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A or B guys. A or B?

Two recent surveys by Intact America have raised the question by some participants of why we asked the men if their penis looked like A (an intact penis) or B (a circumcised penis), which they found either distasteful or an invasion of privacy. This is the A or B image they were talking about.
A. Intact Penis (not circumcised) and B. Circumcised Penis
The short answer is accuracy. Asking this question improves the quality of the survey results. A lot. The reason is that many men don’t know their penile status! A 2004 study of college-aged men found that 33% were mistaken or unsure of their penile status.[i] This is nothing new, a 1960 study found 14% of men were unsure; their status was confirmed by a physical examination.[ii]

More recently, in Intact America’s three, national random sample surveys (2017, 2018, & 2021) of 3298 Americans, 14% of men were mistaken or unsure of their penile status. See below for my decade-old methodology to determine whether men were mistaken or not. But first, here’s an entertaining anecdote to illustrate the problem.

You may have seen the episode of the Graham Norton Show on BBC in 2017 with guest actor Sir Patrick Stewart. He relayed the funny story about him mentioning in passing to his wife that he was circumcised. According to Stuart, in his 70s at the time, the conversation went something like this:

Stewart: I’m circumcised.
Wife: (laughs) You’re not circumcised.
Stewart: That’s ridiculous! I should know if I’m circumcised! End of conversation.
Stewart: The next day, I happened to be seeing my doctor for my annual physical. When the doc was ‘down there,’ I mentioned my disagreement with my wife, and asked, “I’m circumcised, right?”
Doctor: Not!

Surprisingly, even men who call themselves intactivists, and who are presumably knowledgeable about circumcision and male sexual anatomy, aren’t sure. A survey of intactivists found that 13% of intactivist men are mistaken or unsure.

In 2011, I wanted to learn if newborn circumcision was associated with alexithymia. Alexithymia is the inability to identify and express emotions. It is thought that it is acquired at a very early age. Such people have difficulty in relationships, social interactions, and even in therapy. But I could not examine these men who live across the United States. So, I had to develop a viable validation alternative for that peer-reviewed alexithymia and circumcision study. My solution was to ask their penile status and then compare that with their answer to the A-B image question. Entries that did not match correctly were removed from the dataset.

As it turns out, and unknown to me at the time, I’m not the first researcher to realize that self-report is inaccurate when it comes to penises. In 1992, Schlossberger found that: “Use of visual aids to report circumcision status was more accurate (92%) than self-report (68%).[iii] Wow.

Granted, the best way to determine penile status would be a physical examination. But this is so problematic on so many levels that it would be all but impossible to survey. You’d have to pass certain standards using human subjects, hire medical staff, obtain liability insurance, and of course get permission from the men to disrobe. (By the way, the proper way to determine if a man is circumcised isn’t to look for the lack of a foreskin, but the presence of a circumcision scar.)

The solution that I came up with, and one I’ve used many times since, is a three-part survey-question method. The questioning goes something like this:

Are you circumcised or intact (not circumcised)?

Circumcised
Intact
Don’t know

Which one of these images most looks like your flaccid (not erect) penis?

A
B
Unsure

Are you restoring your foreskin?

Yes
No
I don’t know what this is

As you can see, this method results in much more accurate answers, and provides trustworthy data. Nevertheless, some men are not comfortable answering these questions, even to an anonymous researcher. I can appreciate that. That’s why I’ve taken steps to avoid their discomfort: 1) I inform participants that they’ll be asked personal, sexual questions, 2) tell them they can opt out now, 3) tell them they can opt out at any time, 4) mention that this data will only be used in aggregate form, and that at no time will their identity be revealed, and 5) use the image shown above obtained from a medical illustration stock image source instead of using a photo of real penises.

A study I recently conducted, and now in-press, titled “Adverse Childhood Experiences, Dysfunctional Households, and Circumcision,” also employed this method. None of the journal reviewers mentioned a problem with using this image.

So, not using this tripartite image question would make the results skewed, if not unusable, and therefore unpublishable.

Sadly, many circumcision studies being published since I created this method continue to just ask the men if they are circumcised or not, leaving us unsure of what to make of their conclusions. As scientists like to say: “Junk in, junk out.” (no pun intended!)

—Dan Bollinger

[i] Risser JMH, Risser WL, Eissa MA, Cromwell PF, Barratt MS, Bortot A. Self-assessment of circumcision status by adolescents. Am J Epidemiol. 2004;159:1095–1097.

[ii] Wynder EL, Licklider, SD. The question of circumcision. Cancer. 1960;13(3):442 5. 14.

[iii] Schlossberger N, Turne R & Irwin C (1992) Early adolescent knowledge and attitudes about circumcision: methods and implications for research. J Adolesc Health 13(4): 293-297.

Voices – Dusty Drake

Intact America interviewed Dusty Drake (they/she) following her heartwarming and open TikTok account of their circumcision complications. A transcript of the interview and her video follows. 

