Sexual effects of circumcision

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The sexual effects of circumcision are now well documented. Studies have been conducted to investigate the effect of circumcision (amputation of the foreskin) on sexual drive, erectile function, premature and delayed ejaculation, sexual satisfaction, sexual sensation and penile sensitivity. Studies have also assessed whether circumcision affects masturbation or other sexual practices, and the degree to which a heterosexual woman's experience of sex is affected by her partner's circumcision status. Cold & Taylor (1999) stated:

The prepuce is primary, erogenous tissue necessary for normal sexual function.[1]

History

In the beginning

The human foreskin was once thought to have little or no sexual function. Sex researcher Alfred C. Kinsey (1948) placed no importance on the presence or absence of the foreskin.[2]

Masters & Johnson (1966) in their book, Human Sexual Response,[3] showed little interest or understanding of the human foreskin. One illustration, labelled normal penis anatomy, showed a drawing of a penis without a foreskin. A listing of penile pathology in their book included “uncircumcised penis”! Their work was done in St. Louis, located in the highly circumcised Midwest, and almost all of their subjects were circumcised. Their testing was quite limited. With regard to the foreskin, they said only:

Routine neurologic testing for both exteroceptive and light tactile discrimination were conducted on the ventral and dorsal surfaces of the penile body, with particular attention directed toward the glans.

With regard to the glans penis, Masters & Johnson stated:

Routine neurologic testing for both exteroceptive and light tactile discrimination were conducted on the ventral and dorsal surfaces of the penile body, with particular attention directed toward the glans. No clinically significant difference could be established between the circumcised and the uncircumcised glans during these examinations.[3]

Therefore, it appears that Masters & Johnson (1966) performed little or no testing on the foreskins of their few intact subjects and provided no useful information.[4]

The inaccurate reports of Kinsey (1948) and Masters & Johnson (1966) have long distorted and minimized the sexual effects of circumcision and the loss of the foreskin in the American view.

The dawning of the light

There were, however, some other little noticed papers overlooked by Masters & Johnson, that told a different story. Winklemann (1956) investigated the innervation of the prepuce and found it to be highly innervated.[5] Winkleman (1959) later identified the prepuce as "specific erogenous tissue".[6]

William Keith C. Morgan, M.D.[a 1] (1965), a Canadian physician practicing in the United States, had a comment critical of the then American practice of non-therapeutic (routine) circumcision of infants. With regard to sexual function, he identified the ease of penetration and said:

Now let us consider whether the operation is in any way harmful or contraindicated. The function of the prepuce is to protect the glans, the latter being almost insensitive to most ordinary tactile and thermal stimuli. It has, however, specific receptors for other pleasurable sensations. Removal of the prepuce exposes the glans to foreign stimuli which dull these special receptors. During the act of coitus the uncircumcised phallus penetrates smoothly and without friction, the prepuce gradually retracting as the organ advances. In contrast, when the circumcised organ is introduced during coitus, friction develops between the glans and vaginal mucosa. Penetration in the circumcised man has been compared to thrusting the foot into a sock held open at the top, while, on the other hand, in the intact counterpart it has been likened to slipping the foot into a sock that has been previously rolled up.[7]

Morgan (1967) addressed the issue again in the Medical Journal of Australia:

The subcutaneous tissue of the glans is provided with special sensory receptors that are concerned with appreciating the pleasurable sensations that occur during coitus. They are stimulated normally only when the glans is exposed. In the circumcised subject these receptors are constantly stimulated and lose their sensitivity. During the act of coitus, the uncircumcised phallus penetrates smoothly and without friction, the prepuce gradually retracting as the organ advances. In contrast, when the circumcised organ is introduced during coitus, friction develops between the glans and the vaginal mucosa.[8]

Falliers (1970) commented in a critical letter to the Journal of the American Mmedical Association:

The sensory pleasure induced by tactile stimulation of the foreskin is almost totally lost after its surgical removal. The surface of the exposed glans, as we know, has no capacity to receive and transmit any fine sensations of touch, heat, etc. Consequently, the fundamental biological sexual act becomes, for the circumcised male, simply a satisfaction of an urge and not the refined sensory experience that it was meant to be.[9]

And so began the investigation of the sexual effects of male circumcision.

