Thursday, 21 July 2011

Sexual satisfaction & circumcision: latest from IAS 2011

The International AIDS Society's 2011 meeting has now concluded, and — as is often the case these days — there some interesting presentations.

Of particular interest are two abstracts: Breda and Westercamp et al.

In Uganda, Breda reports on a study of 316 adult circumcision patients:
Compared to before circumcision, 87.7% (193/220) reported ease of reaching orgasm as “better”; 92.3% reported sexual satisfaction as “better”; 97.7% and 95.4% were satisfied with and thought their partners satisfied with their appearance, respectively.

In Kenya, Westercamp et al reported on a study of 1016 adult circumcision patients:
Men reported a higher overall level of satisfaction with intercourse after circumcision (71% vs. 87%, p< 0.0001). 54% of men reported their penis being much more sensitive and 36% reported reaching orgasm much more easily 6 months after circumcision.

Also, sexual dysfunctions (for two weeks or more) decreased:
inability to climax (20% vs. 16%, p=0.007), finding sex not pleasurable (31% vs. 24%, p=0.0005), and lack of interest in sex (45% vs. 39%, p=0.008).

And fewer penile traumas were reported (consistent with Mehta et al):
At 6 months, men reported experiencing fewer problems with reproductive health in the last 6 months compared to baseline: painful urination (10% before vs. 7%, p=0.008), difficulty passing urine (7% vs. 4%, p=0.01), and sores around genitals (7% vs. 4%, p=0.002). Similar reductions were found in measures of penile trauma in the preceding 6 months: pain during intercourse (15% vs. 8%, p< 0.0001); scratches, cuts, abrasions during sex (24% vs. 6%, p< 0.0001); and bleeding during or after intercourse (10% vs. 3%, p< 0.0001).

These studies add to the growing body of evidence showing that circumcision does not harm, and may well improve men's sexual experience.

As far as I can tell, neither study reports on RCT data; instead, both report on prospective study of patients circumcised as part of subsequent circumcision programmes in the same locations. Hopefully both studies will be published soon.

Tuesday, 12 July 2011

The so-called "lost list"

Although less prominent these days, I still find that people occasionally cite the "lost list", seemingly unaware of its inaccuracies. For those unfamiliar with it, this is a list of structures or functions supposedly lost through circumcision.

A number of different versions can be found on the Internet, but they're very similar. The text below is taken from NORM-UK. My comments are in italics.

The Foreskin which comprises up to 50% (sometimes more) of the mobile skin system of the penis. If unfolded and spread out flat the average adult foreskin would measure about 15 square inches( the size of a 3x5 inch index card).

This is a gross exaggeration. First, one study has actually measured the surface area of the adult foreskin; it found an average surface area of 36.8 square centimetres (that's 5.7 square inches). (I previously stated that this was the only study. I was mistaken. A second study, with a small sample size, does exist. It reported an average surface area of 46.7 square centimetres, or 7.2 square inches.) Second, as I recently showed in my critique of Barefoot Intactivist's propaganda, it is reasonable to estimate that the foreskin constitutes 14% of the penile skin system. Using the surface area figure from Werker et al., that's 18% — still less than half of the extraordinary 50% figure.

This highly specialized tissue normally covers the glans and protects it from abrasion, drying, callusing (also called keratinization), and contaminants of all kinds.The effect of glans keratinisation has never been studied.

This sentence is dubious in many ways. The most obvious is the statement that the foreskin protects the glans from keratinisation — the only study in the literature to have examined keratinisation by circumcision status found no differences between the level of keratinisation of the circumcised and uncircumcised glans. Less obvious, but still troubling, is the implication that the circumcised glans is susceptible to abrasion or "contaminants". No evidence is cited in support.

[1. M. M. Lander, "The Human Prepuce," in G. C. Denniston and M. F. Milos, eds., Sexual Mutilations: A Human Tragedy (New York: Plenum Press, 1997), 79-81. 2. M. Davenport, "Problems with the Penis and Prepuce: Natural History of the Foreskin," British Medical Journal 312 (1996): 299-301.]

Note that only two sources are cited. One (Davenport) is peer-reviewed but does not support any of the claims attributed to it. The other (Lander) is a non-peer-reviewed paper presented at an anti-circumcision conference, which doesn't inspire confidence.

The Frenar Ridged Band, the primary erogenous zone of the male body.

