indicate that keratinization of the more exposed glans penis would lower the sensibility, hence sexual excitability, of the circumcised male's genitalia. In addition, circumcision removes the foreskin-prepuce which, by secreting smegma, would also minimize any pheromonic qualities which the smegma may generate. Inferential data support the hypothesis that a practical consequence of circumcision, complementary to any religious-symbolic function, is to make a circumcised male less sexually excitable and distractible, and, hence, more amenable to his group's authority figures.
"There is no credible evidence that circ, properly done, has any adverse effect on male sexual function. Telling circ’d men the contrary causes them needless angst and is one of the reasons I get fed up with intactivists who seem determined to make circ’d guys feel miserable. It may be a great recruitment ploy, but it is dishonest and unethical."
DeleteCircumcision causes some verifiable harm, such as the removal or reduction of the frenulum, destruction of the ridged band, limiting the skin mobility, and the keratinization that you are contesting. Those items are real structural and functional changes. I am circumcised and I can understand those changes now. I don't talk about them to make circumcised males feel bad (I would have to start feeling bad about myself). I mention those points because they are real and objective, and a reason not to circumcise babies.
Perhaps some males don't want those structures and functions. But that's a choice that adult males should do (or not) over their own bodies, with understanding and proper information. Not something that parents should impose on babies.
I think it's dishonest and ethical to tell parents that circumcision is not going to affect their babies' sexuality, and then go and cause damage to the frenulum and remove the mobility of the skin. Medical professionals should know better than that.
As circ, done properly, does not affect sexual function or performance, it follows that removal of the frenulum or the wrinkly bit at the end (the so-called "ridged band") do not constitute harm. Nor is it clear if the skin mobility is truly a "function" or just a property. Circ'd men get by very well with reduced mobility. Only if it is so immobile as to impede erection or masturbation, would it be an issue. Why should circ affect sexuality? Sexuality refers to a person's orientation (hetero, homo or bisexual). I assume you mean sexual function, but circ (done properly) does not affect that. To tell parents otherwise is dishonest and unethical. Thankfully many medical professionals know that.
Delete"As circ, done properly, does not affect sexual function or performance"
DeleteYou are assuming to be truth exactly the point that we are debating, so this assumption does not work at this point.
"it follows that removal of the frenulum or the wrinkly bit at the end (the so-called "ridged band") do not constitute harm"
It is harm, whether it is recognized as such or not by the individuals. If I steal something from your home and you don't realize it, I still stole something. The frenulum has been admitted to be a very sensitive area by many males. It's destruction then should be recognized as harm, even if males without frenulum can still reach orgasm.
"Nor is it clear if the skin mobility is truly a "function" or just a property."
It's not clear to those who have not experienced it. A person with 4 fingers in a hand can still grab things, but the loss of one finger is harm nevertheless.
"Circ'd men get by very well with reduced mobility."
Which is why the American market for personal lubricants is a good business. But if reaching orgasm is your measure of "getting by very well", yeah.
"Only if it is so immobile as to impede erection or masturbation, would it be an issue."
And that is the case for many males who were circumcised as newborns. So is their harm and suffering worthless or irrelevant?
"Why should circ affect sexuality? Sexuality refers to a person's orientation (hetero, homo or bisexual). I assume you mean sexual function"
I meant sexual experience. Sexuality as a whole, not sexual orientation.
"but circ (done properly) does not affect that."
Due to miscommunication, this statement does not apply.
"To tell parents otherwise is dishonest and unethical. Thankfully many medical professionals know that."
Ok, I was snarky and you were snarky. Parents are not aware that: the frenulum is going to be impacted, the ridged band is going to be impacted, the skin mobility is going to be impacted and the glans is going to be impacted. This is what circumcision does, and I say it's harm and it changes the sexual experience, and you say it's not harm -and that you don't have evidence of whether it changes the sexual experience. Should parents decide this for their son? Or should their son decide based on his own experience of his own body?
One of the two is an open-future proposition, the other one isn't.
I am not assuming "to be truth exactly the point that we are debating". That would be circular. I'm basing it on the peer-reviewed literature (Tian et al, & others). The scientific evidence is clear. Properly done circ really has no significant effect on sexual performance or pleasure. Happily this is consistent with my own personal experience (although I always prefer science over subjective personal experience).