Penile sensitivity and sexual sensation

Results of studies of the effect on penile sensitivity have been mixed. In a British study of 150 men circumcised as adults for penile problems, Masood et al. (2005) found that 38% reported improved penile sensation (p=0.01), 18% reported worse penile sensation, while the remainder (44%) reported no change.[10] In a survey of men circumcised as adults for medical (93%) or elective (7%) reasons, Fink et al. (2002) found an association between adult circumcision and decreased penile sensitivity that "bordered on statistical significance" (p=0.08).[11]

Glans sensitivity

A number of studies have looked at the question of whether sensitivity of the glans is affected by circumcision.

Yang et al. (1998) concluded in their study into the innervation of the penile shaft and glans penis that: "The distinct pattern of innervation of the glans emphasizes the role of the glans as a sensory structure."[12]

An examination of 7 circumcised and 6 intact males found no difference in keratinization of the glans penis.[13]

Sorrells et al. (2007) measured the fine-touch pressure thresholds of 91 circumcised and 68 uncircumcised, adult male volunteers, They reported "the glans of the uncircumcised men had significantly lower mean (sem) pressure thresholds than that of the circumcised men, at 0.161 (0.078) g (P = 0.040) when controlled for age, location of measurement, type of underwear worn, and ethnicity."[4]

Foreskin sensitivity

Some recent researchers assert that the foreskin is sexually sensitive highly-innervated erogenous tissue.[5][6] [14][1] The foreskin has a large population of Meissner's corpuscles.[15] Proponents of genital integrity have cited these studies, which report on the sensitivity or innervation of the foreskin, claiming a sexual role based upon the presence of nerve-endings in the foreskin sensitive to light touch, stroking and fluttering sensations.

Circumcision removes the ridged band at the end of the foreskin.[14] Taylor (1996) observed that the ridged band had more Meissner's corpuscles — a kind of nerve ending that is concentrated in areas of greatest sensitivity — than the areas of the foreskin with smooth mucus membranes and a rich blood supply to serve the neurological tissue. Taylor (2000) postulated that the ridged band is sexually sensitive and plays a role in normal sexual function. He also suggested that the gliding action, possible only when there was enough loose skin on the shaft of the penis, serves to stimulate the ridged band through contact with the corona of the glans penis during vaginal intercourse.[16] This gliding action was also described by Lakshmanan (1980).[17]

Boyle et al. (2002) argued that circumcision and frenectomy remove tissues with "heightened erogenous sensitivity," stating "the genitally intact male has thousands of fine touch receptors and other highly erogenous nerve endings—many of which are lost to circumcision."[18] They concluded, "Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well."

Sorrells et al. (2007), in the study discussed above, measured fine-touch pressure thresholds of the penis, and concluded "The transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. Circumcision ablates" (removes) "the most sensitive parts of the penis." According to Sorrells et al., the five penile areas most sensitive to fine-touch are located on the foreskin.[4]

In 2009, Schober et al. reported on self-assessed sexual sensitivity in 81 men, 11 of whom were uncircumcised. When assessing areas producing sexual pleasure, the foreskin was ranked 7th, after the glans, lower and upper shaft, and the left and right sides of the penis, but above the area between scrotum and anus, the scrotum itself, and the anus.[19]

García-Mesa et al. (2021) reported that the mechanical motion of the foreskin generates pleasurable sexual sensation.[15]

Erectile function

Reports detailing the effect of circumcision on erectile dysfunction have been mixed. Studies have variously found a statistically significant increase,[11][20] or decrease,[21] [22] in erectile dysfunction among circumcised men, while other studies have shown little to no effect.[23][24][25]

Fink et al. (2002), in an American study of 123 men, found that medically necessitated circumcision resulted in worsened erectile function (p=0.01).[11]

Kim & Pang (2007) reported no significant difference in erection.[25]

Laumann et al. (1997) reported that the likelihood of having difficulty in maintaining an erection was lower for circumcised men, but only at the 0.07 level (OR 0.66; 95% CI, 0.42-1.03).[22]

Ejaculatory function

Circumcision affects ejaculatory function in different ways. In some men, excision of the foreskin causes hyperstimulation of the corona glandis, resulting in premature ejaculation. In other men, excision of the foreskin and its nerves seems to decrease PE.