When I see a claim like this, I immediately wonder: who established this, and what was the study methodology? The cited source (Taylor, see below) established nothing of the sort. While a small number of studies have investigated sensitivity to non-sexual stimulus, only one study, to my knowledge, has investigated the relative degree of sexual pleasure produced by various parts of the anatomy. That study (which was unfortunately limited by the small number of uncircumcised men) found that the foreskin actually produces the least sexual pleasure of any part of the penis.

Loss of this delicate belt of densely innervated, sexually responsive tissue reduces the fullness and intensity of sexual response.
[Taylor, J. R. et al., "The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision," British Journal of Urology 77 (1996): 291-295.]

Note that the cited source says nothing of the sort! Its authors merely "postulate" that the "ridged band" is sensory tissue. They don't attempt to prove it, nor do they evaluate the effects of its removal on the "fullness and intensity" of sexual response.

The Foreskin's 'Gliding Action' - the hallmark mechanical feature of the normal natural, intact penis. This non-abrasive gliding of the penis in and out of itself within the vagina facilitates smooth , comfortable, pleasurable intercourse for both partners. Without this gliding action, the corona of the circumcised penis can function as a oneway valve, scraping vaginal lubricants out into the drying air and making artificial lubricants essential for pleasurable intercourse.
[P. M. Fleiss, MD, MPH, "The Case Against Circumcision," Mothering: The Magazine of Natural Family Living (Winter 1997): 36-45.]

Note that the only source cited for this claim is an opinion piece published in a magazine. It's an interesting hypothesis, but little or no credible evidence supports it.

[Indented box] Nerve Endings transmit Sensations to the Brain - Fewer Nerve Endings means Fewer Sensations

This simplistic model is faulty because the presence of nerve endings do not create sensations by themselves. Likely as not, your genitals are not buzzing with sensations as you read this, because they're not being stimulated. This means that the method and degree of stimulation is as important as the number of nerve endings. Put simply, a smaller number of nerve endings can produce just as much stimulation as a larger number, if stimulated more effectively. And this is effectively what circumcision achieves, by exposing the glans (especially the sensitive corona) to direct stimulation during intercourse, sensation is increased, compensating for the loss of sensation from the foreskin itself.

Circumcision removes the most important sensory component of the foreskin - thousands of coiled fine-touch receptors called Meissner's corpuscles.

Most important? Who established this, and what was the study methodology?

Also lost are branches of the dorsal nerve, and between 10,000 and 20,000 specialized erotogenic nerve endings of several types.

What is the source for this number? Neither of the two cited sources support it. In fact, having researched this in some depth, I feel quite confident in stating that no study has ever counted the number of nerve endings in the foreskin.

Together these detect subtle changes in motion and temperature, as well as fine gradations in texture.
[1. R. K. Winkelmann, "The Erogenous Zones: Their Nerve Supply and Its Significance," Proceedings of the Staff Meetings of the Mayo Clinic 34 (1959): 39-47. 2. R. K. Winkelmann, "The Cutaneous Innervation of Human Newborn Prepuce," Journal of Investigative Dermatology 26 (1956): 53-67.]

Again, the sources fail to support the claims attributed to them.

The Frenulum[.] The highly erogenous V-shaped web-like tethering structure on the underside of the glans; frequently amputated along with the foreskin, or severed, either of which destroys its function and potential for pleasure.
[1. Cold, C, Taylor, J, "The Prepuce," BJU International 83, Suppl. 1, (1999): 34-44. 2. Kaplan, G.W., "Complications of Circumcision," Urologic Clinics of North America 10, 1983.]

Neither of the cited sources actually supports these claims. This isn't terribly surprising because a) the frenulum's potential for pleasure is speculative, and b) the function of the frenulum, such as it is, is to hold the foreskin in place over the glans. Without a foreskin, then, it has no function.

Muscle Sheath[.] Circumcision removes approximately half of the temperature-sensitive smooth muscle sheath which lies between the outer layer of skin and the corpus cavernosa. This is called the dartos fascia.
[Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): Plates 234, 329, 338, 354, 355.]

"Approximately half" is of course an exaggeration, but it is true that the foreskin does contain this layer.