DeleteWe have different views about what constitutes harm. I've had a few teeth extracted - four when I was 11 to relieve overcrowding. Is this harm? I don't miss them, but have irrecoverably lost them, plus whatever sensations (probably just pain) I would ever have had from them. Likewise for those who've lost tonsils or appendix. Done properly, losing a 4skin results in only the most minimal harm. There's a slight scar (sometimes not even perceptible) but the parts that have gone (skin, wrinkly bit, frenulum etc) are really not very important, despite the exaggerations of intactivists. And this minor "harm" is offset by the benefits (you know them, even if you deny them).
I'd rather lose a 4skin than a finger any day (in fact I did). Your comparison is ridiculous. I would miss a finger badly, like right now typing this. I have never missed my 4skin (and where the frenulum was is still delightfully sensitive). Your lack of 4skin experience also shows in your comment about lube. Circ makes the use of lube easier and better, that's all. You just don't get the full effect with a 4skin in the way.
Of course frenulum etc are going to be "impacted" in that they are going to be removed (hopefully not the glans as well). I thought that was obvious. What I dispute is that it actually makes any significant difference to sexual pleasure and function. The best evidence indicates it doesn't.
I'm not into advocacy for routine infant circ, and in an ideal world the son would decide when old enough. But this is not an ideal world. Like it or not, there really are benefits to being circ'd, and they are more and greater if it is done in infancy. There are also cost, practical and medical reasons for why infancy is the best time. Those are just facts, but one can debate about whether infant circ wins a cost/benefit analysis. In a high-HIV country it certainly does. But does it elsewhere? AAP says "Yes", other bodies say "No". There is no consensus, so I stay out of it. I would suggest, however, that whether baby should be circ'd should be decided on evidence, and the best interests of the baby, not dogmatic ideological notions about "bodily integrity".
You ignore what I said in my post. As well as indirectly assessing sensitivity, some studies Tian et al looked at DID assess it directly. It was discussed by Tian et al and they concluded circ has no adverse effect. You also shoot yourself in the foot. If poor sensation quality means a guy has to thrust for half an hour then that would show up as orgasm difficulty. As I said, Tian looked at orgasm difficulty and found circ has no adverse effect. Therefore circ has no adverse effect on sensation quality, using your own argument.
ReplyDeleteThe Danish study you claim links circ to female dyspareunia suffered from participant bias, being based on a self-selected convenience sample with a mediocre response rate.
If some circ’d guys are angry about their circumcision perhaps it is because they have been lied to by intactivists and thereby tricked into believing they have lost something significant and are now sexually crippled as a result.
You say, “an intact man will never want to give up his foreskin” except for medical or religious reasons. Wrong. I did, and I am far from alone.
For every Rocco Siffredi there are many others who say their adult circs were fine, even terrific (mine was a modest improvement). Even so, I prefer peer-reviewed science to anecdote. And the science does not support your caims.
I assume you mean “sexual function” not “sexuality”. I had a “facepalm” moment when I read your line “the fact that telling this to circumcised men causes angst is already an indication that there is truth in it”. NO IT DOES NOT. It indicates that most men have nothing to compare with, and are ignorant of the science, so can easily be misled by scientific-sounding arguments. They don’t realise they are being bullsh!tted.
Immerman & MacKay’s highly speculative article merely parrots the keratinization claim. It provides no data to back it up, not even a reference to a primary source. Nothing. I asked for “actual measurements on stained sections of glans skin examined down a microscope”. Please show me some.
Done properly, circ does NOT have adverse effects on sexual function. To go around claiming that it does on the basis of myths, poor-quality studies, anecdotes and sloppy logic is dishonest and unethical.
I haven't been able to find a reference showing the keratinization. There are a lot of pictures on the internet comparing the glans of a circumcised and of an intact organ. However, I claim that keratinization is the least of the worries. It is the lack of the foreskin, an organ designed to detect stretching, that causes the biggest loss of sensitivity. I like in particular the study by Sorrells et al (2007) "Fine-touch pressure thresholds in the adult penis". They did measurements of sensitivity and also they have a long discussion of the existing literature. The review by Tian et al might rely on biased studies.
DeleteYou don't say why you got rid of your foreskin. But, in any case, that was *your* choice. If this is what you believe, fine. Just don't do it to babies!