How did you discover Intact America and what does the intactivist movement mean to you?
I first discovered Intact America a few years ago on Instagram. Back in 2011 however was the first time that I heard the term intactivist. Without knowing the word though, it is something I advocated against within my social circle even before that because of my own experience. To me, the intactivist movement is about bodily autonomy more than anything else. It’s giving the right to make cosmetic decisions about one’s body to the individual themself. It seems to be a controversial opinion in North America, but I don’t think that parents should be allowed to alter their child’s body for cosmetic purposes just because it’s their child. That child is an autonomous human being and will grow into an adult who can consent to those procedures if they decide they want them.

What encouraged you to share your story, and why now?
I was encouraged to share my story when I saw a prompt posted on September 22nd to Instagram by Intact America. The prompt simply said “Robbed of your foreskin? Tell us your story.” Their email was written below and I thought to myself, “I should email them. I’m shut down so often when I bring up the problems with cosmetic infant circumcision so I’m terrified to share my story but at least they are willing to be a listening ear.” After composing the email though I had a spark of inspiration and decided that I wasn’t going to send it. I have a following on TikTok and though even though I’ve been harassed and shut down before while speaking against cosmetic infant circumcision, this is still something that people need to hear even if they aren’t ready. So I decided to record and post my story instead. I can’t begin to tell you how extremely nervous I was to talk about my own personal experience with having been circumcised as an infant and the issues I experienced during puberty because of it. While recording, it felt just as nerve wracking as if I was speaking to a room full of strangers who had no interest in what I had to say. But I continued, because if my voice can help one parent reconsider their entitlement over their child’s body and prevent them from taking away their child’s bodily autonomy then it was worth the temporary discomfort I felt while recording.

What are some of the reactions to your TikTok video and how do they make you feel?
A majority of the reactions from my TikTok on my own experience have been overwhelmingly positive which I was honestly surprised about. I have posted content against cosmetic infant circumcision in the past and have been met with a lot of hate, harassment, and even bullying. So I was understandably nervous to share my own story, but I am so glad I did. I think the biggest reward from posting about my own experience is the new and expecting parents posting that they are reconsidering doing this to their child, have now made the decision not to, or feel more reassured that they made the right decision by leaving the choice up to their child.

Would you consider sharing more about your experience, or discuss circumcision in future TikTok videos?
If the right inspiration strikes, I will continue to talk about my experience. I absolutely intend to continue making content against cosmetic infant circumcision because the right to bodily autonomy is a human rights issue.

Dusty’s TikTok Transcript:

When I was a baby, only a few days old, a doctor had convinced my parents that there was something wrong with my body and that immediate surgical intervention was needed. There was no infection, no birth defect, and there were no adverse effects that could come from leaving my body in its natural state. Yet despite this, my parents had been convinced that to be good parents and do what was best for their first born child, that immediate surgery was necessary. They hadn’t been properly educated on the surgery, and they had have been given information on the benefits of leaving my perfectly healthy body alone. So they followed through with the doctor’s recommendation.

When I began puberty at around 10 or 11-years-old, my body began to grow quickly, so quickly, in fact that the incision from the surgery that I was unnecessarily forced to undergo as an infant began to tear. The scar tissue began stretching beyond its limits. This increased tension led to years of bleeding and scabbing along the incision line from the scar, not to mention the pain that this caused me during this whole time. But I was scared and ashamed of what was happening to me. I had believed that I had done something wrong, or worse, that there was something intrinsically wrong with me and that this was a punishment for it, and this made sense to me. After all, I was a young closeted queer kid who was being bullied every single day by my peers. Heck, I didn’t even know what queer or gay or any of that was, but I knew that that was something I didn’t wanna be and that it was bad, because that’s what my peers and society had taught me.

So it made sense to me that on top of being bullied every day, that life would just punish me in this way, despite the fact that I hadn’t done anything except for show kindness to others. So I never told anybody what I was going through and I just suffered through it alone. But when I was an adult, I discovered that I wasn’t the only one who had gone through this. There were doctors all over convincing parents to perform these unnecessary surgeries on their children, their newborn children. After I realized that I wasn’t alone in this, I got the courage to speak to my parents about it. They didn’t know what to say at the time, and they were clearly processing the information I was giving them, but they did look really remorseful.

Just last month, I was hanging out with my mom and she came up to me on her own, she sat next to me on the couch and just gave me a big old hug. She looked me in the eyes and she said, “I am so sorry. I would never crop a dog’s ears or tail, but for some reason, I never gave a second thought to mutilating my own newborn baby. I wish I could go back and make an informed decision with the knowledge I have today. I’m so sorry that we circumcised you.”

Ask Marilyn—What are Langerhans Cells?

The penis advice columnDear Marilyn:

I have read that the foreskin produces anti-microbial agents, including Langerhans cells. Is that true? What are Langerhans cells?

—Richard in Virginia

Dear Richard:

Yes, Richard, Langerhans cells have important immunological properties.