The Immunological Defense System of the soft mucosa. This produces both plasma cells that secrete immunoglobulin antibodies and antibacterial and antiviral proteins such as the pathogen-killing enzyme lysozyme.
[1. A. Ahmed and A. W. Jones, "Apocrine Cystadenoma: A Report of Two Cases Occurring on the Prepuce," British Journal of Dermatology 81 (1969): 899-901. 2. P. J. Flower et al., "An Immunopathologic Study of the Bovine Prepuce," Veterinary Pathology 20 (1983):189-202.]

The cited sources utterly fail to support these claims. The second is not even a study of the human prepuce, but rather that of the cow! While the foreskin doubtless contains the immunological functions of any skin, no special mechanisms are known.

Lymphatic Vessels[.] the loss of which reduces the lymph flow within that part of the body's immune system.
[Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): plate 379.]

This is really scraping the bottom of the barrel, but yes, removing skin does remove the lymph vessels within it.

Oestrogen Receptors The presence of estrogen receptors within the foreskin has only recently been discovered. Their purpose is not yet understood and needs further study.
[R. Hausmann et al., "The Forensic Value of the Immunohistochemical Detection of Oestrogen Receptors in Vaginal Epithelium," International Journal of Legal Medicine 109 (1996): 10-30.]

If confirmed, for that matter.

[Indented box] The Body is Well Designed - Altering it Surgically can only Disrupt it's Natural Function

This is more a statement of faith than a serious claim, but we can transform it into a scientifically testable hypothesis: surgical alteration of the body cannot produce positive effects. It seems almost trivial to show that it is false.

The Apocrine Glands of the inner foreskin, which produce pheremones -nature's powerful, silent, invisible behavioural signals to potential sexual partners. The effect of their absence on human sexuality has never been studied.
[A. Ahmed and A. W. Jones, "Apocrine Cystadenoma: A Report of Two Cases Occurring on the Prepuce," British Journal of Dermatology 81 (1969): 899-901.]

A serious problem with this claim is that apocrine glands are absent in the inner foreskin. Amusingly, one of the sources cited above (Taylor et al) says this: "the mucosal surface of the prepuce is completely free of lanugo hair follicles, sweat and sebaceous glands". Similarly, Parkash et al report: "Multiple small pieces were taken from the inner lining of the circumcised prepuce [...] A special search was made for glandular tissue. No such tissue was found in the material".

Sebaceous Glands which lubricate and moisturise the foreskin and glans, normally a protected and internal organ-like the tongue or vagina. Not all men have sebaceous glands on their inner foreskin.
[A. B. Hyman and M. H. Brownstein, "Tyson's Glands: Ectopic Sebaceous Glands and Papillomatosis Penis," Archives of Dermatology 99 (1969): 31-37.]

In fact, according to the studies cited above, no men have sebaceous glands on their inner foreskin.

Langerhans Cells Specialised epithelial Langerhans cells, a first line component of the body's immune system in a whole penis.
[G. N. Weiss et al., "The Distribution and Density of Langerhans Cells in the Human Prepuce: Site of a Diminished Immune Response?" Israel Journal of Medical Sciences 29 (1993): 42-43.]

The cited source actually states the opposite: that the foreskin is deficient in Langerhans cells.

Colouration[.] The natural coloration of the glans and inner foreskin (usually hidden and only visible to others when sexually aroused) is considerably more intense than the permanently exposed and keratinized coloration of a circumcised penis. The socio-biological function of this visual stimulus has never been studied.

Ignoring the keratinisation error, this seems to be rather desperate. The appearance of the penis is changed, so this is a loss?

Some of the penis length and circumference because its double-layered wrapping of loose and usually overhanging foreskin is now missing, making the circumcised penis truncated and thinner than it would have been if left intact.
An Australian survey in 1995 showed circumcised men to have erect penises an average of 8mm shorter than intact men.
[1. R. D. Talarico and J. E. Jasaitis, "Concealed Penis: A Complication of Neonatal Circumcision," Journal of Urology 110 (1973): 732-733. 2. Richters J, Gerofi J, Donovan B. Why do condoms break or slip off in use? An exploratory study. Int J STD AIDS. 1995; 6(1):11-8. ]

It should be noted that this Australian study is in fact the only study to report such a difference.

Blood Vessels[.] Several feet of blood vessels, including the frenular artery and branches of the dorsal artery are removed in circumcision. This loss of the rich vascularity interrupts normal flow to the shaft and glans of the penis, damaging the the natural function of the penis and altering its development. [1. H. C. Bazett et al., "Depth, Distribution and Probable Identification in the Prepuce of Sensory End-Organs Concerned in Sensations of Temperature and Touch; Thermometric Conductivity," Archives of Neurology and Psychiatry 27 (1932): 489-517.� 2. Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): plates 238, 239.]