The reason you cannot find a reference proving keratinization is because there isn’t one. The claim about keratinization, like the “20,000 nerves” figure, is an urban myth. It just gets repeated over and over without question. Doesn’t it worry you that intactivists rely so heavily on claims that are without any basis in fact? Pictures on the internet can be cherry-picked, even Photoshopped. The way to determine the degree of keratinization is to take skin samples, stain them, and look at them down a microscope. The only attempt to do this, comparing circ’d vs uncirc’d was by Szabo & Short: http://www.bmj.com/content/320/7249/1592 They only looked at about half a dozen of each, but could find no difference. And that’s it! I can find no other study. So what scant evidence there is indicates that there is no difference in keratinization. Until more evidence comes to light I suggest you refrain from using this claim again, and correct others who do. It is only causing unnecessary angst to circ’d men.
DeleteYou clearly have not read Tian et al. If you had you’d know they conducted an extensive literature search and narrowed the resulting 183 hits down to 19, then 10, because many of those 183 were, variously, about female “circumcision”, gay sex, had insufficient data, were duplications etc. The ten that remained were, therefore, the best and most relevant. They were: the two African ones (RCTs, the “gold standard”), the Danish one you mentioned earlier, Waldinger et al 2009, Senol et al 2008, Richters et al 2006, Masood et al 2005, Senkul et al 2004, Shen et al 2004 and Laumann et al 1997. If you want the full refs let me know. As some of these are oft cited by intactivists they are, if anything, biased against circ. Yet taken in aggregate they find no overall adverse effect.
It is ironic you worry about biased studies. The study you like, Sorrells et al, was by prominent intactivists! It attracted a detailed technical rebuttal (by Waskett & Morris) in which it was pointed out that, amongst other failings, they had failed to carry out a Bonferroni correction for multiple comparisons. When this is done the supposed effect disappeared. Another inactivist, Hugh Young then weighed in with an attempted counter-rebuttal, but he misunderstood the purpose of W&M’s table, and was simply wrong about the need for a correction. There are multiple comparisons, each has a p-value, there’s one p-value for each hypothesis, therefore there are multiple hypotheses. A correction is therefore appropriate. J&W’s use of Williamson & Williamson was not misguided, it still had a usable sample of 24. Young then resorts to anecdotes, and various fallacies, like, “That the foreskin itself has a sexual function was well-known for centuries before secular circumcision became widespread” (appeal to tradition fallacy – “it has always been known, therefore it is true”).
Even if we allow Sorrells (and clearly I don’t) the whole thing is a red herring anyway. It is not fine-touch that matters. It is stimulation of genital corpuscles, which are abundantly present in glans & shaft, but not the foreskin. Perhaps this explains why, when asked which part of their penis gives the most pleasure, men rank the glans first and foreskin last: http://www.ncbi.nlm.nih.gov/pubmed/19245445
Do you see now why I do not buy into the notion that circ damages sexual function? It does NOT. Telling circ’d men over and over again that it does only causes them distress, and that is false, cruel and dishonest. That is one of the reasons I dislike intactivism. (Another is their denialism about circ and African HIV). And this criticism of intactivism is valid, irrespective of the rights or wrongs of routinely circumcising babies – something I do not advocate for.
Keratinization is not a urban myth, nor an intactivist claim.
DeleteAssuming that you prefer the pro-circumcision site circlist, you can find this claim there:
"The epidermis, which includes the glans of your penis, is divided into several layers where cells are formed through mitosis at the innermost layers. They move up the strata changing shape and composition as they differentiate and become filled with keratin. They eventually reach the top layer called stratum corneum and become sloughed off, or desquamated. This process is called keratinization and takes place within weeks all over the body, including the glans of the uncircumcised male. Why do you think uncircumcised men have smegma (cock cheese)? They secrete an oily substance called sebum that is made of fat (lipids) and the debris of the sloughed off keratinized cells, that all mix to become smegma. If the glans of the uncircumcised man was not keratinized his smegma would be quite different. So don’t worry about keratinization. It is a scare tactic. Your glans will dry out and become very smooth to the touch rather than sticky the way it likely is now. But your sensitivity will be exquisite and you will enjoy sex as much or more than before you were circumcised." http://www.circlist.com/considering/sensitivity.html
Keratinization was also known to the original promoters of medical circumcision. See claims about the "leathery" texture:
"I suggest that all male children should be circumcised. This is "against nature," but that is exactly the reason why it should be done. Nature intends that the adolescent male shall copulate as often and as promiscuously as possible, and to that end covers the sensitive glans so that it shall be ever ready to receive stimuli. Civilization, on the contrary, requires chastity, and the glans of the circumcised rapidly assumes a leathery texture less sensitive than skin. Thus the adolescent has his attention drawn to his penis much less often. I am convinced that masturbation is much less common in the circumcised. With these considerations in view it does not seem apt to argue that "God knows best how to make little boys."