Waldinger et al. (2005) recruited 500 men (98 circumcised and 261 not-circumcised) from five countries: the Netherlands, United Kingdom, Spain, Turkey, and the United States and studied their ejaculation times during sexual intercourse. They found that the circumcised men in the study took on average 6.7 minutes to ejaculate, compared with 6.0 minutes for the uncircumcised men. This difference was not statistically significant. The comparison excluded Turkey, which was significantly different from the other countries studied.[26] Commenting on the study, Sorrells et al. (2007) said "Turkish men, the vast majority of whom are circumcised, had the shortest IELT [Intravaginal ejaculation latency time]."[4]

Collins et al. (2002) conducted a prospective study of 15 adult circumcision patients, using the Brief Male Sexual Function Inventory (BMSFI). The authors did not find a statistically significant effect on ejaculation scores.[24]

In a study of 42 Turkish men circumcised for religious reasons, Senkul et al. (2004) did not find a statistically significant difference in BMSFI ejaculation scores, but found a significant increase in the mean time to ejaculate. The authors suggested that delayed ejaculation may be seen as a benefit.[23]

In a telephone survey of 10,173 Australian men, 22% of intact men and 26% of circumcised men reported reaching orgasm too quickly for at least one month in the previous year. The difference was not statistically significant.[21]

In a study of 255 circumcised men and 118 intact men, Kim & Pang (2006) reported no statistically significant difference in ejaculation or ejaculation latency time between circumcised and intact participants.[25]

In a study of men circumcised for benign disease, Masood et al. (2005) reported that of those who stated they had prior premature ejaculation, 13% reported improvement after circumcision, 33% reported that it became worse, and 53% reported no change.[10]

In a study of 22 men circumcised as adults, Cortés-González et al. reported that 31.8% suffered from premature ejaculation before the procedure; this diminished to 13.6% afterwards.

Sexual practice and masturbation

In a study by Korean researchers of 255 men circumcised after the age of 20 and 18 who were not circumcised, Kim & Pang (2007) reported that masturbatory pleasure decreased in 48% of the respondents and increased in 8%. Masturbatory difficulty increased in 63% but was easier in 37%. They concluded that there was a decrease in masturbatory pleasure after circumcision.[25]

Laumann et al. (1997) reported that circumcised men in their survey displayed a greater rates of experience of various sexual practices, including oral sex, anal sex, and masturbation.[22] For example, among whites the "estimated ratio of the odds of masturbating at least once a month for circumcised men was 1.76 that for uncircumcised men." Dr. Laumann provides two explanations for the difference in sexual practices. "One is that uncircumcised men, a minority in this country, may feel a stigma that inhibits them. Another is that circumcision reduces sensitivity in the penis, leading circumcised men to try a range of sexual activities."[27]

Fink et al. (2002) did not find a change in sexual activity with adult circumcision (p=0.22).[11]

Sexual drive

Several studies have investigated the effect of circumcision on sexual drive. Studies that did not find a statistically significant difference include Kim & Pang,[25] Collins et al.,[24] and Senkul et al.[23]

Satisfaction

Kim & Pang (2007) found that 20% reported that their sex life was worse after circumcision and 6% reported that it had improved. They concluded that "there was a decrease ... sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings."[25]

Masood et al., in their study mentioned earlier of men circumcised for benign disease, found that 61% reported satisfaction with the results, while 17% felt it made things worse, and 22% expressed neutral sentiments. 44% of the patients (p = 0.04) and 38% of the partners (p = 0.02) thought the penis appearance improved after circumcision. The authors of the study concluded that the satisfaction rate was a 'poor outcome,' given the pre-procedure penile disease state and recommended discussing with prospective patients the results of this study during the informed consent process.[10]

Shen et al. reported that adult circumcision appeared to result in improved satisfaction in 34 cases (of 95 adults being circumcised), the association was statistically significant.[20]