It is quite likely that several feet are lost, as the human body has an extraordinary number of blood vessels (a typical estimate is that the adult human body contains 100,000 miles of blood vessels). The claimed consequences, however, are unsupported by the references cited.

Dorsal Nerves The terminal branch of the pudendal nerve connects to the skin of the penis, the prepuce, the corpora cavernosa, and the glans. Destruction of these nerves is a rare but devastating complication of circumcision. If cut during circumcision, the top two-thirds of the penis will be almost completely without sensation. [1. Agur, A.M.R. ed., "Grant's Atlas of Anatomy," Ninth Edition (Williams and Wilkins, 1991): 188-190. 2. Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): plate 380, 387.]

One wonders why such extremely rare, albeit possible complications are included, then. To pad out the list, perhaps?

Complications Every year boys lose their entire penises from circumcision accidents and infection. They are then "sexually reassigned" by castration and "transgender surgery" and expected to live their lives as "females". [1. J. P. Gearhart and J. A. Rock, "Total Ablation of the Penis after Circumcision with Electrocautery: A Method of Management and Long-Term Followup," Journal of Urology 142 (1989):799-801. 2. M. Diamond and H. K. Sigmundson, "Sex Reassignment at Birth: Long-Term Review and Clinical Implications," Archives of Pediatrics and Adolescent Medicine 151 (1997): 298-304.]

It may be an exaggeration to claim that this happens "every year", but cases have been reported, unfortunately.

Death Every year many boys lose their lives from the complications of circumcision, a fact the billion-dollar-a-year circumcision industry in the U.S. routinely obscures and ignores.
[1. G. W. Kaplan, "Complications of Circumcision," Urologic Clinics of North America 10 (1983): 543-549. 2. R. S. Thompson, "Routine Circumcision in the Newborn: An Opposing View," Journal of Family Practice 31 (1990): 189-196.]

Again, death does occur, albeit rarely. However, it would be foolish to consider such deaths in isolation. They should be weighed against deaths attributable to lack of circumcision. That is, if a million boys are circumcised, does this result in more or fewer deaths than if those boys are not circumcised. The evidence indicates that lives are saved.

Emotional Bonding[.] Circumcision performed during infancy disrupts the bonding process between child and mother. There are indications that the innate sense of trust in intimate human contact is inhibited or lost.

Who established this, and what was the study methodology?

It can also have significant adverse effects on neurological development. Additionally, an infant's self-confidence and hardiness is diminished by forcing the newborn victim into a defensive psychological state of "learned helplessness" or "acquired passivity" to cope with the excruciating pain which he can neither fight nor flee.

Who established this, and what was the study methodology? (How on Earth would one be able to prove such a thing? It looks suspiciously like an unfalsifiable statement: a product of pseudoscience, not science.

The trauma of this early pain lowers a circumcised boy's pain threshold below that of intact boys and girls. [1. R. Goldman, Circumcision: The Hidden Trauma (Boston: Vanguard Publications, 1997), 139-175. 2. A. Taddio et al., "Effect of Neonatal Circumcision on Pain Responses during Vaccination in Boys," Lancet 345 (1995): 291-292.]

Neurological Sexual Communication[.] Although never studied scientifically, contemporary evidence suggests that a penis without its foreskin lacks the capacity for the subtle neurological "cross-communication" that occurs only during contact between mucous membranes and which contributes to the experience of sexual pleasure.

What utter nonsense! How on earth would non-scientific evidence suggest such a thing? This appears to be nothing more than a wild theory, dishonestly presented as something suggested by evidence.

Amputating an infant boy's multi-functional foreskin is a "low-grade neurological castration" [Immerman], which diminishes the intensity of the entire sexual experience for both the circumcised male and his partner.)

So prove it. Should be trivial. Except, of course, that scientific studies of satisfaction, etc., don't support this claim.

Tuesday, 5 July 2011

Analysis of the Barefoot Intactivist's claims

A man calling himself the "Barefoot Intactivist" (BI from here onwards) has posted a "Response To Gordon Haber's Justification Of Child Genital Cutting".

It's predictably awful. I thought I'd share my thoughts about it.