[R.W. Cockshut. Circumcision. British Medical Journal. 1935;2:764.]
From Parenting in America: An Encyclopedia, Volume 1 (by Lawrence Balter (Dec 1, 2000), a book that is not anti-circumcision):
"When the foreskin is removed, the surface of the glans becomes thickened (keratinized). This adaptation of the glans to environmental exposure provides some protection akin to that of a condom. Debate continues whether keratinization of the glans works to protect the penis against infection more effectively than does the intact foreskin. Even less clear is the effect of the absence of foreskin on sensation. Some reports by men circumcised later in life indicate a significant decrease in perceived sensation to touch over the glans after the procedure, compared with the level of sensation to touch perceived before the procedure."
Source: http://books.google.com/books?id=d5TqV3A3xWwC&printsec=frontcover#v=onepage&q=keratinized&f=false
Circinfo also mentions the keratinization of the glans as one of the reasons why circumcision would reduce the risk of STDs:
"Circumcision does not prevent V.D. but men who are circumcised, or have naturally short foreskins, are less likely to become infected than those with long foreskins. The protection afforded is due to the toughening of the glans and the dry conditions which are unfavourable for the growth of germs."
Conclusion: Keratinization is not a urban myth, nor an invention from anticircumcision activists. Keratinization is a documented process of which both intactivists and circumcision promoters are aware.
Regarding Morris and Waskett's "rebuttal" of Sorrells' study, have you read it?
DeleteIn order to rebutt the study they remove the columns corresponding to the measurements taken on the foreskin. This is completely spurious. You don't measure differences by eliminating the differences.
The Bonferroni correction may be used to eliminate false positives, but it also carries the risk of introducing false negatives ( http://en.wikipedia.org/wiki/Bonferroni_correction#Criticisms ). That is the problem with improper use of statistics. If you change the statistical model you can alter the conclusions without altering the data.
The foreskin having sexual functions is widely known except in countries where circumcision is prevalent. A man who can't glide the skin over his glans is missing a sexual function, there is no debate about it. James Badger, a member of circlist, performed a poll about the effects of circumcision on masturbation ( http://www.circlist.com/surveys/badger-06.html ). His conclusions support that circumcised males and intact males have different masturbation techniques, which he describes as "preferences". He says: "natural men like pumping the skin, especially moving it back and forth over the glans". Well, it's not that circumcised males don't like to do that, it's just that they CAN'T do that. And if they can't do that, then there has been a loss of function, a harm caused by design.
Males undergoing foreskin restoration become capable of gliding the skin over the glans again. Any of those males will tell you the difference that it makes.
Oh you also say that we are in denial over circumcision and HIV.
DeleteIt is documented that the new infections in Zimbabwe during 2010-2011 were more prevalent among circumcised males than among circumcised males. And just last week there was a report showing that circumcision has failed to reduce the rate of new infections in Nyanza.
Maybe the real world is also in denial.
None of the references to keratinization you cite provide any experimental data to substantiate the claim. Therefore it remains unfounded. It is true that it has been around a long time, and that even circ proponents have claimed it (as a supposed advantage of circ!), but that still does not make it true. Until someone actually does the measurements, on stained, sectioned samples of glans skin, and proves a difference, I am justified in dismissing it as an unproven myth. Szabo & Short remain the only ones to have done this, and they found no difference. I note that intactivist John Taylor acknowledges (in the FAQ section of his website) that keratinization is "probably not to any significant extent".
DeleteI have Sorrells, W&M's rebuttal, and Young's counter-rebuttal all on my computer. Like Young you miss the purpose of W&M's table. They were trying to show p-values for same-point comparisons. Therefore it could not include points present on only one or other type of penis. These were discussed in the text, and did not need a table, as one was already provided by Sorrells. Bonferroni correction is standard when multiple comparisons are being done. There is nothing improper about using it.
