A refutation of the "Sex As Nature Intended It" survey
"It became apparent to me that if we had any hope of getting this topic out in the open, the only hope we had was in making this a women's issue." - Kristen O'Hara
April 14, 2018 In 1999 Kristen O’Hara  revealed the preliminary results of a survey she had conducted to compare the effect of circumcision on a partner’s enjoyment of sexual intercourse. She breathlessly announced a startling result: 86% of the female participants preferred sex with an uncircumcised partner.
O’Hara reported the results of her study in a January 1999 article for BJU International.  The article was eagerly embraced by circumcision opponents as proof that most women prefer sex with an uncircumcised partner. Results of the survey were cited in other studies to show that circumcision adversely affects a woman’s sexual experience and is harmful to sexual intimacy.
The survey formed the centerpiece for O’Hara’s 2002 book, Sex As Nature Intended It.  She devoted one chapter to discussing the survey methodology, the results, and her conclusions; several other chapters included references to the survey.
Many have accepted her conclusions without question. O’Hara was invited to present her findings at a 2002 anti-circumcision conference.  She was interviewed for a 2007 San Francisco Chronicle article,  and a 2011 article in Psychology Today described the survey as “a landmark study.” 
Despite the inclusion of a caveat that the study contained some methodological flaws and a caution that her findings should be confirmed by other researchers,  it doesn’t appear that a review was conducted. And since medical journals have been known to publish junk articles with no scientific validity,  a single published study shouldn’t be considered decisive in answering the question of how a man’s circumcision status might affect his partner’s sexual pleasure.
So is the study valid? Do women really prefer uncircumcised men? This paper will examine the survey methodology and the author’s interpretations. This paper will demonstrate that the entire study is worthless, built on a foundation of quicksand. Every step of the survey process was hopelessly flawed: from the solicitation of respondents to the reliance on their ability to self-report, from the suggestive survey questions to an incomplete set of response options; from the failure to consider viable explanations to a singular focus on coital sex. Before and during the study the researcher assumed the conclusion she was trying to prove.
In her book Kristen O’Hara described her own sexual history in great detail. She reported that she had enjoyed sexual intercourse with uncircumcised men, but had less pleasure and more discomfort with circumcised partners. This dissatisfaction continued into her marital relations with her husband Jeffrey O’Hara, a relationship that she described as good but not great. After ten years of marriage she began to suffer significant post-coital vaginal discomfort.
At her urging Jeffrey O’Hara had his foreskin surgically restored. Kristen’s vaginal pain gradually vanished and her sexual experiences with her husband began to yield the intense pleasure that rivaled her earlier experiences with uncircumcised partners.  She later explained, “That's when I realized that millions of women are having abnormal sex because of circumcision, and millions of women fake orgasm because of it.” 
Survey of Women
In the early 1990’s O’Hara developed a questionnaire designed to show that circumcision is the cause of women’s sexual discomfort. She explained, “The purpose of the survey was to determine the impact circumcision … has on the intercourse experience of the female partner.”  In assuming that circumcision impacts a woman’s sexual experience, she didn’t consider the default possibility that circumcision might not affect a woman’s enjoyment.
Placing an announcement in an anti-circumcision newsletter asking for women to participate in a study, O’Hara was rewarded with 64 completed surveys. She likely realized that the survey results would be dismissed based on a biased pool of respondents. So she sought to substantiate the results by moving the solicitation to mainstream newspapers and magazines. Unfortunately publishers for the New York Times and USA Today rejected the ad, possibly due to its sexual nature.
She was forced to settle for ads in the personals section of her local newspaper and one in Mother Jones magazine. She explained to this author, “Since so few people read the classifieds, and since so few women would qualify and/or would want to take part, we only got one or two women answering every time we ran it, so it was a slow process.” Using this erratic and intermittent method, she compiled 74 completed surveys over the course of several years. Combining these responses with the 64 that she had received from the anti-circumcision newsletter produced a total of 138 responses to analyze. 
A sufficient sample size is an important factor in determining how well a survey represents the population at large. The larger the sample size, the more confident a researcher can be that the results of her survey accurately reflect the views of the target population. The typical sample size of a Gallup poll of American adults is 1,000. 