Senkul et al. reported that they did not find a statistically significant difference in BMSFI satisfaction scores in their study of 42 adult circumcision patients.[23]

Collins et al. reported on a study of 15 adult circumcision patients. No statistically significant difference in BMSFI scores was observed.[24]

Fink et al. reported improved satisfaction (p=0.04). Half of the circumcised men reported benefits, while 38% reported harm. "Overall, 62% of men were satisfied with having been circumcised." Fink attributes the improved satisfaction to the respondee's aesthetic considerations and to a resolution of previous painful conditions.[11]

Uberoi et al. (2022) surveyed reports from circumcised men on social media. The authors reported:

The qualitative review of social media posts clearly demonstrates that some men are experiencing a complex constellation of negative psychological, physical, and sexual associations that lead to significant emotional distress directed both internally and externally.[28]

Female preferences and response

Wildman & Wildman (1976) surveyed 55 young women in Georgia, US, reporting that 47 (89%) of respondents preferred the circumcised penis (the remainder preferred the intact penis).[29] (There were very few intact males in Georgia in 1976 because of the prevalence of non-therapeutic infant circumcision so it is quite likely that few of the subjects tested had any experience with an intact male.)

Williamson et al. (1988) studied randomly selected young mothers in Iowa, where most men are circumcised, and found that 76% would prefer a circumcised penis for achieving sexual arousal through viewing it.[30] There were very few intact males in Iowa in 1988 because of the prevalence of non-therapeutic infant circumcision so it is quite likely that few of the subjects tested had any experience with an intact male.)

O'Hara & O'Hara (1999) argue that foreskin is a natural gliding stimulator of the vagina walls during intercourse, increasing a woman's overall clitoral stimulation and helping her achieve orgasm more quickly and more often. Without the foreskin's gliding action, they suggest, it can be more difficult for a woman to achieve orgasm during intercourse.[31]

Boyle & Bensley (2003) reported that the lack of a foreskin in the male partner produces symptoms similar to those of female arousal disorder.[32] The authors hypothesized that the gliding action possibly involved intercourse with an intact partner might help prevent the loss of vaginal lubrication.[32] They stated that the respondents were self-selected, and that larger sample sizes are needed.[32]

A study by psychologists Bensley & Boyle (2003) reported that vaginal dryness can be a problem when the male partner is circumcised.[32]

Effect of circumcision on heterosexual relations

As previously reported, the foreskin reduces the force required for penetration of the female partner's vagina by as much as ninety percent,[33], so the lack of the foreskin makes penetration more difficult. The gliding action of the foreskin reduces friction and abrasion, while conserving vaginal lubrication,[34] so the lack of the foreskin in the circumcised partner renders the female experience less satisfactory.

In a first of its kind, O'Hara & O'Hara (1999) carried out a retrospective survey of 138 women with experience of both intact and circumcised partners. The women overwhelmingly concurred that the mechanics of coitus was different for the two groups of men. Of the women, 73% reported that circumcised men tend to thrust harder and deeper, using elongated strokes, while unaltered men by comparison tended to thrust more gently, to have shorter thrusts, and tended to be in contact with the mons pubis and clitoris more, according to 71% of the respondents. Women with intact partners had a higher rate of orgasms than women with circumcised partners. O'Hara & O'Hara concluded:

Clearly, the anatomically complete penis offers a more rewarding experience for the female partner during coitus. While this study has some obvious methodological flaws, all the differences cannot be attributed to them. It is important that these findings be confirmed by a prospective study of a randomly selected population of women with experience with both types of men. It would be useful to examine the role of the foreskin in other sexual activities. Because these findings are of interest, the negative effect of circumcision on the sexual enjoyment of the female partner needs to be part of any discussions providing 'informed consent' before circumcision.[35]

Solinis & Yiannaki (2007) concluded; "[t]here was a decrease in couple’s sexual life after circumcision indicating that adult circumcision adversely affects sexual function in many men or/and their partners, possibly because of complications of surgery and loss of nerve endings."[36]

Frisch et al. (2013) surveyed a very large group of men and women in Denmark. They concluded:

"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."[37]

See also

External links

Abbreviations

  1. ↑ REFweb Doctor of Medicine, Wikipedia. Retrieved 14 June 2021. In the United Kingdom, Ireland and some Commonwealth countries, the abbreviation MD is common.