BI begins (after a brief introduction) by complaining that:
Here we go. First Haber says I’m assuming he’s biased because he disagrees with me -- in reality, my response called him out on his bias exactly one time, in response to a specific, incredibly biased remark: Haber called the foreskin a “bit of skin.”

This is utterly irrational: the foreskin is a bit of skin, so why on earth shouldn't it be described as such? To claim that somebody is biased because they made an accurate statement is absurd.

Actually, what we call the foreskin is easily 12-15 square inches of skin (depending on where the cut is made - think the size of an index card), and it’s loaded with erogenous nerve endings.

Two claims here, so lets address each in turn. First, only one study in the literature has actually measured the surface area of the adult foreskin; it found an average surface area of 36.8 square centimetres (that's 5.7 square inches). Second, while it's true that nerve endings are present in the foreskin, it's disingenuous at best to claim that it is "loaded" with "erogenous" nerve endings: the actual number is unknown. Furthermore, no study has shown that those present are particularly erogenous in nature; in fact the only study to pose a remotely comparable research question found that the foreskin actually produced the least sexual pleasure of any part of the penis.

Before Haber even gets into my arguments he starts with ad hominem attacks, saying that I either lack “reading comprehension” or I’m “batshit crazy.” You’ll notice this tactic throughout Haber’s response, as opposed to the calm, rational tone of both his original article and my response to it.

As we shall see, the pot is calling the kettle black.

Remember, Haber allowed part of his own son’s genitals to be amputated based on the flaws in his reasoning that I exposed. So it’s perfectly normal that he would get upset when confronted with facts about the harm of genital cutting.

The mistake that BI is making here is to assume that what he has to say is "factual", and that what Haber has to say is "flawed reasoning". He is apparently unwilling to consider the notion that others might legitimately have alternative viewpoints, and for that matter that he might actually - gasp - be wrong.

Circumcision is the amputation of the foreskin of the penis. Contrary to popular belief, the foreskin is not a discrete entity, but rather a part of the contiguous penile skin system. The amount of skin cut off is entirely up to the person doing the cutting. Based on my own unscientific observation of YouTube videos online, it appears that easily around 50% of the penile skin is typically cut off in infant circumcisions (more on this later) -- sometimes significantly more, sometimes significantly less.

(At this point BI includes a still frame from a circumcision video, which he has annotated to indicate that half of the skin is being removed. Two problems here. First, the line at which he has decided the foreskin begins is his own arbitrary choice, so drawing a conclusion based upon its placement tells us more about his opinion about circumcision than about circumcision itself. Second, and more importantly, he's failed to take into account the fact that the penile skin system is extremely elastic, and the foreskin is under tension, as it is being stretched. So it should stand to reason that this will exaggerate the apparent length of the foreskin.)

Assume that the average penis is 5.9 inches long and has a circumference of 5 inches (these figures are taken from Further assume (for the sake of argument) that the average glans is 1 inch in length, and that the foreskin can (with assistance if necessary) fully cover the glans when erect.

Since the foreskin is a double fold, we'll count it twice. The penile skin of the penis is therefore a cylinder 5.9 + 1 + 1 = 7.9 inches long and 5 inches in circumference. This means that the surface area is 39.5 square inches.

As noted above, the adult foreskin is, on average, 5.7 square inches. 5.7 is 14% of 39.5.

(At this point BI includes a pair of videos. It's unclear what his point actually is, so I won't even try to address it.)

Regarding a study by Sorrells et al:

Haber first admits that the study, which shows that the five most “fine-touch” sensitive parts of the penis are amputated during circumcision, is “interesting,” but then he completely discards it because it was funded by NOCIRC. [para break] Nevermind that the design of the study was sound. Nevermind that it was published in the British Journal of Urology.

While the study was, unquestionably, published in BJU International, this is an extraordinarily weak argument. Weaker still is BI's claim that the design of the study was sound, for which he provides no evidence whatsoever.

In fact, despite Sorrells’ study on penile sensitivity being widely cited by critics of circumcision, there has never been a legitimate published critique of the study made by circumcision advocates. The closest was a letter written by Waskett and Morris, two notorious circumcision fetishists, neither of which have any medical credentials. (Morris is known for calling on the state to institute compulsory male infant circumcision.)