The O’Hara survey had just 138 people, less than 14% of the typical Gallup survey. A survey with a sample that size would have a margin of error of about 9% with 95% confidence.  That means that if O’Hara’s respondents had been selected at random, one could be 95% confident that a survey of the population at large would result in a figure within 9% of the result of her survey.
But O’Hara’s selection was not at all random.
A survey in which people select themselves to participate by responding to a request can result in bias to the extent that respondents who choose to participate are not representative of the entire target population.
The vast majority of Americans have little interest in the controversy over circumcision. In fact most people aren’t even aware that there is a controversy in the first place. But many people who are opposed to circumcision are extremely interested in the matter. There are hundreds of anti-circumcision groups and online pages devoted to the topic. Anti-circumcision activists appear in protests, write letters for publication, and respond to any mention of circumcision on the internet.   A circumcision survey that relies on self-selection is likely to include an over-representation of respondents with a negative view of circumcision.
In addition, any woman who did not read the selected publications where the ad was placed would have been excluded from the pool of potential respondents. No pollster would consider such a group to be an accurate representation of the general population of sexually active women.
The survey also suffered from a high non-response rate of 51.1%. A researcher may assume that those who didn’t respond to a solicitation would have given the same answers as those who did respond. However the highly-motivated circumcision opponent will make a greater effort to have her responses counted than a less passionate respondent.
Another critical factor is that the first 64 of the 138 surveys were solicited via an announcement placed in an anti-circumcision newsletter. It can be assumed that respondents recruited from this ad already had a negative view of circumcision. A survey relying on such responses cannot possibly be considered scientifically valid. Based the use of the anti-circumcision newsletter, one study that cited O’Hara’s study cautioned that the results should be viewed with skepticism. 
A mail-in survey would be unable to measure the accuracy of responses. As one attempts to recall events further back in time, the memory is increasingly unreliable. And yet each respondent was expected to remember and evaluate specific details about every sexual encounter in her life, many of which may have occurred decades earlier. It’s questionable whether respondents, particularly those with numerous partners, would be able to remember their experiences with each one.
O’Hara explained that in order to assist respondents in determining each partner’s circumcision status, she provided drawings of circumcised and uncircumcised penises, both flaccid and erect. But a 2002 study of 1,508 adolescent boys showed that a male may not even be able to report accurately whether his own penis is circumcised. Prior to a medical examination male subjects were asked whether or not they were circumcised, or if they didn’t know. Later, during the exam a clinician recorded each subject’s actual status as fully circumcised, partially circumcised, or uncircumcised. The subjects who thought they knew their status were correct more than 90% of the time. Yet 23% of the fully circumcised and 31% of uncircumcised boys didn’t know their status. Significantly, the 85 subjects (5.6%) who did not know were asked to identify their status from a picture of a circumcised penis and an uncircumcised penis. Just 82% of fully circumcised adolescents and 43% of uncircumcised adolescents were able to correctly identify their status. 
Presumably most of those boys were familiar with the appearance of their own genitals. By contrast, each woman in the O’Hara study was asked to recall the circumcision status of penises that she might have viewed decades earlier – possibly in dim light or darkness. The researcher had no way of determining the accuracy of these reports. 
Furthermore, a researcher conducting a survey by mail may not be able to clarify survey questions that a respondent doesn’t understand. O’Hara admitted that she needed to reword some questions on later surveys “to make them more easily understood.”
One of the most prevalent flaws in the survey is the pervasive use of highly prejudical terminology.
Pollsters have learned that the way a survey question is phrased can affect respondents’ answers. A 2013 CNBC survey polled two different groups, referring to the same controversial health care law by different terms. According to the survey results, 37% of one group expressed opposition to “the Affordable Care Act.” Opposition rose to 46% in the other group, which was asked their opinions of “Obamacare.” A term associating the law with President Obama may have caused some respondents to give a different answer than they would have given if the law was identified by its less political title. 