References

  1. ↑ a b REFjournal Cold CJ, Taylor JR. The prepuce. BJU Int. January 1999; 83, Suppl. 1: 34-44. PMID. DOI. Retrieved 8 July 2021.
  2. ↑ REFbook Kinsey AC, Pemeroy AC (1948): Sexual Behavior in the Human Male. A. C. Saunders. Retrieved 21 December 2019.
  3. ↑ a b REFbook Masters WL, Johnson VE (1966): Human sexual response. Toronto, New York: Bantam. ISBN 0-553-20429-7. Retrieved 21 December 2019.
  4. ↑ a b c d REFjournal Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, Van Howe RS. Fine‐touch pressure thresholds in the adult penis. BJUI. 19 March 2007; 99(4): 864-9. PMID. DOI. Retrieved 10 January 2021.
  5. ↑ a b REFjournal Winkelmann RK. The cutaneous innervation of human newborn prepuce. Journal of Investigative Dermatology. January 1956; 26(1): 53-67. PMID. Retrieved 21 December 2019.
  6. ↑ a b REFjournal Winkelmann RK. The erogenous zones: their nerve supply and significance. Mayo Clin Proc. 21 January 1959; 34(3): 39-47. PMID. Retrieved 4 June 2021.
  7. ↑ REFjournal Morgan WKC. The rape of the phallus. JAMA. 1965; 193: 123-4. PMID. DOI. Retrieved 21 December 2019.
  8. ↑ REFjournal Morgan WKC. Penile Plunder. Med J Aust. 27 May 1967; 1(21): 1102-3. PMID. Retrieved 21 December 2019.
  9. ↑ REFjournal Falliers. Circumcision (letter). JAMA. 21 December 1970; 214(12): 2194. Retrieved 21 December 2019.
  10. ↑ a b c REFjournal Masood S, Patel HR, Himpson RC, Palmer JH, Mufti GR, Sheriff M.K. Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly?. Urol Internationalalis. 2005; 75(1): 62-66. PMID. DOI.
  11. ↑ a b c d e REFjournal Fink KS, Carson CC, DeVillis RF. Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol. May 2002; 167(5): 2113-2116. PMID. DOI.
  12. ↑ REFjournal Yang CC, Bradley WE. Neuroanatomy of the penile portion of the human dorsal nerve of the penis. British Journal Urology. July 1998; 82(1): 109-113. PMID. DOI.
  13. ↑ REFjournal Szabo R, Short RV. How does male circumcision protect against HIV infection?. BMJ. June 2000; 320(7249): 1592-1594. PMID. PMC. DOI. Retrieved 9 July 2006.
  14. ↑ a b REFjournal Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol. 1996; 77: 291-5. PMID. DOI. Retrieved 23 September 2019.
  15. ↑ a b REFjournal García-Mesa, Yolanda, García-Piqueras, Jorge, Cobo, Ramón, Martín-Cruces, José, Suazo, Iván, García-Suárez, Olivia, Feito, Jorge. Sensory innervation of the human male prepuce: Meissner's corpuscles predominate. Journal of Anatomy. October 2021; 239(4): 892-902. PMID. PMC. DOI. Retrieved 15 November 2021.
  16. ↑ REFjournal Taylor JR. Back and forth (letter). Pediatric news. October 2000; 34(10): 50.
  17. ↑ REFjournal Lakshmanan S, Parkash S. Human prepuce: some aspects of structure and function. Indian journal of surgery. 1980; 44: 134-137. Retrieved 19 December 2019.
  18. ↑ REFjournal Boyle GJ, Bensley GA. Adverse Sexual and Psychological Effects of Male Infant Circumcision. Psychological reports. July 2001; 88(3, Part 2): 1105-1106. PMID.
  19. ↑ REFjournal Schober JM, Meyer-Bahlburg HF, Dolezal C. Self-ratings of genital anatomy, sexual sensitivity and function in men using the 'Self-Assessment of Genital Anatomy and Sexual Function, Male' questionnaire. BJU Int. September 2009; 103(8): 1096-103. PMID. DOI.