Langerhans cells reside in the epidermis of the foreskin, the body’s outermost and thinnest layer of skin and the layer responsible for protecting you from the outside world. Langerhans cells determine the appropriate adaptive immune response (inflammation or tolerance) by interpreting the microenvironmental context in which they encounter foreign substances. In a normal physiological, “non-dangerous” situation, Langerhans cells coordinate a continuous state of immune tolerance, preventing unnecessary and harmful immune activation. But when they sense a danger signal, for example during infection or when the physical integrity of skin has been compromised as a result of a trauma, they instruct T lymphocytes of the adaptive immune system to mount efficient responses against the danger.

Thus, Langerhans cells in the foreskin play an important role in fighting infections and protecting the rest of the penis.

—Marilyn Milos, RN

Ask Marilyn—Kiddo Is Having Painful Erections

The penis advice columnDear Marilyn,

My almost 5 year old keeps having erections and is complaining that it’s hurting. Is that normal for an intact kiddo? My oldest is circed as is hubby so this is new to me and hubby. What can I do to help him?

—Emily in Indiana

Dear Emily,

How does your son’s penis look? Are there any changes in his foreskin? Is it red or swollen? If not, then your son’s painful erections may need to be directly addressed. Erections are normal and begin in babies in utero. If your son’s erections are painful, then the development of his penis needs to be explained to him. When he understands that at birth the foreskin is usually non-retractile because the foreskin and glans (head of the penis) are attached when they develop. These two structures will separate over time. Once the foreskin and glans separate, the foreskin becomes retractable. As the foreskin becomes retractable, erections may cause sensations as the foreskin separates from the glans or because the opening of the foreskin is not yet large enough to accommodate retraction of the glans. Discussion of these aspects of his penile development should help determine where the pain is coming from so that your son can consider and accept the sensations as a part of the developmental process or something that needs to be addressed.

—Marilyn

Ask Marilyn—Can a Tight Foreskin be Treated without Circumcision?

The penis advice columnDear Marilyn:

I’m a 35-year-old man. I have been having trouble with a very tight foreskin. My doctor says it’s phimosis, and the only treatment is circumcision. Is there any other remedy? I’d really like to keep my foreskin.

—Harold, New Orleans, LA

Dear Harold:

The word phimosis means muzzled, to indicate that the glans (head of the penis) is muzzled by the foreskin. At birth, most babies have “physiological phimosis,” a normal condition because the glans and foreskin have not yet separated. The foreskin separates from the glans over time, usually by adolescence.

Sometimes a retractable foreskin of an adult male will close down; this condition is called “pathological phimosis.” From your letter, I cannot determine why your foreskin has closed down, so I will suggest a number of possible causes and cures.

  1. Exposure to soap, shampoos, and chlorinated water in swimming pools or hot tubs can kill normal, beneficial bacteria on the foreskin, which can result in yeast overgrowth, inflammation, itching, and stinging with urination; it can also make the foreskin close down. This condition can be corrected by eliminating soap and shampoo, or by using barriers creams on the foreskin before swimming. To help the healing process. liquid Acidophilus culture purchased from the health food store or pharmacy can also be applied to the foreskin by pouring some of the liquid into the palm of the hand, dipping the foreskin into the solution, and letting it drip dry; do this six times a day for 3 or 4 days.
  2. Sometimes the foreskin will close down if a male has been too vigorous sexually, which can cause small tears in the foreskin. The opening will become tight while the tissue heals. Time and gentleness are the cure for this.
  3. Pathological phimosis can result from a condition called “lichen sclerosus” (formerly called “BXO”), characterized by the presence of small, shiny, and smooth white patches on the foreskin. These patches may become larger, and the skin may become itchy, thin, and wrinkled, and may tear easily and bleed. A dermatologist can diagnose lichen sclerosus, which is commonly treated with two creams, Clotrimazole and hydrocortisone, both available over-the-counter at your local pharmacy or by prescription, depending upon the desired strength.
  4. Finally, before considering circumcision, ask your urologist about a Y-V- or Z-plasty—a surgery in which small slits are cut in the foreskin, and then they are sewn together in a way that widens the opening. This surgery saves the foreskin and its specialized nerve endings that allow for full sexual sensations and enjoyment.

So, you can see, Harold, that finding the reason for your phimosis is a critical step to solving the problem and avoiding the loss of your foreskin.

—Marilyn

Ask Marilyn—Is It Normal to Have Hair on Your Penis?

The penis advice columnDear Marilyn:

I have hair going up the shaft of my penis. Is this normal?

—Daniel F., Tulsa, OK

Dear Daniel:

Hair on human bodies varies by individual. Penile shaft hair is rare but most frequently it is the result of circumcision, which pulls scrotal skin onto the shaft. Men with this problem sometimes manually remove the hairs one-by-one with a tweezer, or resort to electrolysis to eradicate unwanted hair growth on the shaft. If we stop doing circumcisions, this problem will end.

—Marilyn