Throughout the O’Hara survey, loaded terms led respondents toward a specific preference for the uncircumcised penis. Question 5 asks each respondent about her experience with “natural (i.e. uncircumcised) men.” All subsequent questions refer to uncircumcised men as natural men and sex with uncircumcised men as natural intercourse. Natural is a loaded term; that which is “natural” is considered good. If uncircumcised is natural, then by contrast circumcised must be unnatural.
That O’Hara would use an unfamiliar and loaded term is perplexing – since she clearly knew that most women understood “uncircumcised.”   Even a term like “uncut” or “intact” wouldn’t have conveyed such a judgmental connotation.
Acquiescence bias – leading questions
Questions 28 and 30, in which the researcher unwittingly asked respondents to reflect her own sexual experiences, are particularly vulnerable to acquiescence bias, a “tendency for survey respondents to agree with statements regardless of their content.”  Note that O'Hara discouraged dissent, since only respondents who disagreed with these questions were asked to explain their answers. 
Several questions offered only a binary choice, forcing respondents to prefer one type of penis. Since the researcher developed the survey based on her assumption that circumcision must have a discernible impact on sexual pleasure, she failed to offer the perfectly reasonable options of “both” and “neither.”
Choices for those who might answer “both,” “neither,” or “I am not presently in a monogamous relationship” were not offered.
How important is it to offer such choices? In a 2014 Adam & Eve.com survey asking women about their circumcision preferences, 33% of respondents expressed no preference. (And 54% of respondents preferred a circumcised partner, while just 3% preferred uncircumcised.)  Now it’s true that an online poll won’t provide scientifically verifiable results. But neither does a survey with blatantly unbalanced methodology.
Lacking, Leading, and Loaded Question 22 featured a trifecta: a leading question, using loaded terminology, and a lack of viable options.
The question assumes that a woman’s experiences must differ. Even if she provided a negative answer, the question impresses the idea that such a difference is real and should be expected.
Confirmation of Bias? Each question included a line to include comments. Some of the candid thoughts that women and their spouses added suggest that respondents were influenced by the survey itself.
PREFERENCE FOR VANILLA SEX
The survey focused almost exclusively on vaginal intercourse. Questions 1-9 query women about their sexual intercourse experiences. Women who had oral or anal intercourse with some partners – but not vaginal intercourse – may have considered those experiences when answering these questions. However Questions 10-24 and 26-40 ask only about vaginal intercourse.
And the survey didn’t assess the possible effect of circumcision on oral sex, anal sex, or manual stimulation – practices that can significantly enhance a woman’s satisfaction, enjoyment, and sense of intimacy. Just one question referred to any practices besides coitus.
O’Hara didn’t include the results of Question 25 in her article or book. But she cited a 1997 study which concluded that manual, oral, and anal sex are more common practices among circumcised men.  And she suggested that partners of circumcised men had a greater preference for such activities because they found vaginal intercourse unsatisfying. 
Such a conclusion conveys a bland, vanilla view of sex. O’Hara seems locked in a 1950’s mentality in which penis-in-vagina is the only flavor on the menu. She didn’t explore the possibility that a woman might prefer a circumcised partner for other activities. This author will suggest some possible reasons why some women might hold such preferences.
A woman may prefer oral sex with a circumcised partner if she finds his penis to be more visually pleasing. She may decline to perform fellatio on an uncircumcised penis if repulsed by an unpleasant odor. And she may be reluctant to insert an organ with germ-harboring foreskin into her mouth.
As sexual activity is typically reciprocal, a man who often receives oral sex may be more willing and enthusiastic to perform. Thus a woman who regularly provides fellatio (for her circumcised partner) might find herself the happy recipient of more oral stimulation. If she frequently climaxes via cunnilingus, she might not consider orgasm to be the singular goal of every vaginal intercourse session.
A woman may prefer a circumcised partner for manual stimulation if she considers his penis easier to handle. She may be averse to uncircumcised anal intercourse if she fears that the foreskin will tear or cause injury during insertion and thrusting.
Interestingly, the results of some studies seem to contradict O’Hara’s assumptions about interest in alternative sex practices. According to a 2010 study published in the Journal of Sexual Medicine, just 65% of surveyed women who had vaginal sex in their last encounter reached orgasm. Yet 81% of those who had oral sex and an incredible 94% of those who had anal sex achieved orgasm. A male writer for Slate expressed surprise that “anal sex outscored cunnilingus” in accompanying female orgasms. 