  20. ↑ a b REFjournal Shen Z, Chen S, Zhu C, Wan Q, Chen Z. Erectile function evaluation after adult circumcision. Zhonghua Nan Ke Xue. January 2004; 10(1): 18-19. PMID.
  21. ↑ a b REFjournal Richters J, Patel HR, Himpson RC, Palmer JH, Mufti GR, Sheriff MK. Circumcision in Australia: prevalence and effects on sexual health. International Journal of Sexually Transmissible Diseases and AIDS. 2006; 17(8): 547-554. PMID. DOI.
  22. ↑ a b c REFjournal Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. JAMA. 2 April 1997; 277(13): 1052-1057. PMID. DOI. Retrieved 8 August 2021.
  23. ↑ a b c d REFjournal Senkul T, Iseri C, Sen B, Karademir K, Saracoglu F, Erden D. Circumcision in Adults: Effect on Sexual Function. Urology. 2004; 63(1): 155-158. PMID. DOI.
  24. ↑ a b c d REFjournal Collins S, Upshaw J, Rutchik S, Ohannessian C, Ortenberg J, Albertsen P. Effects of circumcision on male sexual function: debunking a myth?. Journal of Urology. 2002; 167(5): 2111-2112. PMID. DOI. Retrieved 18 February 2020.
  25. ↑ a b c d e f REFjournal Kim DS, Pang MG. The effect of male circumcision on sexuality PDF. BJU Int. March 2007; 99(3): 619-622. PMID. DOI. Retrieved 4 November 2023.
  26. ↑ REFjournal Waldinger MD, Quinn P, Dilleen M, Mundayat R, Schweitzer DH, Boolell M. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. Journal of Sexual Medicine. 2005; 2(4): 492-497. PMID. DOI.
  27. ↑ Study Is Adding to Doubts About Circumcision By SUSAN GILBERT Published: April 2, 1997. New York Times. [1]
  28. ↑ REFjournal Uberoi M, Abdulcadir J, Ohi DA, Santiago JE, et al. Potentially under-recognized late-stage physical and psychosexual complications of non-therapeutic neonatal penile circumcision: a qualitative and quantitative analysis of self-reports from an online community forum. Int J Impot Res. 23 October 2022; PMID. DOI. Retrieved 19 February 2023.
  29. ↑ REFjournal Wildman RW, Wildman RW 2nd, Brown A, Trice C. Note on males' and females' preferences for opposite-sex body parts, bust sizes, and bust-revealing clothing. Psychological Reports. 1976; 38(2): 485-486. PMID.
  30. ↑ Williamson ML, Williamson PS. Women's Preferences for Penile Circumcision in Sexual Partners. J Sex Educ Ther 1988; 14: 8
  31. ↑ REFjournal O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU International. January 1999; 83(Supplement 1): 79-84. PMID. DOI. Retrieved 27 April 2020.
  32. ↑ a b c d REFjournal Bensley GA, Boyle GJ. Effects of male circumcision on female arousal and orgasm. New Zealand Medical Journal. 12 September 2003; 116(1181): 595-596. PMID. Retrieved 27 April 2020.
  33. ↑ REFjournal Taves D. The intromission function of the foreskin. Med Hypotheses. 2002; 59(2): 180. PMID. DOI. Retrieved 4 January 2020.
  34. ↑ REFjournal Warren J, Bigelow J. The case against circumcision. Brit J Sex Med. September 1994; Retrieved 4 January 2020.
  35. ↑ REFjournal O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int. 1999; 83 Suppl 1: 79-84. PMID. DOI. Retrieved 22 October 2019.
  36. ↑ REFjournal Solinis, Yiannaki. Does circumcision improve couple's sex life?. Journal of Men's Health and Gender. September 2007; 4(3): 361. Retrieved 4 January 2020.
  37. ↑ REFjournal Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol. 14 June 2011; 40(5): 1367-81. PMID. DOI. Retrieved 26 September 2021.
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