Here BI engages in ad hominem attacks against the authors of the critique (which he apparently feels either isn't legitimate or isn't published; it's unclear which). Note that, even if his claims about Prof Morris and myself were true, they still wouldn't constitute an argument against what we actually said. BI hasn't even attempted to address the substance of our critique, perhaps because we actually made some rather solid points.

But no, we should disregard Sorrells’ study because it was funded by NOCIRC. My question for Haber -- who the hell do you think is going to fund a study about the negative effects of circumcision in the U.S., the epicenter for foreskin cluelessness in the world? Who do you think NOCIRC is made up of? Does NOCIRC stand to earn profits by discouraging circumcision?

Surely it should be obvious that NOCIRC is made up of people who are opposed to circumcision, and who are extremely passionate about that? He seems to imply that because there is no financial gain to be made then NOCIRC have no reason to be biased, but that is rather short-sighted. People are willing to fly planes into skyscrapers for their beliefs, after all.

Personally, I doubt that NOCIRC would deliberately falsify their results, but I suspect that the strength of their beliefs may have blinded them to the flaws in their study, and may have influenced their dodgy interpretation.

How is this any more noteworthy a conflict then the Circumcision/HIV studies conducted by a woman (Dr. Wawer) who has built her entire reputation and career on “researching” the benefits of circumcision?

This bizarre attack against Dr Wawer is utterly unprovoked and false. Searching PubMed for articles by MJ Wawer reveals 136 results. Adding the term "circumcision" returns only 35 results; about a quarter of the total. Why make such a claim without checking the facts? It doesn't make sense.

Sorrells is a medical doctor. His study was conducted in a research university setting and published in a well known peer-reviewed medical journal. We are now four years removed from its publication, and the veracity of the study’s results have never been seriously challenged.

Actually, the results have been seriously challenged. Flatly claiming otherwise in the face of evidence to the contrary is unconvincing at best. Furthermore, the arguments in favour of the study are almost pathetically weak.

Okay, here’s another study for you. This one’s from South Korea, where circumcision has apparently taken hold after being exported by American military doctors 60 years ago. Based on a survey of 373 sexually active men, all of whom had been circumcised after the age of 20 years old [...]

Ah yes, Kim and Pang's 2006 study. Interestingly, the authors of this study attended a NOCIRC symposium in 2000, where they received a "human rights award" for their work to stamp out circumcision (see here).

It's a very poorly described study, and BI clearly hasn't read it. (Compare, for example, his above claim with the following: "The study included 373 sexually active men [...] of whom 255 were circumcised [...] and 118 were not [...]".) The study does state that "To focus on the effects of circumcision on their sexual lives, only those 138 men who could compare the quality of their sex lives including masturbation before and after circumcision were asked to complete questions 7–11, which compare the quality of sex life before and after circumcision"; however it is far from clear which results stem from which comparisons. Also unclear (in fact, completely undocumented) is the selection process, making it impossible to evaluate the study for possible biases.

More reliable results are found in RCT-based studies (one of which BI attacks below; another which can be found here.

(At this point BI announces his intention to "quickly pick apart" an RCT-based study, apparently having forgotten that it was a) it's conducted by a medical doctor, b) in a research setting, and c) published in a peer-reviewed journal.)

Unlike the Korea study, the circumcised men in this study were never asked to compare sexual pleasure before and after circumcision. In fact, the men were not asked about pleasure at all, only about desire and satisfaction.

Apparently BI has created a distinction between satisfaction and pleasure. I'm not altogether sure what that distinction is: the two seem closely related to me.

The men were only given two levels of possible satisfaction as options: “Satisfied” and “Very satisfied.”

Once again, BI appears to be attempting to criticise a study without the benefit of having read it. It is quite clear from the appendix that the possible responses were: Very satisfied, Satisfied, Dissatisfied, Very dissatisfied, No response, and Other (specify). Again, why make a claim like that without bothering to check?

Selection bias -- they are taking men who volunteered to be circumcised as adults, circumcising them, and asking them about sex afterwards. This, after telling the men that circumcision is healthy and prevents disease. Are we supposed to believe that neither the fact that the men selected themselves to be circumcised nor the fact that they were told it was a healthy, disease-preventing measure had an impact on their survey answers?

But "healthy" does not imply "better sex".

The survey was conducted two years after circumcision. What about negative sexual impacts 5, 10, 25 years later, as what’s left of the penis is left to become keratinized (calloused) through exposure to air and rubbing on clothing?