Why would women who engage in anal sex have more orgasms? One might look at it the other way around. Achieving orgasm may increase a woman’s interest in trying alternate activities. And while some women prefer a traditional position, others are simply more adventurous. 
This author doesn’t suggest that these explanations, individually or collectively, explain the popularity of alternate sexual activities. Rather, it would be irresponsible for a researcher not to consider them.
DISMISSAL OF DEEFICIENCIES
O’Hara interpreted the results of her survey in both the 1999 article and the 2002 book. In Chapter 13, when analyzing the survey results, she demonstrated a zealousness unsuitable for a scientific researcher. An unbiased researcher might be skeptical if 8 out of 9 survey respondents preferred one type of partner over the other. But not only was O’Hara unsurprised, she offered several reasons to dismiss the remaining 14% of women who preferred circumcised partners.
For instance, she noted that 7 of the 14 women who preferred circumcised sex had had sex with just one uncircumcised partner. O’Hara dismissed their insights, since they weren’t based on a large sample, but on a single negative experience. She presumed that their opinions might be different if they had more uncircumcised partners.  Yet in Chapter 7 she trumpeted the opinion of a woman who ranked her one uncircumcised partner above three dozen other lovers. She asked, “Considering that this woman had intercourse with 38 circumcised men and only one natural man, what are the odds that out of 39 men, she found only one man to be superior and he just happened to be natural?”  Thus she dismissed a ranking that placed the one uncircumcised partner at the bottom of the list. But she rejoiced when a respondent ranked one uncircumcised partner at the top of the list.
O’Hara blamed the 14 uncooperative respondents for a lack of sensitivity and other supposed flaws. With no apparent sense of irony, she accused her respondents of harboring a prejudice against one type of penis.  This author finds it remarkable that a researcher would have such a low opinion of volunteers who donated their own time to complete a 40-question survey for her.
As noted earlier O’Hara recognized a few of the inherent weaknesses in her survey.  She admitted that
Respondents were not selected randomly.
Nearly half were recruited via an anti-circumcision newsletter.
Recall bias may have affected the reliability of responses.
Some respondents failed to answer every question.
Some respondents misunderstood several questions.
The survey measured only vaginal intercourse, and ignored other activities.
Rather than recognize that these flaws cast doubt on the validity of her conclusions, O’Hara tried to excuse or justify them. For instance, she compared the small sample size to a tire recall following a series of 100 fatal auto crashes. In fact the Firestone tire recall followed nearly 300 complaints of accidents.  And those who reported the auto accidents would have been representative of the driving population at large. Presumably motorists didn’t hold an anti-Firestone bias prior to suffering a tire blowout accident, and they didn’t suffer recall bias. Moreover, accident reports are not comparable to an opinion survey, much less one with such severe methodological flaws.
Other deficiencies, such as the lack of a random sample, were also dismissed. O’Hara insisted, “While this study has some obvious methodological flaws, all the differences cannot be attributed to them.” She preemptively dismissed skeptics as hardheaded and emotionally attached. 
O’Hara failed to consider the effect of penile length or girth on a partner’s comfort, satisfaction, intimacy, and emotional bonding. She failed to consider the effect of condom usage. She didn’t consider the history of sexually-transmitted infections among respondents and their partners. Nor did she consider the effect of age, race, ethnicity, physical build, or alcohol and drug use.
O’Hara admitted that she didn’t consult a physician or sex therapist when researching her book.  It doesn’t appear that she contacted a professional pollster or statistician. This dismissal of expert assistance was a serious mistake. Had she checked with such experts, she would have been alerted to various defects in her research and conclusions, and could have taken action to mitigate the damage.
A peek into a methodologically sound study
In July 2015 the Canadian Journal of Human Sexuality published a circumcision study conducted by researchers at Queen’s University in Ontario. The authors stated that their survey “procedures were approved by the University's General Research Ethics Board.” The survey used unbiased terms, referring to the uncircumcised penis as “intact.” A total of 196 participants were recruited through print advertisements around the Queen’s University campus and in online advertisements via social media.