Circ is no impediment to masturbation, as millions of males know (up yours Kellogg!). In fact it opens up alternative options (lube is so much better than when a 4skin is in the way), so it is questionable if the ability to get skin over the glans is really a function, or just a property. As long as there is enough movement in the shaft (and there nearly always is) "pumping" is easily, and enjoyably, done. Besides, some guys like to do it with 4skin back.
Re restored males. Their accounts are anecdotal, and likely represent placebo effect at work. Besides, there are cases of restored males getting circ'd again. Placebo does not work for all, it seems.
You do not provide your source for your claim about Zimbabwe, so I cannot verify it.
If your source for your claim about Nyanza is the Kenya AIDS Indicator Survey 2012, then you are cherry-picking one bit that suits your agenda, and ignoring all those that don't. Nyanza has the highest HIV prevalence by far of Kenya's regions (14.9 % in 2007, 15.1 % in 2012), but the lowest incidence of circumcision. Even though circ in that region has increased by 18 % over those 5 years, at 66 % it still falls well short of the current >90 % in all other regions. HIV has fallen, often dramatically, in all but one other region (excluding North Eastern for which there is no data). The increase is just 0.2 % (same as for Central region, the only other where it increased). Which begs the question how much greater would it have been without circ? Without a control you cannot say. We do not know how that increase breaks down in terms of circ'd vs uncirc'd men. But the implication from figure 10 is that most of those new cases will be in the remaining 34 % uncirc'd men. In 2007 uncirc'd Kenyan men were 3.4 times more likely to get HIV than circ'd ones. In 2012 the disparity had risen to almost 5.5. In short as medical circ is rolled out the protective effect increases (previously many circ'd men will have suffered, and I mean suffered, barbaric ritual circs which are dangerous and can actually spread HIV). The only other people I have debated who share your ability to cherry-pick a single detail that fits their agenda, whilst ignoring overwhelming contrary data in the same article, are creationists. Truly, you are in denial.
I already explained why the bonferroni correction makes a difference. And I insist that if a point is not present in the circumcised penis but is present in the intact penis, the correct action is not to erase the existing data, but to assume that the non-existing data is 0/Null (there is no sensitivity in parts of the body that are not present).
DeleteI agreed that circ. is not impediment to masturbation, yet it can make things more difficult for some. See this person's dilemma in a body building forum: http://forum.bodybuilding.com/showthread.php?t=145757911&page=1&welcome=true
It does not however, open alternatives. An intact male can masturbate with lubricant if he so desires. A circumcised male cannot masturbate by gliding the skin. Whether lube is better than gliding or not, is a subjective appreciation, and one that shouldn't be restricted by parental preference - destroying one possibility.
Some guys may like to do it with foreskin back, but circumcised males cannot decide to do it with foreskin forward. See the dilemma?
"Cases of restored males getting circumcised again". You probably mean ONE case that has been loudly spoken about.
Placebo? Maybe. But also differences in stimulation. In my other comment I mentioned that gliding produces a squeeze and release action on the glans. This is a different way of stimulation. It also causes the foreskin to stimulate the corona and viceversa.
The Zimbabwe articles were in some news websites, and those unfortunately seem to remove articles after a couple of months. But let's not get distracted again on a different topic. I hope HIV prevalence decreases in Africa very soon, Voluntary Male Medical Circumcision programmes in action or not. Human lives are more important. And definitively traditional circumcisions have far worse chances of complications, pain, suffering and death, than medical ones.
Personally, I look forward to HIV vaccines, so Morris can retire his "surgical vaccine" postulate.
Of course a Bonferroni correction makes a difference - it eliminates false positives!
DeleteDo you know of credible studies (not the amateurish Korean one by Kim & Pang, before you mention it) looking into the effects of circ on hand jobs? There are informal surveys, opinion polls and personal testimonies galore, but few proper studies. I note one Australian one (http://www.ncbi.nlm.nih.gov/pubmed/?term=Circumcision+in+Australia%3A+further+evidence+on+its+effects+on+sexual+health+and+wellbeing.) found that circ'd men are actually more likely to masturbate! No one has even looked at this gliding motion we read so much about. Some men have short 4skins that retract naturally upon erection and stay back until proceedings have concluded, then return forward again. Do they complain? Would the lack of gliding be compensated for by the more direct stimulation received by the bare glans?
