Don't Put That in There! (4 page)

Foreskins, what are they good for?

For such a small part of the body, the foreskin is quite a controversial piece of tissue. For thousands of years, the decision to circumcise or not circumcise the penis was associated with the rules and traditions of certain religions. Wars have been fought over these religious traditions—wars over the foreskin.

While not as horrific as the historical clashes, the battles over the foreskin continue today. You can find anti-circumcision advocates protesting with giant signs about how male circumcision reduces sexual pleasure and constitutes a form of torture.

Whether or not men are circumcised varies dramatically based on where you live. Around the globe, about one-third of males are circumcised, for reasons that vary from religious traditions to medical needs to cultural preference. Currently, baby boys are often circumcised in places like the United States, Canada, Australia, much of the Middle East, and West Africa. Circumcision of male infants is relatively uncommon currently in Europe, East and Southern Africa, and other parts of the world. In some of these places, boys are circumcised later in life; in other parts of the world most men are never circumcised.

In recent years, scientists have made some important new discoveries about the foreskin. One of these discoveries is that male circumcision actually protects against several diseases. Men who have been circumcised are less likely to have urinary tract infections, herpes, syphilis, chancroid, and invasive cancer of the penis. Perhaps the most important discovery along these lines is that being circumcised protects you against HIV. Men who have been circumcised are actually 50 to 60 percent less likely to get HIV. When it comes to preventing HIV, male circumcision seems to be a huge help. Since lots and lots of things do not work to prevent HIV, figuring out that something
does
work is a big deal.

Scientists first got the idea that circumcision might decrease the chance of getting infected with HIV by looking at large databases of men over time, and whether or not they were getting infected with HIV, and then comparing this information to characteristics like being circumcised. This is reasonable science when you have lots and lots of people involved (which these studies did), but now the research has gotten even better. Male circumcision has been studied in very large trials, where adult men are actually randomized to either get circumcised or to not get circumcised. Randomized controlled trials are usually the best type of scientific evidence for proving causality. The results of these trials show that the circumcised men are significantly less likely to get infected with HIV.

Male circumcision also seems to prevent certain infections for women. In particular, two sexually transmitted infections,
Trichomonas
and bacterial vaginosis are less common in women whose partners have undergone circumcision.

These might seem like good reasons to promote circumcision, but there are also a lot of reasons why people are not in favor of circumcision. Like any surgical procedure, there is a risk of bleeding, developing an infection, cutting the wrong thing, or developing a hematoma, or collection of blood. These risks are very low for babies (0.2 to 0.4 percent), but can happen. There seems to be greater risk for complications when you circumcise an adolescent or adult man, but there are not a lot of data on how often problems happen. Whether or not the provider is experienced, whether the procedure happens in a clinical setting, what tools are used, and what kind of follow-up is available, all might contribute to the safety of circumcision.

One of the biggest arguments against male circumcision has been that it decreases the sensation of the penis. This seems to be the reason for most of the protests. There is clear evidence that the foreskin itself is sensitive; it has thousands of nerve endings, and these would be lost when the foreskin is removed. Some small studies have suggested that circumcised men report less sensitivity of the penis, and more problems with erections and ejaculation. There is also a lot of expert theory to support this idea based on what happens to the tissue when you circumcise a man. When you remove the foreskin, the glans or head of the penis is left exposed, which changes the tissue that covers it, making it a drier tissue that might also be less sensitive.

For a long time, this theory and these smaller studies seemed like the best evidence we were going to have on the topic. And yet, we had a big problem with those studies comparing circumcised and uncircumcised men because most of these men grew up with their circumcised or uncircumcised penises and could not really weigh in on the difference that circumcision makes for an adult. They had not experienced it both ways. In the few studies that measured the actual sensitivity of the penis, there did not seem to be a difference. No one thought there would be a day when it was okay to do a study that would randomly assign men to either get circumcised or not get circumcised.

But that all changed when scientists began to question whether circumcision prevented HIV. Suddenly, they needed to answer this important question, and it made sense to get that answer using the best science possible. Scientists then conducted studies involving thousands and thousands of men in Kenya who were randomized to either get circumcised or not get circumcised. (Yes, the men signed up voluntarily to be in the study, so they knew that they were going to be put randomly into one of these groups to either go under the knife or not, and they were okay with that.)

These large, randomized, controlled studies actually gave us very good evidence about the impact of circumcision on men’s sexual satisfaction and the sensitivity of their penises. These studies do not show any problems with the penis becoming less sensitive after circumcision or any problems with the men reaching orgasm. In fact, the opposite seems to be true. Overall, the circumcised men actually report that their penises are more sensitive, and that they have an easier time reaching orgasm. These large studies suggest that male circumcision does not hurt men’s sexual function at all.

Once you take off a foreskin, it is awfully difficult to put something back on! Because this is such an important question to answer up front, researchers have done an extensive search, called a systematic review, where they collected all of the available studies on the topic, and combined them together into a meta-analysis. When they put ten studies together, combining findings from almost 20,000 men, they did not see any differences between circumcised and uncircumcised men in terms of sexual desire, pain during sex, premature ejaculation, problems with erections, or problems with orgasms. We have a very good answer to the question of whether circumcision creates sexual problems for men.

While the foreskin is certainly a sensitive part of the male anatomy, there can be some benefits to removing it in terms of preventing infections, particularly HIV. The bulk of the existing evidence suggests that circumcision does not hurt a man’s sexual experience. These benefits should be considered when one weighs decisions about whether or not circumcision should occur.