The authors summarized their findings.
Circumcision status did not appear to impact sexual functioning for women… Women with intact partners reported higher levels of sexual satisfaction. Women with circumcised partners reported higher levels of satisfaction with their partner’s circumcision status as compared to those with intact partners only when their partner’s penis was flaccid... Despite differences in satisfaction across circumcision status, women…rated overall high levels of satisfaction with their partner’s circumcision status and did not wish for it to change.
Referencing the O’Hara study, the researchers rejected her hypothesis that “sex with an intact penis would be more enjoyable for men’s [female] sexual partners due to the mobility of the foreskin.” 
Contrast the zeal displayed by O’Hara with Queen’s researcher Jennifer Bossio’s lack of bias. Bossio stated that she neither expected nor hoped for a particular outcome. Referring to a related study she was conducting to measure the effect of circumcision on penile sensitivity, she wrote modestly, “Regardless of what we find – whether circumcision decreases penile sensitivity, increases it, or has absolutely no difference – I hope that this research is used to make a difference in people’s lives in some small way.” 
The O’Hara study is instructive at showing the systemic failure that is likely to occur when a biased and amateur researcher conducts a study in order to advance an agenda.
Kristen O’Hara didn’t seek to preach to the choir, but to convert a nation. She declared that her study provides “many astonishing and disconcerting revelations.”  She asked, “Are these findings destined to change the sex life and sexual attitude of America’s men and women forever?”  She hoped that women would “confront this issue, acknowledge it, change our attitudes, embrace its truths, and get on with our lives, knowing that tomorrow’s child will enter the world in a better way, and that humanity, and the world, will be a better place because of it.” 
With such a grandiose vision, O’Hara must be deeply disappointed that her study has garnered little attention outside of a close-knit community of anti-circumcision activists. It’s true that some researchers have accepted the results without question. Perhaps they didn’t have the time to review her study. Perhaps they were blinded by their own confirmation bias. At any rate her findings have made virtually no impact on the circumcision rate in the United States. (While the national rate of neonatal circumcision declined by 10% from 1979 to 2010, nearly all of the change was in the West, and coincided with a large influx of immigrants from non-circumcising cultures.) 
The researcher explained that she would automatically dismiss the insights of those who might disagree with her findings. “My experience has taught me that there is a great deal of hardheadedness and emotionalism associated with the circumcision issue, particularly since many parents have circumcised their sons. And circumcised men, themselves, may have difficulty facing up to the idea that they could be deficient or inferior in their sexuality.” 
O’Hara unwittingly admitted to this author that she conducted her study, not to understand the effects of circumcision, but to advance a personal crusade to end circumcision. She wrote, “I have spoken and corresponded with many men over the years on the circumcision topic. The one thing I hear over and over again is, ‘I'm circumcised and I'm fine.’ So it became apparent that if we had any hope of getting this topic out in the open, the only hope we had was in making this a women’s issue, since women would not have their sexual egos involved.”  In other words, too many nonchalant circumcised men refused to play their assigned part; she sought to bypass their reluctance by recruiting women to assume the victim role.
O’Hara wrote candidly of the pain and discomfort she suffered with her own circumcised partners, in sharp contrast to the glowing terms she used to describe her experiences with uncircumcised men. She erroneously assumed that her sexual experiences are relevant to every other woman, when in fact her experiences apply only to herself. Each woman understands and achieves fulfillment through her own sexual explorations. O’Hara might be surprised to learn that many sexually-experienced women don’t relate to her vision of painful unsatisfying sex.
Millions of women with circumcised partners routinely enjoy breathtaking encounters without pain, discomfort, or disappointment. These lovers cherish soft, tender, intimate, and sensuous rendezvous. Their own personal observations confirm a reality that no survey can obscure. An appendix to this paper provides a glimpse into the opinions of experienced women who offer decidedly positive reports of their circumcised sex experiences.
Sex therapist Dr. Ruth Westheimer has observed that the largest and most important sexual organ is not the one between our legs, but the one between our ears.  The presence or absence of a flap of skin cannot prevent the human brain from transforming a routine sexual encounter into euphoric bliss.