I can understand why someone with a very tight circ will be more restricted in what techniques he can use, but then there are guys who actually like it tight (I even met one once who went and got his tightened up, because the original wasn't tight enough!) If tightness is an issue then perhaps a little partial restoration, at least to provide some slack, might be helpful. I have yet to find convincing evidence that circ, done properly, diminishes ease or pleasure of masturbation (certainly didn't for me). And I have yet to meet a circ'd guy complain about difficulty jacking off (at least the 20 or so I've asked, in my own informal "poll", though its not a topic I can easily broach!) It does seem an area that would benefit from more research.
Which is the "ONE case" of a restorer recircumcising you had in mind?
I wonder if those Zimbabwean circs were traditional ones? That would explain their reduced effectiveness. I am vehemently opposed to African-style traditional circs, which I regard as brutal, barbaric and insane. they should be banned immediately. I also wish there was an effective HIV vaccine, but am not optimistic. It is proving a very intractable virus. Until then, medical circ is one of the best weapons we have and should be deployed, along with the "ABC" approach (Abstinence, Be faithful, Condoms). And intactivists should not be getting in its way.
It's good that you don't advocate for that :)
ReplyDeleteSzabo et al compared the glans of 7 circumcised vs 6 intact men. Sorry, you can't really draw any conclusions from that.
You should be able to find better comparisons in this book:
Barreto J, Caballero C, Cubilla A. Penis. In: Sternberg SS, ed. Histology for pathologists. 2nd ed. Philadelphia: Lippincott-Raven, 1997.
I don't have access to it right now, but if I find it in the library I can scan it for you or something.
Also, the review by Cold and Taylor "The prepuce" (1999) BJU (83) 34-44 gives a nice overview of the elements of the foreskin, like nerve endings, blood vessels, dartos muscle, ridged band, etc. In other words, circumcision removes an entire sexual organ. Cold and Taylor's review contains 104 references, have fun!
Also, you try to convince us that there is no difference between being circumcised or intact concerning sexual function. Why did you get circumcised then?
Also, I am confused by the review by Szabo and Short (2000). They say "... but we have examined the glans of 7 circumcised and 6 uncircumcised men, and found the epithelia to be equally keratinized." WHERE??? They do not provide any reference to the data. Also, what does it mean "equally keratinized"? The glans always has a keratin layer, whether intact or circumcised, but the question is how thick? Szabo et al say nothing about the thickness and do not show the data, letting us wonder :(
DeleteAnd in the methods, they say: "samples of penile tissue obtained from 13 perfusion fixed cadavers of men aged 60 to 96 years". Gimme a break! It's a shame that this irrelevant article gets cited over and over again.
DeleteYou miss my point about Szabo & Short. The point is that theirs' seems to be the ONLY attempt to actually measure and compare the two states. And they found no difference. I acknowledge the weaknesses - I said they only looked at about a dozen samples, and I said "what SCANT evidence there is" (emphasis added). In short there is NO evidence (i.e. actual measurements) to indicate that the glans gets keratinized. And what little evidence there is (which has its weaknesses, as discussed) suggests otherwise. A claim without evidence can be dismissed. The claim that the glans gets keratinized following circ is without evidence, therefore I am justified in dismissing it until such time as evidence that it actually occurs comes to light.
ReplyDeleteI look forward to your perusal of Barreto et al. If it does contain actual measurements I'd like to know what they are please.
I have Cold & Taylor 1999. Skin itself is an organ, and any piece of it is likely to be full of nerves, blood vessels, dartos muscle etc. Spend enough time peering at it though a microscope and you could write volumes on what you see - as has been done. There is a whole field of medicine devoted to it - dermatology. But does that little extra bit on the end of one's manhood really matter as much as claimed? The evidence (e.g. Tian et al) suggests not. I find the "ridged band" name mildly amusing. It's the wrinkly bit at the end, where it has to be concertinaed to give it the stretchiness to get over the glans. But "wrinkly bit" doesn't sound as good, so intactivists give it a more "sciencey name" - ridged band. Parts of C&T are speculative. It was used by Lang in his recent opinion piece in J Med Ethics. My eLetter in response "Sloppy scholarship and the anti-circumcision crusade" may be read here: http://jme.bmj.com/content/39/7/429/reply#medethics_el_16627
You may also find my response to Hill of interest: http://jme.bmj.com/content/39/7/431/reply#medethics_el_16565
I am ambivalent about infant circ. I won't stand in the way of it if done medically, but won't advocate for it either. There is a strong case to be made in high-HIV countries. Elsewhere the absence of a medical consensus is one thing that keeps me away from advocating for it. AAP thinks it wins a cost/benefit analysis. Other bodies disagree. So I'll let the medics battle that one out. But I will answer sloppy arguments against it (and even for it - I cringe when I hear people say they want baby circ'd "to look like dad". The words, "fat, bald and ugly" come to mind). It's an important issue, and bad arguments don't help settle it. My main concern is the damage intactivists are doing by making circ'd men needlessly miserable, and by undermining an important public health measure in high-HIV countries (and, arguably, elsewhere).