That myth has been well and truly disproven. The only study in the literature found no difference in keratinisation levels between circumcised and uncircumcised penes, and multiple studies have shown that the two are equally sensitive, even in adults circumcised as neonates.

Conflict of interest: This survey was conducted by the same team (headed by Dr. Wawer) trying to prove that circumcision prevents HIV. Establishing that the foreskin does not benefit sexual pleasure was required in order to promote the results of their HIV study.

BI is being disingenuous by implying that the researchers were seeking a predetermined outcome. In fact they were trying to determine whether circumcision protects against HIV. Science is about gathering data.

Haber completely ignores my argument (maybe it just went over his head?), which is that any negative sexual impact of circumcision is unlikely to be noticed for many years: possibly when a boy reaches puberty and starts masturbating, when he becomes sexually active, or maybe not even until many years later after the penis is fully calloused and/or damaged from excessive friction.

As noted above, this myth has been disproven.

How is a study of circumcision complications in babies addressing any of the sexual complications a circumcised man could have? Here are just a few of the possible complications that the studies Haber is referring to would never catch, because they would have to follow up 5, 10, 15, 25 years later: [...]Here is a gallery of botched circumcisions if you think I am inventing all of these

BI displays a worrying lack of logic here. Firstly, three of the speculative complications that he lists ("Tight, painful erections", "Numbness", and "Pain") couldn't be determined from a photograph. Secondly, the remaining items would be apparent in babies ("Skin bridges", "Curvature", "Twisting", and "Excessive scarring"). Thirdly, the existence of a photograph establishes that something has happened once; it doesn't provide any indication of frequency.

Answer the fucking question, Haber -- who is checking up on kids 15 years later and asking them how their dick works when they start masturbating? How many of these kids are having tight, painful erections from so much skin getting cut off? Who is checking up on 40-year old men asking them if they have any feeling left in their penises after decades of keratin build-up to the exposed glans and remnant inner foreskin?

First of all, the keratinisation claim is, as we've seen, a myth. Second, it's very unlikely that a circumcision should cause pain on erection. In fact most evidence seems to indicate that the opposite is true.

(At this point BI includes a video of a guy singing about his circumcision. Strange.)

Haber again completely avoids my point: that the foreskin isn’t just “a bit of skin” but 12-15 square inches of skin. He makes an irrelevant comparison to the total amount of skin surface area on the human body.

I'm utterly perplexed here. Even if the foreskin were that large (and it appears exaggerated by about three-fold), would that mean it wasn't a "bit"? Is there an upper size limit on "bittiness"?

The important point is that 50% (HALF) of the penile skin is being cut off.

Addressed above.

There’s actually an even more important element here. Not only is a massive amount of penile skin being removed in circumcision, but a large percentage of the most sensitive tissue, which is everything on the inside of the fold, or the “inner skin,” including specialized penile structures like the “Ridged Band” of nerve endings and the frenulum. (See Sorrells’ study above.)

The evidence does not support this claim. When properly analyses, Sorrells' study shows no differences between the foreskin and other parts of the penis. But that is sensitivity to light touch (Sorrells did not measure any of the other kinds of sensitivity), which is arguably least important to sexual pleasure, and which the foreskin (due to its innervation) would be expected to be most sensitive.

It turns out the most sensitive sexual tissue on the penis is on the inside of the foreskin

Interesting approach. Make a completely unsupported (and unsupportable) claim and prefix it with "it turns out that".

I should have been more clear here. My point was that circumcision does not work in the real world to prevent HIV. It only works in a fabricated clinical setting due to a number of flaws that call into question the validity of the results of the studies.

But they were performed by medical doctors, weren't they? In a research setting? And published in peer-reviewed journals? Gosh, is BI applying a different standard to studies depending upon whether he likes the results of a study?

I’m not going to spend a ton of time on this, because others have already done a much better job than I could hope to do.

If BI changes his mind, we can certainly analyse his arguments.

A couple of quick things to consider from these clinical trials: [...] The men who were circumcised also received counseling on condom use.

BI is being very disingenuous here. While what he says is technically correct, he's omitting the important point that both groups of men, circumcised and uncircumcised, received counselling.

The same studies also found that men who were HIV-positive were actually more likely to pass on HIV to their wives if they had been circumcised.

Wawer's study actually found no statistically significant difference.

More importantly, babies are not even sexually active.

But they do become sexually active, when they grow.