Your Balls Sag with Age

A man’s scrotum and testicles are an amazingly well-regulated set of equipment. The testicles (aka, testes) are supposed to come down out of the body by the time a baby boy is born, or shortly thereafter. Once the testicles are down, the body does its best to keep the testicles at just the right temperature—not too hot or too cold. The body wants to make sure that the testicles can produce sperm at maximum capacity, and this works best when the temperature is just right.

Testicles will start to grow in size when boys first begin to enter puberty, usually around the age of ten to thirteen years. The sac around them will also start to grow in size, to darken, to hang lower, and to grow hair.

Where exactly the testicles hang is actually a very interesting process. To keep the testes at the right temperature, the skin of the scrotal sac has a layer of muscle that is very sensitive to temperature, touch, and stress. When conditions are warm, the muscles lining the scrotal sac relax, and the testes hang lower down from the body where they can stay cool enough. When conditions are cold, these muscles contract, and everything is held tighter and closer to the body. For some men, these muscles also contract during sex or during times of emotional stress.

Some men actually consider it very desirable to have low-hanging balls. In fact, there is an entire practice dedicated to trying to expand the skin of the scrotal sac to get your testicles to hang lower. For some, this is also considered a very sexually enjoyable practice. Men will even use weights or “ball stretchers” to try to get their scrotum to stretch out. (Photos are not for those faint of heart—or sensitive of scrotum!) Challenges with this practice include dealing with the pain, knowing what to wear with low-hanging balls, and not having your testicles hang in the toilet water when you are trying to go to the bathroom. Despite our mentioning the practice in this book, ball stretching is not physician recommended!

Even if you are not trying to stretch out your scrotum, many people have heard that men will become “low hangers” as they age. They expect a decrease in the strength of those scrotal sac muscles with age and a sagging of the balls to go along with it. Earlobes, breasts, balls—all of these body parts are expected to droop with age.

But, does this really happen? Do a man’s balls start to sag with age?

The male reproductive tract definitely goes through a number of changes with age. While the cells in the testicles that make sperm are formed continually, they start to produce fewer sperm, slower sperm, and sperm that are less able to fertilize an egg. Older men’s sperm are also more likely to have genetic abnormalities. Very old men can still get a woman pregnant under the right conditions, but it is much less likely than when they are younger because of these issues with sperm production.

The components of the testicles also start to change and wear out with age. The tiny tubes where sperm are produced start to degenerate, as do the other structures within the testicles. Overall, testicles also become smaller. Smaller testicles may seem like they are hanging lower, because the sac itself is just a bit emptier. This might create an illusion of extra droopiness.

There are no real studies on the measurements of where testicles hang over time. It is clear that the biggest change in where the balls hang happens when boys enter puberty and they have that significant increase in the size of the testicles and of the scrotal sac. After that, experts say that the changes are pretty minimal. There might be some weakening of the skin of the scrotal sac, but the smooth muscle that controls the movement of the scrotal sac up and down continues to function for a man’s entire life. And that kind of muscle—smooth muscle—is unlikely to sag very much.

Wait for a Whopping Wad

A lot of guys have heard that they will have a lot more ejaculate if it has been a long time since they last came. We have no idea why people seem obsessed with the volume of a man’s ejaculate, but obsessed they are. You can read any number of stories on things that increase or decrease the amount of semen that a man will produce when he orgasms.

While the general population seems concerned with the volume of ejaculation, scientists are much more concerned with the actual content of it (i.e., sperm). That’s because sperm are what’s involved in reproduction, and that’s what most doctors and researchers really care about. Nonetheless, we found lots of information in the medical literature about how just much ejaculate comes out when a man comes.

For instance, in 1975, a group of researchers gathered 1,300 men who had fathered at least two children. We imagine they chose fathers to make sure that they knew these were men with “functioning” reproductive systems. They somehow persuaded all of these men to give a “sample.” Then, they performed a semen analysis.

They found that the volume of their “emission” ranged enormously from about 0.1 milliliters to 11 milliliters. That’s like a few drops all the way to more than a third of a small shot glass. The average amount of semen produced in one ejaculation was about 3 milliliters (mL), or just over half a teaspoon. But can anything change this?

Fast-forward to 2005. A study of more than 6,000 men providing almost 9,500 samples was conducted from 1995 through 2003. They found that the volume did increase gradually the longer a man went between orgasms. Men who had not ejaculated in seven days had an average semen volume of 3.7 mL. Men who had orgasmed the day before had a semen volume of 2.3 mL. That’s a change, but this is really a small volume difference. It’s less than a third of a teaspoon. It’s not something anyone would be likely to notice. Even men who had come earlier that day still had an average volume of 2.4 mL, which was actually more than those who waited a day. In fact, the difference between coming twice in a day, and waiting three days was less than a quarter of a quarter of a teaspoon. We’re talking drops.

But some people really want to make a splash. They’ll try anything. Some believe that priming the pump will make a difference. Will it? Will your quickie produce any more or less than your lengthy sexual encounter? Let’s go to another study out of Canada. Twenty-five men between the ages of twenty-two and forty-four were gathered together, and they provided more than 290 different specimens over a four-month period. They were told that they had to forego any ejaculations for at least three days before producing their contribution to the study. The scientists found that the time taken to produce an ejaculation was significantly related to the concentration of sperm in the ejaculate, but that it had no relation to the actual volume. This was confirmed in another study of 142 men in a clinic in Sweden in 2008. So slow down, speed up—it doesn’t matter. It doesn’t change how much you will come.

There’s just not that much you can do. Moreover, even if you can make a statistically significant difference, it’s not likely to be one you’re going to notice in real life. Most men come less than a teaspoon. Shouldn’t that be enough?