My own story, of my roughly 15 year journey from fierce foreskin defender, to grudging acceptance that circ may not be a bad thing, to thinking it a good thing (done properly), to wanting it done but not being able, to finally finding a way of getting it done, is too long to tell here. Suffice to say I had 30 years with, and now 20 years without, and I prefer without.
Szabo et al, just because they say that they measured it, has no value if they do not show the results. They might have done a very sloppy job. Maybe they saw that there is a difference and decided to not share the data. In any case, claiming something and not showing the data is suspicious and worthless.
DeleteI don't believe the claim that circumcision prevents HIV. I read all three RCTs done in Africa. I'm not sure that any conclusions can be drawn from their data. This is because it is not clear how frequently and when men were using condoms. It relies on self reports but those seem to be vague. If a man wears a condom, theoretically the chance to get infected is 0%. In order to draw conclusions, they should have compared the number of coituses without condoms performed by circumcised men with the number of coituses without condoms performed by intact men. Simply counting how many circumcised men got infected and how many intact men got infected has no value. Ideally, the men should have kept a log after each sex act notating use of condom, whether oral sex etc. They should have also kept a log how many times they were going to a clinic and why. The analysis should have been much more accurate. The studies were done kind of sloppy. Also, there are other pathways how to get infected. The study was also not blind folded. All these issues are commented on in PLoS Medicine. Enforcing a health policy based on dubious data is unethical.
As to your story. There are also women who decide to have their clitoral hood removed for aesthetic reasons or their internal labia trimmed. I know that many women have a very sensitive clitoris and for them removing that protective tissue would not be thinkable. So, everybody is different and it is because everybody is different that one should give it the benefit of the doubt and don't enforce it on babies or bully men in countries with high HIV prevalence into it.
You are too dismissive of Szabo & Short. Whilst it would have been nice to see more data, for them it was almost incidental. They mentioned it and moved on to other things. But even if we discount Szabo & Short, the fact remains that there is just no evidence (as in actual measurements) that the glans becomes keratinized. It is just a myth that gets repeated over and over again, without challenge. In fact even circ proponents buy into it! It has been around that long, but not challenged. It is time it was. At least one prominent intactivist does doubt it. From the FAQ section of John Taylor's website: http://research.cirp.org/faq1.html
ReplyDelete"Probably not to any significant extent. There is a slight increase in the thickness of the glans epithelium due to exposure to clothing." But he provides no data. He says it is doubtful if this alleged "slight increase" interferes with perception of those stimuli the glans can detect.
Your attitude to the African trials is just denialism. There is no reason to suppose there was any difference in condom use between the two groups in each of the three trials. Other criticisms are answered here: http://www.ghdonline.org/uploads/JLM2012_Male_circ_does_prevent_HIV_infection.pdf Circ does protect against HIV. Get used to it.
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DeleteSorry, posting for the 3rd time for clarity...
DeleteAs I mentioned before, recent news show that new infections in Zimbabwe 2010-2011 were more prevalent among circumcised males than intact males, and increasing rate of circumcision in Nyanza has failed to decrease the rate of new infections.
It is verifiable (CIA data) that Latin American and European countries have less prevalence of HIV than the U.S. in spite of lower rates of circumcision. Same with HPV.
In other words, all the theory can be awesome, can be great, but if results are not visible then what is there to deny?
If adults want to get circumcised and they think that it will help them prevent HIV, all the power to them. That was what VMMC meant after all, right? Voluntary Male Medical Circumcision -emphasis on "voluntary". Better in a medical setting than in the bush!
But children are not volunteers.
Assuming that circumcision was an appropriate way to prevent HIV, it would still not justify implementation on newborns who cannot consent, who are not sexually active, and who may wish differently once they grow up. The WHO recognizes this issue of consent.