Forcing this on a non-consenting child on the other hand -- based on clinical studies that are questionable at best and contradict all available real-world data (see below)

Here BI completely misrepresents the facts. The three clinical trials were not conducted in a vacuum. They were conducted because of a series of 40 or more observational studies, from the late 1980s onwards, the majority of which showed that the risk was considerably lower among circumcised men.

The USAID data shows quite clearly that there is no real-world evidence of circumcision having any benefit whatsoever for HIV prevention on entire populations that practice it.

That's one observational study among many. Most find results consistent with the RCTs. BI has merely shown his ability to cherry-pick studies with conclusions that he likes.

Circumcision as HIV prevention just does not work in the real world. Ask the families of all the American men who died of AIDS in the 1980’s.

Here BI attacks a strawman. Nobody has claimed that circumcision completely prevents HIV; it reduces the risk. So it should be expected that a non-zero number of circumcised men will become HIV positive.

You are correct, men have penises and women have vaginas/vulvas (congratulations on recognizing this). That doesn’t mean male and female genital cutting aren’t analogous (more on this below),

One could construct an analogy with mowing the lawn (which does, after all, usually involve the use of a blade), but that doesn't mean that the analogy is particularly meaningful.

You want to know what sexism in genital cutting is? It’s when you call it “circumcision” on boys, but “mutilation” on girls, in the very same sentence.

No, that's not sexism, it's realism. FGM/C is a net harm. Circumcision isn't.

As of 1996, all forms of female genital cutting have been outlawed by federal law, down to the slightest pinprick. That means boys have no legal protection from having half or more of their penile skin removed*, despite all of the significant sexual impact and risk of further complications (see above),

But, as we've seen, BI's claims about those issues were nonsensical.

(Hilariously, BI inserts a note claiming that "Circumcision of boys is quite clearly illegal". Not according to any court decision that I've heard of.)

So congratulations, you got something right: Intactivists think people should be just as outraged by the forced genital cutting of little boys as they are with the forced genital cutting of little girls. That sounds perfectly logical to me.

I suppose it might seem logical, if one were either ignorant of the differences between the two or unwilling to learn.

(At this point BI gives a lengthy discussion of what FGC and circumcision are "all about". He offers nothing more than his opinion, so in the hope of finishing this analysis at some point I'll skip it.)

This is where even the most basic history lesson on circumcision could have saved Haber. Let’s start with religious circumcision -- nobody knows exactly how it started, but it’s very much about controlling and reducing a man’s sexuality. Famous Jewish scholar Maimonides had this to say[...]Even to Maimonides the function of the foreskin and the purpose of circumcision were obvious.

I'm skipping what Maimonides had to say, because it's completely irrelevant. Maimonides lived in the 12th century, thousands of years after circumcision began, and thus would have no way of knowing why it began. All he could do is to speculate. Similarly, scientific understanding was poorly developed in the 12th century, and Maimonides' views about the function of the foreskin are hardly authoritative.

But how did circumcision get started among non-religious people in the U.S.? Believe it or not -- it was introduced by medical doctors in the 1800’s to “cure” or reduce masturbation and excessive sex, which were believed to cause a number of diseases. This is all over the medical literature from the mid-to-late 1800’s through the mid 1900’s. Here is one particularly damning quote from a medical journal:

I wonder if BI has ever heard of the "fallacy of the striking instance"... That something is striking does not imply that it was representative or even influential. In fact, Gollaher, in his exhaustive "Circumcision: A history of the world's most controversial surgery", states that circumcision began for a quite different reason, and devotes only a handful of pages to masturbation.

(At this point, BI engages in a long and frankly bizarre digression, including an Eminem video of all things.)

So you see, YES male circumcision is performed to reduce/control male sexuality.

This is illogical. Sure, Maimonides and a handful of 19th century doctors believed that circumcision might reduce or control male sexuality, but in what way does that establish that parents today are choosing circumcision for that reason?

(At this point BI presents a list of similarities between FGC and circumcision. As I've noted above, one can easily find similarities between dissimilar things, and such a list proves little except its authors determination to write it. So I'll omit it.)

You may have different values. But to say that it is okay for one sex to be genitally cut but not the other? Pure sexism and an incredible double standard.

If it is "okay" or "not okay" because of gender, yes, that's sexism. If it's "okay" or "not okay" because of consequences, that's not inherently sexist.