And assuming that the data from Africa was sound, it would still not apply to different populations with different circumstances.
Personally, as an adult I feel that I have control over my lifestyle. If I was graced with a foreskin I wouldn't give it up for HIV prevention, as I am not a promiscuous person and I favor the use of condoms. But I'm not going to keep anyone from taking their own conscious decisions in this matter.
But this blog entry was not about HIV.
So we are discussing keratinization. People in this debate often get locked in semantics and words.
There is a known process that takes place on the surface of the glans. I don't know the exact nature of this process. Whether the glans becomes dry (lack of moisture of the subpreputial space), or thicker (slightly or not), or the composition changes, that's something I don't know and I would rather leave it to the experts to explain it. But what is undeniable is that there is a visible difference.
The best comparison I have is the surface of the lips. The part outside the mouth has a different texture from the part of the lips that remains inside the mouth when it is closed. You can see the transition from one area to another. In fact, under certain weather, the outer side of the lips can crack due to dryness. That's why there is chapstick, and why some people often lick their own lips to keep them moist.
The glans of the intact male is more like the inner side of the lip, while the glans of the adult circumcised male is more like the outside of the lips. Is it chemically different? I don't know. Thicker? Just dried out? I don't know, but I can see it.
Does it affect sensation? Maybe, or maybe not. Maybe there's only a slight difference between one type of glans and the other. Payne et al, and Sorrells et al, are not so different in method. The main difference is that Sorrells measured also sensitivity on the foreskin and Payne did not. What Sorrells says is that some areas of the foreskin detect soft-touch faster (easier) than the glans.
Of course there are anecdotal reports from males undergoing foreskin restoration (I know, Brian Morris thinks they are crazy and need psychological help). However the phenomenon is more complex than that, as males with some level of restoration also recover the mobility of the skin, so regardless of whether the glans is more sensible or not, the stimulation is different because the mechanics of the penis are different, so even if the sensitivity of the glans was the same, the different mechanics could explain the reported change in intensity of sensation.
After all, with skin mobility, the new "foreskin" squeezes and releases the glans every time it glides over it. This is a part of the stimulation not available to those who don't have a foreskin, and this could likely explain part of the difference.
I answered your comment about Nyanza in detail earlier.
Delete"Latin American and European countries have less prevalence of HIV than the U.S"
USA has 0.6 %
Latin America: Belize 2.3, El Salvador 0.6, Guatemala 0.8, Guyana 1.1, Honduras 0.7, Panama 0.8, Suriname 2.4, Uruguay 0.6
Europe: Estonia 1.3, Latvia 0.7, Portugal 0.7, Ukraine 0.8
(WHO data, 2011).
Keratinization is quite clear - it refers to an increase in thickness of the keratin layer on the epidermis. Not mere drying out or subtle changes in skin tone. It can be measured by staining and sectioning skin, and looking at the section down a microscope. As yet there is no such evidence it occurs. Until it does, intactivists (and even their opponents!) should desist from making the claim.
Nor is there good evidence that sensation is affected. What there is indicates probably little, if any, effect. I also suspect that the sensation issue (by which I mean specifically the fine-touch sensation, or "soft-touch" as you call it) is something of a red herring. It is genital corpuscles that convey sexual pleasure, not Meissner's corps (which are the fine-touch ones). There are plenty of genital corps in the glans and shaft, but I've yet to see convincing evidence they are present at all in the 4skin.
I'd be concerned if a 4skin "squeezes and releases the glans every time it glides over it". It would have to be tight to do that, and then it would cause problems. If it is slack enough to glide then it will not "squeeze and release". It will simply glide and do little else. If gripped by a hand then squeezing/releasing will occur (from the pressure of the grip), but something similar (at least I find it feels much the same, and just as good, perhaps slightly better) is got by the hand banging into the corona when exploiting the residual mobility of the shaft skin.
Must sign off now. It's late in my time zone.
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ReplyDeleteHmmm, Steve660 looks like the same Stephen here:
ReplyDeletehttp://www.spectator.co.uk/features/9055801/the-first-cut/
I see the ardent pro-cutter is hard at work. Or perhaps it's Jake Waskett in disguise. :p
Apcalis is the one product produced by Exact Pharma for the treatment of ED, which stands for Erectile dysfunction, the male sexual disorder.
ReplyDelete